■ORIGINAL ARTICLE

Interplay between type-1 diabetes and occupation:
Results from a pilot study
Theoretical paper exploring new treatment technique

Venthan J. Mailoo1, Nick Best2, Sarah Cheal3, Francesca Kelly4, Jeremy Turner5
1Anaesthetics Senior House Officer, Northampton General Hospital NHS Trust
Locum Occupational Therapist, Day Webster Limited, Unit 103A, Sterling House
3
Lead Occupational Therapist, Urgent Care Centre and Accident & Emergency, Norfolk Community Health & Care NHS Trust,
Norfolk and Norwich University Hospital4
Occupational Therapy Team leader – Medicine and Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust
5
Consultant Endocrinologist and Honorary Senior Lecturer, Elsie Bertram Diabetes Centre, Norfolk and Norwich University
Hospitals NHS Foundation Trust
2

Abstract: Type-1 diabetes results from cessation of endogenous insulin production. Self-management is essential forpatients with type-1 diabetes to prevent secondary organ damage and premature death. Self-management may be inhibited by a vast array of psychosocial factors, and therapy is unlikely to be successful unless these factors are identified
and addressed. A pilot study of seven patients from Norfolk in the United Kingdom was undertaken to investigate thepsychosocial factors interfering with diabetes self-management. Occupational therapy assessments and interventions
were provided in an outpatient clinic. Patients’ capacities for diabetes self-management were adversely affected byphysical and psychological comorbidities, financial hardship and family responsibilities. Health problems resulting
from sub-optimal diabetes self-management included visual impairment, lower limb amputation, erectile dysfunction,
hypoglycaemia and diabetic ketoacidosis. A combination of these problems impacted on patients’ spiritual lives, interpersonal and intimate relationships, employment prospects, finances and personal power, pleasure and security.
Keywords: Diabetes, NDOSQ, mental-health, self-care(Asian J Occup Ther 12: 1−7, 2016)

Introduction
Type-1 diabetes mellitus is usually an autoimmune
disease which results in the human body producing no
insulin. Insulin is essential to control blood sugar levels.
Self-management is usually essential for good outcomesin diabetes [1]. The self-care behaviours required to
avoid long-term complications include home glucose
monitoring; adjustment of food intake, administration of
insulin, foot care and attendance of healthcare appointments [2]. In the long-term, poor diabetes self-management can lead to secondary organ damage such as visual
impairment, kidney failure, cardiovascular disease or
limb-loss secondary to peripheral neuropathy or infecReceived: 15 August 2015, Accepted: 22 June 2016
Corresponding to: Venthan J. Mailoo, Northampton General Hospital
NHS Trust, Cliftonville, Northampton NN1 5BD
e-mail: VenthanMailoo@gmail.com©2016 Japanese Association of Occupational Therapists

tion. Poor self-management of type-1 diabetes can also
lead to rapid death from diabetic keto-acidosis (DKA).
For most cases of DKA poor adherence to therapy is thelikely cause [2]. Qualitative research has shown that patients appreciate advice adapted to suit their individual
lifestyles [3], family and economic circumstances [4].
Conversely, when these factors are ignored patients may
consider clinicians’ advice to be not relevant to them[4]. The prevalence of diabetes among individuals withmental health problems has been estimated as high as
double the general population [5]. The prevalence ofdepression in people with diabetes has been estimatedto be between 11% and 32% [6]. It could therefore
be argued that consultations should elicit relevant
information about how psychosocial factors impact on
individual patients and identify mental-health problems
in need of treatment. This pilot study was undertaken
to determine the nature of psychosocial factors that canbe revealed with a one-off holistic occupational therapy
consultation.

2Interplay between type-1 diabetes and occupation

Literature Review
Research has shown motivational, patient-centredconsultations to be more effective than traditional,
didactic approaches for facilitating lifestyle change andimproved self-management of diabetes [7]. Hornsten
et al. [1] interviewed 44 patients with type-2 diabetes
in Sweden and found agreed goals, patient autonomy
and feelings of self-worth to be features of satisfying
consultations, while disagreement about goals and perception of being forced into submission were features of
unsatisfying consultations. Patients wanted non-diabetic
factors affecting their lifestyles to be taken into account.
‘Patient-centred communication’ has been defined as“communicating in a way that conveys sensitivity tothe patient’s feelings and needs, encourages patientparticipation, seeks to include the patient’s perspective,
and attempts to fully inform the patient” [7]. Featuresof patient-centred practice include a bio-psychosocial
perspective, a therapeutic alliance based on sharing
responsibility and power and a personal relationshipbetween the patient and clinician [4]. Trust, rapport andcommunication success are associated with positive
therapeutic alliance [8]. Patient-centred care may bepatient-led or clinician-led [4]. Qualitative research has
indicated that the holistic, patient-centred consultations
given by alternative therapists may influence patientsto select complementary therapies that lack scientificlegitimacy. It has been argued that adoption of these features into conventional healthcare consultations could
increase patient concordance [9].
Occupational therapists commonly treat people withorgan damage secondary to poorly controlled diabetes[10], such as stroke, visual impairment or limb amputations. It has however been argued that occupational
therapy should have a more pro-active, preventative rolein facilitating diabetes self-management. Outpatient occupational therapy for diabetes is not a new concept [11].
The American Occupational Therapy Association [12]advocates occupational therapy for exercise, habituationof glucose monitoring, healthy-eating and self-medication, emotional regulation and compensations for secondary organ damage. This has been delivered by direct
occupational therapy intervention, sign-posting to community resources [11] and setting up peer-support [13].
As a general trend over time, the focus of publishedoccupational therapy diabetes literature developed from
specific, prescribed input based primarily on medical
needs, to broader, holistic input incorporating more individualised psychosocial factors. Early articles described
multi-disciplinary interventions in which occupational
therapists delivered sessions on specified subjects, themost common being exercise [11, 14, 15]. A programmewith a much broader remit was described by Scott et al.
[16], and was designed to incorporate diabetes management skill-building into everyday functioning; however
the extent to which this programme was individually
tailored to the user remains unclear.
When psychosocial issues were brought to thefore in more recent studies it was often through theoccupational therapy researchers listening to the viewsof service-users. Hwang, Truax, Claire & Caytap [17]carried out a survey of a mixed type-1 and-2 diabetes
population over the age of 55 in the USA. They foundthat subjects would value assistance in a number ofareas which lend themselves to a more holistic, psychosocially-oriented frame of reference such as “improving
relationships” and “help with fatigue management andpacing”. Interestingly, only 13.7% had ever seen an
occupational therapist. Pyatak’s [18] qualitative study
into young adults with type-1 diabetes produced similar
results, with psychosocial issues very prominent inparticipants’ accounts. The young adults interviewed described peer-pressure, social events involving excessive
eating or alcohol consumption and concerns about theattitude of others towards insulin injection as major barriers to effective diabetes self-management. Both articles
highlighted the potential of occupational therapy’s psychosocial frame of reference to help address such issues.
The idea that psychosocial interventions are needed indiabetes services, and that occupational therapists arewell placed to deliver them, was further developed in asystematic review by Pyatak [19]. The theoretical trend
over time towards a less medically prescribed role was
identified within the review and the author suggested‘Lifestyle Redesign’, an approach developed to address
the psychosocial needs of elderly people, as one which
could be adapted for use by occupational therapists ina diabetes service. She gave a detailed description of
how this was achieved [20], focusing on her attempts tocombine the consistency of a manualised intervention
with the tailored individualisation of therapy demandedby the differing psychosocial needs of this client group.
The need for psychosocial interventions and thepotential for occupational therapy to provide them werealso explored by Haltiwanger [13] and Haltiwanger &Brutus [21]. These studies tested peer support overseen by an occupational therapist, in which MexicanAmerican participants were free to discuss any issuesof importance to them. Once again, psychosocial issues
were prominent in the concerns raised, including specific discussions of the difficulties diabetic MexicanAmericans had with cultural taboos against refusing
food. The results of these preliminary studies suggested that the peer-support group, with its psychosocial
focus, was more effective than a health educator-led

Asian J Occup Ther 12: 1−7, 2016group. Overall it appears that psychosocial issues are
an important area to address when providing diabetes
management interventions, but that this area is often neglected within existing diabetes services. Occupational
therapy’s biopsychosocial frame of reference may havethe potential to address this deficit.
The Norwich Diabetes Occupational Satisfaction
Questionnaire (NDOSQ, Appendix 1) was developed
from a model first published in the Asian Journal of
Occupational Therapy [22] to assess psychosocial
factors impairing diabetes self-care and the impact of
diabetes on patients’ lives from the patients’ perspectives. It encourages patients to identify and prioritise
their own problems in the following categories: 1.
Spiritual, 2. Self-actualisation through psycho-spiritual
integration, 3. Expression and communication, 4. Compassion, 5. Personal power and social standing, 6. Hedonism, 7. Basic survival needs. The NDOSQ was used
for this research to explore the two-way relationshipbetween type-1 diabetes and occupation.

Research Methodology
Participants
53 patients aged 18 years or over with diabetes
mellitus type-1 and adequate mental capacity to consent were invited to take part in this research by theirdiabetes consultant physician during routine outpatient
clinic appointments at the Norfolk & Norwich University Hospital in England. Exclusion criteria were:previous inpatient psychiatric admissions, suspected orconfirmed personality disorders and those taking part inother medical research at the time of recruitment. Eachpatient was given the NDOSQ and the ‘Do you want to
get the most from life?’ leaflet produced by the Collegeof Occupational Therapists [23] while the consultant
explained that the research was to explore the potential
for occupational therapy to improve quality of life forpatients with type-1 diabetes. Patients were contacted by
telephone at least 24 hours later, and asked whether theywould like to take part in the research. Eight patients (5males and 3 females aged 39−71) consented and wereinvited to outpatient occupational therapy appointments.
One of these did not attend his occupational therapy
appointment. Patients are identified by sex (M/F) andage in years only (M40, M55, M56, M63, F39, F59,
F71) to preserve anonymity.
• F39 previously managed a career in healthcare despite
problems with alcoholism. She later developed diabetes and was unable to continue work due to frequent
emergency hospital admissions for DKA, compounded by agoraphobia. She lived alone but received some
support from a substance-abuse mental health team.

Mailoo VJ et al.

3• F59 was a healthcare professional, married with children. She had successfully managed her diabetes, andso had no significant secondary organ damage. She
had caring responsibilities for family members withphysical and mental health problems.
• F71 had retired, but had also successfully managed
her diabetes, so her career had not been affected andshe had no significant secondary organ damage.
• M40 was married. He was unable to work due toseveral health problems and was being treated with
anti-depressant medication.
• M55 was previously a lorry driver but was unable
to work due to complications of diabetes. He had abelow-knee amputation and presented at the occupational therapy interview with a new ulcer on his
amputation stump.
• M56 was in the process of divorce, socially isolated
and unable to work due to multiple health problems
including generalised musculoskeletal pain. He had
visual impairment likely to be secondary to poor
glycemic control and cognitive impairments that
may have been due to pseudo-dementia secondary
to anxiety and depression, or micro-vascular disease
secondary to poor glycaemic control.
• M63 had attended grammar school as a child but was
distracted from his education by the diagnosis of diabetes. He was married and cared for his children who
had multiple disabilities. Due to successful diabetes
management he had no significant secondary organ
damage.
Materials
Structured interviews based on the NDOSQ wereconducted in the General Medical Outpatients Department of the Norfolk & Norwich University Hospital.
Procedure and Data analysis
Patients were asked to think about and complete the
NDOSQ before attending their occupational therapy appointment. They were then assessed by an occupational
therapist in a 45-minute outpatient clinic appointment
during which any issues the patients raised on the
NDOSQ were discussed. Three different occupational
therapists took part in this study but each patient wasseen by only one occupational therapist. The occupational therapists offered practical advice and signposting or
referrals for appropriate follow-up. Patients’ responses
to the NDOSQ and issues raised during the occupational
therapy appointments were analysed for themes. Thispilot study was approved by the South Central - Berkshire Research Ethics Committee in accordance with the
ethical standards of the Helsinki Declaration.

4Interplay between type-1 diabetes and occupation

Results and discussion
Spiritual domain
The NDOSQ is based on the assumption thatspirituality is the core of being, on which everythingelse is constructed. Spiritual awareness is therefore
assessed with the question “What is the most important
thing to you in your life?” For most people, success inthis domain is thought to depend on opportunities for
altruistic actions that contribute to a sense of self-worth[22]. For people with antisocial personality disorderaltruism may not be required for spiritual fulfilment, butpeople with personality disorder were excluded fromthis research. Capacity for altruistic action may dependon either self-sacrifice or success in the other domains.
Of the 7 patients who took part in this pilot study only
two identified altruism as the most important thing intheir lives:• F59’s career was based on altruism. The most important things to her were “being able to care for” herrelatives with a stroke and mental health problems,
while also staying in work. Diabetes had minimal orno impact on her occupational freedom. She statedhowever that the demands placed on her by her caring
and work responsibilities made her vulnerable to hypoglycaemia.
• M63 stated his “wife and two children” were mostimportant in his life. His children had “multiple
disabilities” and his “diabetic control requirements”
impaired his ability to care for them. “Sometimes myrequirements take second place”.
Of the other 5 patients, one (F71) identified mindfulness as the most important thing in her life. Thissuggests a high capacity for psycho-spiritual integration.
The other patients indicated that basic survival needs
were most important. This reflects limited opportunities
or capacity for spiritual fulfilment. Occupational therapy
intervention for basic health and social needs may benecessary before altruism can be addressed.
Psycho-spiritual integration
This domain depends on self-actualisation despitesocial pressures that may discourage individuals fromliving spiritually authentic lives. The NDOSQ assesses
this by asking “How is diabetes affecting your ambitions
or goals?” This question is based on the assumption thatpeople may not pursue their inner-callings due to fears
or low expectations. F59, F71, M55 and M63 expressed
no problems with this domain though M63 wondered
whether his life ambitions would have been different if
he did not have diabetes. F71 stated “Living the day”
was the most important thing in her life, reflecting an
attitude of mindfulness conducive to psycho-spiritual in-

tegration. This mindfulness had not however been mastered and F71 expressed uncertainties about the future,indicating that she was worried that she would not beable to manage her diabetes if she acquired cognitive
impairments in the future. The other three patients’ capacities for self-actualisation were limited by more basic
unfulfilled health or social needs.
• M40: “For over 40 years none with other healthissues, not being able to achieve”• M56: “Internet cut off. OU degree cancelled. No ambitions.”• F39: “was high functioning initially despite alcoholism. Diabetes threw this balancing act”
Occupational therapy interventions for basic healthand social needs, facilitated goal-planning or vocational
rehabilitation could be useful for psycho-spiritual integration.
Expression and communication
Self-expression is assessed in the NDOSQ by thequestion “In life generally, do you feel able to express
yourself and have your questions answered?” F39
described herself as “quite British and quite reserved”
even when she became angry. This behavioural trait
has been associated with poorer prognosis for patientswith autoimmune diseases [24]. F39 complained thatoccasionally as an inpatient she thought the insulin
doses she was being given were too high, but healthcare
staff did not listen to her and she subsequently became
hypoglycaemic. “I do not need a nurse telling me what
to do.” This disempowering alienation may have been
secondary to judgements made by clinical staff based on
the frequency of F39’s DKA recurrences. F39 explainedthat DKA only occurred when her mental capacity was
impaired by intoxication secondary to alcoholism, andshe felt capable of self-care following detoxification
in hospital. M56 believed that “people do not have thetime” to listen to him. Use of the NDOSQ followed up
by group occupational therapy may be a good start ataddressing the alienation experienced by these patients.
Compassion
The NDOSQ assesses this domain with the question“How is diabetes affecting your relationships?” Twopatients (F39 and M63) said that aggressive behaviour
secondary to hypoglycaemia impaired their relationships
with other people such as family or healthcare staff.
F59 stated her “husband gets annoyed by” her hypoglycaemic episodes if they are frequent, and expressed
getting “stressed with juggling everything trying to keep
everyone happy.” One patient’s intimate relationship had
previously been affected by erectile dysfunction, but thishad been remedied with a vacuum pump. M40 attendedAsian J Occup Ther 12: 1−7, 2016

with his wife. They both described how recent deteriorations of his physical health had emotionally strained
them both despite a strong, loving relationship. M40
reported tearfulness and “being snappy at times” despite
being treated with anti-depressant medication. M56
was “half-way through a divorce.” This may have been
precipitated by his diabetes and multiple co-morbidities
straining his relationship, but the stress of divorce wasalso impairing his diabetes self-care due to maladaptive
coping strategies. Occupational therapy interventions toincrease social support could reduce the strain on thesepatients’ personal relationships.
Personal PowerThe NDOSQ uses career success as a crude measureof personal power and social standing. This is not anacute measure, as materially successful people can suffer
acute losses of personal power during acute illness. F39
for example, felt that control was taken away from her
during hospital admissions and “a patient should beallowed to manage” their own diabetes “if they have capacity.” Similarly M55 was trying to manage a painlesspressure sore on his amputation stump himself without
seeking medical attention. When the occupational therapist spotted this she referred him to the consultant physician for immediate review, who then referred him to a
podiatrist for tissue viability care to prevent further limb
loss. M55 expressed dissatisfaction with his autonomy
being disrespected and described this intervention as“cheeky”. These examples of patients prioritising senseof personal power over diligent management of basic
survival needs may be considered by healthcare professionals to be maladaptive behaviour. F39, M40 and M56
felt unable to work due to co-morbidities. F39 was worried she would be discriminated against due to diabetes
and M40 stated “I feel that I have to prove I can do morethan others to be the same.” M56 said he had “no careerprospects” and was “unable to work.” These patients
generally fared worst in all domains of the NDOSQ.
Other patients had varying degrees of success. M55 feltthat his mobility affected his glycaemic control. “I lostmy class 1 heavy goods vehicle licence but do my best
to stay in work.” M63 described himself as a successful
grammar school student who lost his sense of ambition
when he was diagnosed with diabetes. He wondered
how his life may have differed if he had not developed
diabetes in his youth. F59 said that hypoglycaemia occasionally affected her at work, but this had not affected
her career. F71 believed that due to adjusting well to her
diagnosis, her career had not been significantly affected.
Occupational therapy for vocational rehabilitation or patient advocacy by occupational therapists could be used
to reduce patient disempowerment.

Mailoo VJ et al.

5

Hedonism
Patients whose basic survival needs had been fulfilled were generally able to seek pleasure. Conversely
F39 reported inability to have fun due to agoraphobia
and alcoholism. M63 wanted to go abroad on holiday
but was afraid to do so because of his diabetes, andtherefore had not travelled. If younger patients had
been recruited into the sample greater adverse effects ofpleasure-seeking on diabetes self-care may have been
revealed by the data. Speaking of his youth M63 said:“Yeah it does stop you having fun … all your matesused to go out drinking, so you would as well, feelrough for a few days after but”
M56 reported frequently binge-drinking alcoholand consuming sugary foods as maladaptive coping
strategies to deal with the stress of divorce and financial
insecurity. These behaviours are likely to lead to secondary organ damage. M56 also stated “I don’t have fun.”F59 reported that what she most wanted was leisure timewith her husband, but that caring for her relatives andher own diabetes management made this “impossible”.
The occupational therapist signposted her to carers’
support and sources of funding for hired carers. Patients
may benefit from occupational therapy to introduce
less-harmful pleasurable behaviours and peer-supported
group recreational activities.
Basic survival needs
Poorly controlled diabetes is a direct threat tosurvival. F71 had attended a Dose Adjustment For
Normal Eating diabetes self-management course andwas happy with her diabetes self-management at present
despite feelings of insecurity regarding the future. She
expressed clear indicators of success in every domain of
the NDOSQ except spirituality. This specific deficit may
reflect a weakness of the NDOSQ rather than an absenceof spiritual awareness in the patient’s life. In contrast,
the patients who expressed deficits in multiple other domains expressed underlying problems in this one. M63
felt he and his wife needed a “well overdue break” fromtaking care for their disabled children. Rest is a basic
survival need; not a pleasure-seeking need. M40 worried
about financial insecurity because both he and his wife
were not working due to long-term illness. He said his
resulting stress levels negatively impacted on his diabetes self-management. M56 stated he had “no money”,”stress”, a “bad diet” and fears about an undiagnosed
cognitive impairment and said “I only feel safe when mymates pop in.” His function was also limited by chronic
musculoskeletal pain, visual and cognitive impairment.
All of these factors adversely impacted on his ability toattend to diabetes self-management. This patient would

6Interplay between type-1 diabetes and occupation

benefit from further occupational therapy for in-depth
cognitive testing and medical screening for dementia.
He was therefore referred to community occupational
therapy and his general medical practitioner.
M55 already had a below-knee amputation secondary to poor glycaemic control. His reluctance to reporta new stump ulcer to medical staff put him at risk offurther limb loss. Of all 7 patients, F39 had the mostadmissions for DKA and was at greatest risk of sudden
loss of life due to poor diabetes self-management. F39
had not been seen by an occupational therapist before
and was dissatisfied by her perceived lack of psychological support for alcoholism provided by the local
substance misuse service. She was initially obsessive
about glycaemic control and set an alarm to check her
blood glucose level every 2 hours. This resulted in sleep
disturbance. She described becoming “nonchalant” laterin her disease course though she experiences continual
anxiety regarding possible secondary organ damage
such as blindness or amputation of her feet. Threats toF39’s basic survival had overwhelmed her to the extent
that she is no longer able to pursue success in any of theother domains. F39 could benefit from intensive community occupational therapy to connect her with coping
resources to fill every domain of the NDOSQ in addition
to ongoing support from substance misuse services andpsychiatric support for agoraphobia. Diabetes can also
complicate the treatments of other medical problems.
M63 for example said: “I had a hydrocortisone injection
in my shoulder and it really did scupper me for a few
days.”
This pilot study was limited by a small sample sizeof self-selected patients. It is possible that only the concordant patients with psychosocial problems would consent to an extra hospital appointment to try occupational
therapy. It is important to gather data from patients who
are non-concordant with diabetes care and do not attend
their clinic appointments. No younger patients consented to take part in this research. It is possible that thehedonistic behaviours of teenage patients may increase
their risk of DKA or secondary organ damage. It would
therefore be useful to repeat this research with inpatients
admitted to hospital with DKA. The NDOSQ is a crude,
un-validated tool and cannot be used as a substitute forin-depth holistic occupational therapy interviews.

Summary and Conclusions
This small pilot study of 7 patients confirmed that
type-1 diabetes can impact on patients’ self-awareness,interpersonal relationships, employment and careerprospects, sense of autonomy and social standing, enjoyment, sexual function, mental health, physical health andsense of security. The patients’ responses also confirmedthat co-morbidities, financial factors, pleasure-seeking
and interpersonal relationships all impact on patients’capacities for diabetes self-care. Many of these problems
were occupationally mediated. Unless patients are provided with holistic treatment plans to help them manage
their life problems, diabetes management is unlikely to
be optimal. This pilot study has therefore revealed a rolefor occupational therapy in diabetes out-patient clinics.
Acknowledgements: The authors would like to thankDr Gemma Bowers (Clinical Psychologist) for methodological advice and the seven patients who kindly
volunteered for this research.

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Life area
What is the most important thing to you in your life?
a) How is diabetes affecting this issue?
b) How does this issue affect your diabetes?
How is diabetes affecting your ambitions or goals?
How are your ambitions and goals affecting yourdiabetes?
In life generally, do you feel able to express yourself
and have your questions answered?
How is diabetes affecting your relationships?
How are your relationships affecting your diabetes?
How is diabetes affecting your career prospects?
How does your career impact on your diabetes?
How is diabetes affecting your opportunities to havefun?
How are fun activities impacting on your diabetes?
Do you feel safe?
How does this affect your diabetes?
How does your diabetes affect this?

7

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2006; 13: 503−10.

Appendix 1
Norwich Diabetes Occupational Satisfaction Questionnaire (Version 1)
How is diabetes affecting your life, and what can
we do about it? Occupational therapy is to help people
live happy, healthy lives. Please think about thesequestions while waiting for your appointment and write
down any issues you would like to discuss. It may not
be possible to discuss everything in one appointment, so
the issues most important to you will be discussed first.
Continue writing on the back of this page if necessary.

Problems

Please allocate these problems an order of priority toshow how important they are to you. The most important
problem should be numbered ‘1’ with less important
problems given higher numbers ‘2, 3, 4’ etc.

■ORIGINAL ARTICLE

Do presentation modality and cognitive load affectstanding stability?
Yoko Kimura1, Shinji Satake2, Hiromi Fujii2, Takaki Kafuku3, Miyuki Fujikura3
1

Department of Occupational Therapy, Tohoku Medical College, Hachinohe, Japan
Department of Occupational Therapy, Yamagata Prefectural University of Health Sciences, and the Area of Occupational
Therapy, Graduate School of Health Sciences, Yamagata Prefectural University of Health Sciences, Yamagata, Japan3
Department of Occupational Therapy, Tohoku Medical College, Hachinohe, Japan
2

Abstract: There are some brain disease sufferers, who face difficulties in performing various tasks while maintaining
standing posture. We examined how the difference in presentation modality and cognitive load affect information processing and the maintenance of standing posture. We assigned tasks based on the Paced Serial Addition Test (PSAT)
to 11 healthy adults. More precisely, we presented digits auditorily or visually and analysed parameters, namely, theprecision and the speed of processing as well as the center of pressure (COP). It was found that both the precision andthe speed of processing were higher in visual presentation than in auditory presentation, and as cognitive load increased
these parameters began to show poorer results. COP became unstable when cognitive load exceeded a certain degree.
Keywords: modality, cognitive load, information processing, standing posture(Asian J Occup Ther 12: 9−15, 2016)

1. Introduction
In our daily lives we perform various tasks while
standing. For example, we talk, watch or think while
simultaneously maintaining standing posture. Unlike
healthy people, however, there are patients who facecertain difficulties in such task performance due tocerebrovascular disease, schizophrenia or other brain
diseases. As long as they concentrate only on maintaining standing posture, the posture remains stable. Whenothers talk or show something to them, however, theposture may become unstable and conversation or thinking process could be interrupted. In human actions, aseries of information processing from receiving external
information through various sensory organs, cognizing
it to choosing adaptive movements is carried out forvarious tasks at a time.
It has been reported that many factors such as age[1, 2], visual information [3], auditory information [4],mental arithmetic [5] and recognition tasks [2, 4, 6]affected standing posture. But the influence of the difReceived: 16 May 2014, Accepted: 18 February 2015
Corresponding to: Yoko Kimura, Tohoku Medical College, 3-6,
Nashiro­zawa, Gonohe, Sannohe, Aomori, 039-1522, Japane-mail: ichikawa-kim@rinken.ac.jp©2016 Japanese Association of Occupational Therapists

ference in presentation modality or in cognitive load has
never been documented.
It is generally believed that humans collect 80%
of external information visually and 10% auditorily. In
addition, there are reports that auditory sense is superior
to vision with regard to sensory memory duration andsimple reaction time [7−9]. In other words, the difference in presentation modality may have a certain kindof influence on subsequent information processing andtask performance. Moreover, it is said that information
processing depends heavily on the capacity of working
memory [10−12]. It is likely that when we have brain
disease, the sensory input mode shifts and working
memory load increases, hence changes in information
processing and standing posture.
Elucidation of such influence may enable us todevelop an assessment battery for examining one’s
ability to perform tasks and maintain standing posture
at a time. In addition, it may suggest appropriate waysof presenting information which allow one to think andperform tasks while safely maintaining standing posture.
Therefore, the purpose of this study is to clarify the influence of the difference in presentation modality and incognitive load on information processing and standing
posture with the use of parameters: processing precision,
processing speed and the center of pressure (COP).

10

Do presentation modality and cognitive load affect standing stability?

2. Material and methods
2.1. ParticipantsParticipants were 11 healthy adults (gender: male 6,
female 5, age: 23 ± 4 years, height: 168.09 ± 11.46 cm,
weight: 59.82 ± 10.82 kg) with no hearing impairments
and visual acuity of 1.0 (measured by the Landolt C).
All of them were right-handed and had never received
the Japanese abacus training. They were able to standstill while adjusting the initial COP to the base pointof the force plates. People with disorders or problems
which could affect standing posture or mental arithmetic
were not included. This study was approved by the
ethics committees of Yamagata Prefectural University
of Health Sciences and Tohoku Medical College andall participants agreed to join, having been given due
explanation about the purpose of this study prior to theexperiment.
2.2. Tasks and Procedures
Tasks were derived from the Paced Serial Addition
Test, or PSAT [13], which required that participants
should be presented with 61 single digits in random
order and quickly add each new digit to the one immediately prior to it. PSAT is a measure of attention deficit
and has two types, both of which were applied for thisstudy. One is the Paced Auditory Serial Addition Test,
or PASAT [14], where digits are presented auditorily
and the other is the Paced Visual Serial Addition Test, or
PVSAT [15], where digits are presented visually.
Four types of cognitive load were provided in
the form of N-back tasks [16] for PASAT and PVSAT
respectively. The tasks were adding each new digit to
the digit immediately before it (1-back), to the digit
two previous to it (2-back), to the digit three previous

Fig. 1. PASAT/PVSAT Administrative Conditions.

to it (3-back) or just repeating each new digit (0-back).
Participants were asked to answer (the range of correct
values: 3−17) or repeat (the range of correct values:1−9) as quickly as possible while maintaining static
standing posture.
Although 61 single digits were presented randomly,
the same digit was never presented consecutively. Theinterval between two digits was 3.0 seconds both in
PASAT and in PVSAT just as it was in PSAT. The duration of digit presentation was about 0.5 seconds, i.e.,
the time length for an auditorily presented digit to soundnatural enough, and in PASAT the average time fromthe beginning of the first syllable of a digit until the beginning of the last was 0.288 seconds. Arabic numerals
were used in PVSAT. Tasks were provided in a randommanner in order to avoid the effect of memory, and theduration of each task was planned not to exceed threeminutes to prevent fatigue. There was a break between
tasks, and the experiment was resumed only after confirming that participants were feeling no fatigue. Fig. 1
illustrates these tasks and procedures.
2.3. Participants’ Posture and Device Setting
2.3.1. Participants’ posture
As in Romberg’ test, participants were requested tostand barefoot on force plates placed in a dim room [5],letting arms hang down naturally (Fig. 2).
2.3.2. Device setting
In PASAT digits were presented at the right volume
through earphones connected to a PC. In PVSAT digits
were presented on a screen set in front of the participant
through a projector connected to a PC. The position ofdigits was adjusted to the eye level of each participant.
Digits were presented in 1.7 degrees of visual angle soAsian J Occup Ther 12: 9−15, 2016

Kimura Y et al.

11

Fig. 2. Participants’ Posture and Device Setting.

that they were large enough for any participant to fully
identify. Participants were requested to keep opening
their eyes during tasks. In PASAT, they were also requested to watch on the same height point on the wallas digits presented in PVSAT. Throughout the task performance COP was recorded at the sampling frequencyof 50Hz using two force plates (Kineto GravicorderG-7100 manufactured by Anima Corp., Tokyo, Japan).
In order to distinguish correct answers and incorrectones, presented digits (sounds or images) and participants’ oral answers were recorded with two digital video
cameras (NV-GS300 manufactured by Panasonic Corp.,
Osaka, Japan: 30 frames per second) placed in the participant’s overhead and side positions respectively. In
addition, in order to measure reaction time, oral answers
were recorded at the sampling frequency of 2,000Hzwith a microphone (ECM-TL1 manufactured by Sony
Corp., Tokyo, Japan) connected to a PC. At the sametime, the whole data, namely, COP, presented sounds/
images and participants’ oral answers, were recordedwith a real-time synchronous recording system for
digital motion pictures and waveforms (Teraview manufactured by Gigatex Co. Ltd., Osaki, Japan).
2.4. Analysis
2.4.1 Analyzed items<Processing Precision>
Processing precision was quantified in the formof the percentage of correct answers for all tasks (60answers) both in PASAT and in PVSAT.
<Processing Speed>
Processing speed was quantified in the form ofreaction time both in PASAT and in PVSAT. For every
answer in each task (60 questions), the time from the
beginning of the digit presentation until the beginning of
the answer was measured.
<Instability of Standing Posture>
For each task the distance COP travelled during thetime from the beginning of the first digit presentation
until the end of the last (60th) answer was measured. Instability of standing position was quantified in the formof that distance divided by the time consumed (mm/s).
2.4.2. Comparison of items
In order to identify the influence of the differencein presentation modality on information processing
and the maintenance of standing posture, we compared
the percentage of correct answers, reaction time andtravel distance of COP between the tasks of PASAT and
PVSAT sharing the same N.
Also, in order to identify the influence of the difference in cognitive load on information processing and themaintenance of standing posture, we compared the same
items as above between the tasks with different Ns bothin PASAT and in PVSAT.
For the purpose of statistical data treatment the
Wilcoxon signed-rank test was used and the level ofsignificance was set at less than 5%.

12

Do presentation modality and cognitive load affect standing stability?

3. Results
The percentage of correct answers, reaction time
and travel distance of COP are shown in Table 1.
3.1. Influence of Difference in Presentation Modality on
Information Processing and Maintenance of Standing Posture (Table 2)<Processing Precision>
In 0-back tasks no significant difference was foundin the percentage of correct answers between PASATand PVSAT.
In 1-back, 2-back and 3-back tasks the percentage
of correct answers of PVSAT was significantly higher
than that of PASAT ( p < .01, p < .05 and p < .05, respectively).
<Processing Speed>
In 0-back, 1-back, 2-back and 3-back tasks, reaction
time of PVSAT was significantly shorter than that of
PASAT ( p < .01, p < .05, p < .01 and p < .01, respectively).
<Instability of Standing Posture>
No significant difference was found in travel distance of COP between PASAT and PVSAT.
3.2. Influence of Difference in Cognitive Load on Information Processing and Maintenance of Standing
Posture (Table 3)<Processing Precision>
The percentage of correct answers decreased ascognitive load increased, and a significant difference
was found whenever two tasks with different Ns werecompared both in PASAT and in PVSAT ( p < .01 andp < .01, respectively).
Table 1. Percentage of Correct Answers, Reaction Time and Travel
Distance of COP.
PASAT

PVSAT

Percentage ofCorrect
Answers (%)

0-back
1-back
2-back
3-back100
88 (65−100)
48 (42−93)
37 (18−55)

100
93 (85−100)
72 (42−85)
47 (25−70)

Reaction Time(s)0-back
1-back
2-back
3-back

1.07 (0.936−1.26)
1.27 (1.17−1.47)
1.46 (1.13−2.04)
1.90 (1.35−2.29)

0.593 (0.535−1.34)
1.05 (0.801−1.50)
1.16 (0.819−1.80)
1.41 (1.01−1.88)

Travel Distanceof COP (mm/s)

0-back
1-back
2-back
3-back11.9 (7.1−16.1)
11.5 (6.6−17.4)
12.7 (7.6−23.4)
14.2 (6.7−23.4)

11.3 (7.5−15.6)
9.8 (6.5−19.4)
12.4 (5.8−19.6)
12.4 (7.0−21.7)

Note. N = 11.
Median (Minimum – Maximum)<Processing Speed>
In PASAT reaction time became longer as cognitive
load increased, and a significant difference was foundwhenever two tasks with different Ns were compared( p < .05 or p < .01).
In PVSAT reaction time became longer as cognitive
load increased, and a significant difference was foundbetween 0-back and 1-back tasks ( p < .01), between
0-back and 2-back tasks ( p < .01), between 0-back and3-back tasks ( p < .01), between 1-back and 3-backtasks ( p < .01) and between 2-back and 3-back tasks ( p< .05). However, no significant difference was foundbetween 1-back and 2-back tasks.
<Instability of Standing Posture>
In PASAT travel distance of COP became longer
as cognitive load increased, and a significant difference
was found between 0-back and 3-back tasks ( p < .05)
and between 1-back and 3-back tasks ( p < .05). No significant difference was found in other combinations oftasks.
In PVSAT travel distance of COP became longer
as cognitive load increased, and a significant difference
was found between 1-back and 2-back tasks ( p < .05)
and between 1-back and 3-back tasks ( p < .01). No significant difference was found in other combinations oftasks.

4. Discussion
Data Summary is shown in Table 4.

Table 2. Influence of Difference in Presentation Modality on Information Processing and Maintenance of Static Standing Posture.
PASAT

PVSAT

Percentage ofCorrect
Answers

0-back
1-back
2-back
3-back

−
<
<
<

n.s.
**
*
*

Reaction Time0-back
1-back
2-back
3-back

>
>
>
>

**
*
**
**

Travel Distanceof COP

0-back
1-back
2-back
3-back

−
−
−
−

n.s.
n.s.
n.s.
n.s.

Note. N = 11.
*p < .05. **p <.01.

Kimura Y et al.

Asian J Occup Ther 12: 9−15, 201613

Table 3. Influence of Difference in Cognitive Load on Information Processing and Maintenance of Static Standing Posture.
PASAT

PVSAT

Percentage of Correct
Answers

0-back0-back0-back
1-back
1-back
2-back

>
>
>
>
>
>

1-back
2-back
3-back
2-back
3-back
3-back

**
**
**
**
**
**

0-back0-back0-back
1-back
1-back
2-back

>
>
>
>
>
>

1-back
2-back
3-back
2-back
3-back
3-back

**
**
**
**
**
**

Reaction Time0-back0-back0-back
1-back
1-back
2-back

<
<
<
<
<
<

1-back
2-back
3-back
2-back
3-back
3-back

**
**
**
*
**
*

0-back0-back0-back
1-back
1-back
2-back

<<<<<1-back
2-back
3-back
2-back
3-back
3-back

**
**
**
n.s.
**
*

Travel Distance of COP

0-back0-back0-back
1-back
1-back
2-back

<<-1-back
2-back
3-back
2-back
3-back
3-back

n.s.
n.s.
*
n.s.
*
n.s.

0-back0-back0-back
1-back
1-back
2-back

<<-1-back
2-back
3-back
2-back
3-back
3-back

n.s.
n.s.
n.s.
*
**
n.s.

Note. N = 11.
*p < .05. **p < .01.
Table 4. Data Summary.
Influence of Difference in
Presentation Modality on Information Processing and Maintenance of Static Standing Posture

Influence of Difference in
Cognitive Load on Information
Processing and Maintenance of
Static Standing Posture

PASAT

PVSAT

Small Load

Large Load

Percentage ofCorrect Answers

Lower

HigherHigherLower

Reaction TimeLongerShorter

Shorter

LongerShortest in
1-back Task

Longest in
3-back Task

Travel Distanceof COP

No Difference

4.1. Influence of Difference in Presentation Modality on
Information Processing and Maintenance of Standing Posture
Processing precision, namely, the percentage ofcorrect answers, was higher in PVSAT than in PASAT
when N, the indicator of cognitive load, was more than
0. As for processing speed, reaction time was longer in
PASAT than in PVSAT regardless of the value of N.
Past literatures on mental arithmetic reported thatcognitive load was smaller in visual presentation than inauditory presentation [17], and that the same part of thecerebrum was active whether the presentation was auditory or visual [18]. Thus it is suggested that mental arithmetic depends conclusively on visual images. In otherwords, addition of visually-presented numbers may be
actually performed in two steps, namely, recognition of

Arabic numerals and following practical calculation,
whereas addition of auditory stimuli may need threesteps, namely, phonological identification, recollectionof Arabic numerals and practical calculation.
Considering the above, it is presumed that the results of PASAT in processing precision and speed wereinferior to those of PVSAT because its intricate procedure preceding practical calculation became an extra
burden and interfered with the maintenance of auditory
information. That burden, however, may not be heavy
enough to disturb the maintenance of standing posture,
as no difference was found between PASAT and PVSAT
in travel distance of COP.

14

Do presentation modality and cognitive load affect standing stability?

4.2. Influence of Difference in Cognitive Load on Information Processing and Maintenance of Standing
PostureBoth in PASAT and in PVSAT the percentage ofcorrect answers, i.e. the indicator of processing precision, decreased and reaction time, i.e. the indicatorof processing speed, became longer as cognitive loadincreased. This result suggests that the increase ofcognitive load imposed on working memory affects a
serial process from perception, cognition, encoding,maintenance, recollection to mental arithmetic, only tocomplicate information processing.
Both in PASAT and in PVSAT again, travel distanceof COP, the indicator of instability of standing posture,
became long when N, the indicator of cognitive load,
reached 3. This result may be related to the distributionof attention which happens in the dual-task situation
where one is asked to perform information processing
and to maintain standing posture simultaneously. It is
likely that in daily activities one divides his/her attention
which is supposed to be a limited processing potential.
Therefore, the more attention one task attracts, the lessattention the other is allocated, which induces the latter’spoor performance.
Considering the above, it may safely be said
that this study suggests that the increase of cognitive
load imposed on working memory boosts attention to
PASAT/PVSAT while reducing attention to the maintenance of standing posture. Standing posture seems tobecome unstable especially in 3-back tasks. 0-back tasks
include the load of just one digit, which can be regarded as one chunk of memory [19, 20]. Then, working
memory load in 3-back tasks, where one is requested toremember at least 4 digits while performing addition,
may be equivalent to more than 4 chunks of memory.
Therefore, it is suggested that even a healthy person’s
standing posture may become unstable when he/she isgiven more than 3 units of information, regardless ofpresentation modality, and, on top of it, the necessity of
relevant mental operations.

5. Conclusion
This study suggested that visual presentation of
information was more effective than auditory presentation in maintaining the precision and the speed of task
performance while standing. It also indicated that no
more than 3 chunks of information should be presented,
whether auditorily or visually, in order to prevent postural instability.
Because of the limitaiton that the participants were
only healthy adults in this study, a certain consideration
should be given when adapting these findings to patientswith brain diseases. The number and the time of tasks
might burden patients if this method is simply appliedin a clinic. Therefore, further research will be needed
to simplify the method to make it applicable to patientswith brain diseases.

6. AppendicesFigure1: PASAT/PVSAT Administrative Conditions
Figure2: Device Setting
Table1: Percentage of Correct Answers, Reaction Timeand Travel Distance of COP
Table2: Influence of Difference in Presentation Modality
on Information Processing and Maintenance of
Static Standing Posture
Table3: Influence of Difference in Cognitive Load on Information Processing and Maintenance of Static
Standing Posture
Table4: Data Summary
Acknowledgements: We thank Dr. Takashi Kujirai andprofessors of Yamagata Prefectural University of Health
Sciences for valuable suggestions. We also appreciatefaculty and students of Tohoku Medical College for help
with data collection.

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■ORIGINAL ARTICLE

Differences between older and younger drivers
in a Japanese road sign recognition task
Tsutomu Sasaki1, 2, Kyohei Yamada1, Takao Kojima3, Kunihiro Kanaya4,
Kazuki Umeda5, Yusuke Nakajima6
1

Hokkaido Chitose Institute of Rehabilitation Technology, Chitose, Japan
Division of Occupational therapy, School of Health Sciences, Faculty of Medicine, Shinshu University, Matsumoto, Japan3
Department of Rehabilitation, Shuyukai Hospital, Sapporo, Japan
4
Department of Rehabilitation Medicine, Sasson-Sugata Clinic, Otaru, Japan
5
Department of Rehabilitation, Aizawa Hospital, Matsumoto, Japan
6
Department of Rehabilitation, Shinano-Iryo Fukushi Center, Shimosuwa, Japan
2

Abstract: Recent years, cases in which an occupational therapist is involved in the evaluation of patients’ driving
ability are rapidly increasing in Japan. One of the neuropsychological tests which are predictive of driving ability is aroad sign recognition task (RSR). However, no RSR available in Japan has yet been reported. Hence, in this study, wedeveloped a Japanese version of road sign recognition task (J-RSR). A total of 44 younger drivers and 43 older drivers
living in the community took part in the study. We compared the number of correct answers and the total time taken
to complete the task between the two groups. Results showed that there was no statistically significant differences forthe number of correct answer ( p = 0.43), while older drivers took significantly much longer than younger drivers tocomplete the task ( p < 0.000001). Qualitative analysis on incorrect answer for each question revealed that older drivers
chose the same incorrect road sign answer while younger drivers chose incorrect answer evenly among options. These
results suggest that J-RSR is predictive of knowledge of road sign, non-verbal reasoning ability, mental speed, andmight reflects subjects’ driving experience.
Keywords: driving, assessment, road sign recognition task

(Asian J Occup Ther 12: 17−22, 2016)

Introduction
It is estimated that about 65% of the Japanese population currently has an ordinary motor vehicle license(i.e., driver’s license) [1]. Indeed, for many, cars are
an indispensable means of transport in daily life. If
individuals are deprived of the use of their cars due todisability, their quality of life can significantly decrease[2]. Therefore, it is very important to evaluate disabled
subjects’ driving ability while they are hospitalized.
Cases in which an occupational therapist is involvedin the evaluation of patients’ driving ability are rapidly
increasing at medical institutions that deal with stroke
Received: 23 May 2014, Accepted: 26 February 2015
Corresponding to: Tsutomu Sasaki, Division of Occupational therapy,
School of Health Sciences, Faculty of Medicine, Shinshu University,
3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japane-mail: t-sasaki@chitose-reha.ac.jp©2016 Japanese Association of Occupational Therapists

and dementia patients in Japan.
One aspect of driving ability evaluations carried out
at medical institutions is the neuropsychological evaluation. This evaluation assesses whether an individual has
the necessary cognitive functions required to drive a car,and often includes a visual search task [3−5], reaction
time task [6−8], visuo-spatial recognition task [9−11],
useful field of view test [12, 13], and intelligence test
[14−16]. However, these tests have a shortcoming inthat they do not use actual driving scenes in their assessments. This, in turn, leads to clinical problems suchas lack of agreement between patients and occupational
therapists on whether the test results reflect patients’actual driving ability.
One test, called the Stroke Driving Screening
Assessment (SDSA), has been developed specificallyfor the evaluation of driving ability [17]. The SDSA is
widely used for predicting the results of on-road evaluations [18−21]. The SDSA comprises four tasks: dot
cancellation, compass, square matrix, and the road sign

18

Differences between older and younger drivers

recognition test (RSR). Dot cancellation is used as anindicator of visual attention function, while the squarematrix and compass are used as indicators of the ability
to identify orientation and the RSR as an indicator ofknowledge of road signs. The result of each sub-test correlates with the result of an on-road evaluation [20−23].
Among these sub-tests, we are most interested in
the RSR, which is more closely related to actual driving.
The test requires the patient to identify the road sign
appropriate for a given road situation. Passing this test
requires both knowledge of road signs and non-verbal
reasoning ability [24−25]. However, in all cases reported
to date, drawings of road signs and road situations havebeen used instead of photographs. In addition, becauseroad signs and traffic regulations differ by country, tests
developed in a foreign country cannot be used in Japan.
We have therefore developed the Japanese version of
the RSR (J-RSR) using photographs to present the roadsituations. In this study, we report the results of an analysis of the characteristics of older and younger driver’s
license holders.

Methods
Participants
A total of 44 younger driver’s license holders (17male drivers and 27 female drivers; age: 22.0 ± 2.9
years old) and 43 older driver’s license holders (22 male
drivers and 21 female drivers; age: 68.0 ± 6.0 years old)
living in the local community took part in the study. The
average score of the Mini-Mental State Examination(MMSE) of the older driver’s license holders was 28.7 ±1.4. Among younger driver’s license holders, 5 obtained
their licenses less than a year ago, 13 obtained them between one and two years ago, 12 obtained them between
two and three years ago, 11 obtained them between threeand four years ago, and 3 obtained them more than three
years ago. In terms of driving frequency, 2 were driving
daily, 4 were driving once every 2 or 3 days, 6 were
driving once a week, 15 were driving a few times a year,
and 17 hardly drove. Among the older driver’s license
holders, 32 had obtained their licenses more than forty
years ago, 2 each had obtained them between 10 and 20
years ago and between 20 and 30 years ago, and 7 had
obtained them between 30 and 40 years ago. All participants received an explanation of the study verballyand in writing and gave consent. The study was carriedout upon obtaining approval from the Medical Research
Ethics Committee of Shinshu University (approval
number: 2081)
Tasks and procedures
The participants took the J-RSR and the Trail

Making Test (TMT) using a touch-screen notebook computer (CF-C1B 12.1"; Panasonic Corporation, Japan;
hereafter “PC”).
The J-RSR is a task in which the participant chooses a road sign appropriate for the road situation. In thephotographs presenting the road situations, the roadsigns are obscured via photo editing. The participant isasked to evaluate the road situation and choose the mostappropriate road sign (Fig. 1). Each question is worth
one point and there are ten questions in total. The PC
records the number of correct answers, the road signs
chosen, whether these signs are correct or not, and thetotal time taken to answer the questions.
As for the TMT, a new version was developed
wherein the arranged stimulus from the paper version isplaced onto the PC screen at the same ratio. The majordifferences between the paper and PC versions of the
TMT are a) when the correct target is touched, the PC
produces a target sound indicating a correct answer, andwhen an incorrect target is touched, it produces a soundindicating an incorrect answer, and b) all targets remainon the screen even after the correct target is touched.
Preceding studies have found that part B of the TMT(TMT-B) requires more time to complete and produces
more incorrect answers than does part A (TMT-A) [26].
The PC records the time taken to complete the task andthe number of correct and incorrect answers. When thetime taken to complete the task exceeded five minutes, it
was treated as a missing value.
The program for the tasks was constructed by
Nishizawa Electric Meters Manufacturing Co., Ltd.

Fig. 1. An example of the Road sign recognition test.
The participant chooses a road sign appropriate forthe road situation. For this question, Option 1 is thecorrect road sign.

Sasaki T et al.

Asian J Occup Ther 12: 17−22, 2016

Analysis
The result of each task was compared between theolder and younger groups. In the case of the J-RSR, thecomparisons were made between the number of correct
answers, the time taken to complete the task, and thecorrect answer rate for each question. In the case of the
TMT, comparisons were carried out in terms of the time
taken to complete the task and the number of incorrect
answers. Unpaired t-tests were used for all statisticalanalyses, and the significance level was set at 5% for all
analyses.

Results

19

Table 1. Percentages (%) of correct answer between the two groups.
No statistically differences were found between the twogroups other than Question 1.
Older(N = 43)

Younger(N = 44)

Statistical value(p value)

46.5
90.7
69.8
90.7
95.3
74.4
90.7
93.0
83.7
86.0

68.2
97.7
61.4
81.8
97.7
77.3
81.8
97.7
93.2
88.6

Z = −2.05 ( p < 0.05)
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.

Q.1
Q.2
Q.3
Q.4
Q.5
Q.6
Q.7
Q.8
Q.9
Q.1O

n.s.; not significance

There were no statistically significant differences between the two groups in the number of correct
answers on the J-RSR (t (85) = −0.80, p = 0.43; older
group: 8.2 ± 1.7 [range: 4−10]; younger group: 8.5 ± 1.2[range: 5−10]; Fig. 2-a). On the other hand, the older
group took significantly longer to answer the questions(t (85) = 7.20, p < 0.000001; older group: 246.0 ± 113.8
seconds; younger group: 114.7 ± 40.8 seconds; Fig. 2-b).
As for the correct answer rate for each question, in thecase of Question 1, 46.5% of the older group answered
correctly, while 68.2% of the younger group answered
correctly; this difference in favor of the younger groupwas significant (Z = −2.05, p < 0.05). There were no
significant differences between the two groups for anyof the other questions (Table 1). There was an interesting finding for Question 1: while the correct answer
is option 1, many of those from the older group who
answered incorrectly chose option 3, whereas those who
answered incorrectly among the younger group had
evenly distributed answers among options 2−4 (Fig. 3).
In the case of the TMT-B, one participant from theolder group took more than five minutes to complete
the task; this participant’s answer was thus treated asa missing value. The older group took significantly
longer to complete the tasks for both the TMT-A andthe TMT-B (TMT-A: t (85) = 7.96, p < 0.000001; older
group: 73.8 ± 19.5 seconds; younger group: 48.0 ± 9.0
seconds; TMT-B: t (84) = 9.70, p < 0.000001; older
group: 133.3 ± 45.6 seconds; younger group: 62.2 ±16.4 seconds; Fig. 4-a). There was no significant difference between the two groups in terms of the number ofincorrect answers on the TMT-A (t (85) = 1.33, p = 0.19;
older group: 0.6 ± 2.6 times; younger group: 0.0 ± 0.3
times). However, on the TMT-B, the number of incorrect answers was significantly higher for the older group(t (84) = 4.53, p < 0.00001; older group: 2.6 ± 3.4 times;
younger group: 0.3 ± 0.5 times; Fig. 4-b).

Discussion
As far as we know, there have been reports on fourkinds of tests using road signs. Carr et al. [27] developed the traffic sign naming test and reported that thetest can differentiate between patients with dementia ofFig. 2. Results of the road sign recognition test.
For the number of correct answer, no statistically significant differences were found (a), while the older
group took significantly longer to answer the questions (b). n.s.; not significance, **; p < 0.000001

20

Differences between older and younger drivers

Fig. 3. Distribution of participants’ response in the Question 1 (The correct answer is option 1).
Many of those from the older group who answered incorrectly chose option 3, whereas those who
answered incorrectly among the younger group had evenly distributed answers among options 2−4.

Fig. 4. Results of the TMT-A and the TMT-B.
The older group took significantly longer to complete the tasks for both the TMT-A and the TMT-B (a). While
there was no differences between the groups for the number of misses on the TMT-A, older group showedsignificantly higher number fo incorrect answeres on the TMT-B. n.s.; not significance, **; p < 0.000001

Sasaki T et al.

Asian J Occup Ther 12: 17−22, 2016

the Alzheimer’s type (AD) and neurologically healthyelderly people (healthy). This task uses photographs ofactual road signs and requires participants to identify
their meaning. Since this test only addresses knowledgeof road signs, it is very different from the J-RSR, which
requires the subject to comprehend the road situationfrom a photograph and to choose a road sign appropriate
for that situation. Uc et al. [28] examined the Landmark
and Traffic Sign Identification Task and reported thatit can differentiate AD from healthy subjects. The test
measures how many landmarks and signs that appear ina driving video can be identified. While it does require
visual searching ability, it does not require knowledgeof road signs, which makes it different from the J-RSR.
Brown et al. [29] examined the driving scenes test,
wherein the subject is consecutively shown two color
drawings of a road situation, separated by a brief interval, and is then required to point out the differences
between the two drawings. This test requires visualmemory capacity, not knowledge of road signs, whichmeans that completing it requires different abilities thanthose required for completing the J-RSR. While the
RSR in the SDSA [18, 21, 30, 31] is very similar to the
J-RSR, as pointed out in the introduction, it differs fromthe J-RSR in that it uses drawings, not photographs; furthermore, it does not present Japanese road situations.
These findings suggest the novelty of the J-RSR.
It has been reported that the RSR is predictive of
the results of on-road evaluations (Lincoln et al., 1992,[5, 20, 21, 31−33]. The RSR is a complex task that
requires good visual cognition, mental speed, working
memory, executive function, and non-verbal reasoning
simultaneously [21, 23−25, 34]. Each cognitive facultyis necessary to drive a car. Since the major difference
between the J-RSR and RSR is the fact that the former
uses photographs of road situations in Japan while thelatter does not, they can be considered to assess thesame cognitive faculties. Our analysis of the results
showed that while there is no difference between older
and younger driver’s license holders in the number ofcorrect answers, the younger group was faster at answering the questions. This suggests that while there is nodifference between the two groups in terms of the ability
to evaluate a driving situation or choose an appropriate
road sign, there is a difference in mental speed to reachthe conclusion. In other words, the result highlights that,among all cognitive faculties necessary to complete thetask, the primary difference between the groups wasin mental speed. This assumption is supported by thefact that the younger group was significantly faster in
the TMT. However, analysis of the correct answer rate
for each question indicates that the results cannot be
explained by mental speed alone (Fig. 3). In Question

21

1, the subject is required to comprehend a situation inwhich “one cannot go straight ahead” and to choose
the road sign that reflects that situation. Option 1 (thecorrect answer) is a “no vehicle entry” sign, option 2 isa “maximum speed 50km/h” sign, option 3 is a “stop”
sign, and option 4 is a “no vehicle entry except bicycles
and motorcycles” sign. Many of the older participants
who chose the incorrect option chose option 3, while
younger participants’ incorrect answers were evenly
distributed over options 2−4. The fact that the answers
were not distributed evenly suggests that there aretrends present in comprehending the situation. It has
been inferred that the difference in the distribution ofanswers is related not to mental speed but to differencesin the ability to comprehend situations based on driving
experience [35, 36]. Preceding studies on the RSR
including older people have reported that in a 12-point
test, the older drivers’ median score was 7 (interquartile
range 6−10; [20]) and the mean was 8.2 ± 2.4 (range:
2−12; [30]). In comparison to these reports, the resultsof the present study suggest a higher correct answer
rate. In order to examine the effectiveness of the J-RSR
as an evaluation of driving ability, future investigations
among stroke and dementia patients must be performed.
In relation to the errors that we identified that are causedby cognitive factors other than mental speed, tests
should be carried out among patients with brain damage
who show symptoms of reduced cognitive function.
Acknowledgments: This study was performed with thesupport of a Grant-in-Aid for Young Scientists (B) (Grant
number 26750182). We are grateful to Mr. Hideya
Momose of Nishizawa Electric Meters ManufacturingCo., Ltd., for his exceptionally valuable program development advice.

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■CASE REPORT

Therapeutic Value of Using Two-step Splinting
for Mallet Finger
Kazuo Saito1, Hitoshi Kihara, MD2
1
2

Department of Rehabilitation, Fuchinobe General Hospital
Kihara Orthopaedic Clinic

Abstract: In the present study, we report two cases of splinting therapy where favorable results were obtained using
splinting of two types, consisting of a first step of fixation at PIP joint extension position and DIP joint extension position, followed by a second step of further fixation at DIP joint extension position, followed thereafter by hand therapy
on mallet finger. As the first splint flexes the PIP joint, and, further, as the DIP joint is taken as the hyperextension position, it is thought that the ruptured tendon ends sufficiently entwined more than with the conventional splint at the DIP
joint extension position. The splinting therapy we used, with its two-type splinting, is thought to have enabled fixation
and ROM acquisition that were in tandem with the tendon healing process. This treatment hints at the effectiveness ofconservative therapy in the treatment of swan neck deformities and bony mallet finger.
Keywords: tendinous mallet finger, bony mallet finger, two-step splinting, hand therapy(Asian J Occup Ther 12: 23−28, 2016)

Introduction
Generally, conservative therapy is used to treat
mallet finger. For simple closed mallet finger, surgery
is controversial because results of studies indicate thatsplinting is effective. Nevertheless, surgery is indicatedunder certain conditions [1, 2]. However, difficulties
often arise in such cases because of extension lag.
Thus, fixing a splint with slight extension at the distalinterphalangeal (DIP) joint is often used in conservative
treatment [2−6]. The standard recommendation is
splinting for ≥ 6 weeks, followed by active movement[2, 4]. The splinting method has not been standardized,
and various techniques have been reported. Research on
specific fixing methods used in conservative treatmentof mallet finger includes studies on the effectiveness offixing the proximal interphalangeal (PIP) and DIP joints
by Wehbé and Schneider [7], Evans [8], and O’Conner[9], but their studies did not include comparisons of theimmobilization duration or types of splints. Pike et al.
Received: 18 April 2014, Accepted: 20 February 2015
Corresponding to: Kazuo Saito, Department of Rehabilitation, Fuchinobe General Hospital, 3-2-8 Fuchinobe, Chuouku, Sagamihara-City,
Kanagawa, 252-0206, Japane-mail: kasuo_saitoh@yahoo.co.jp©2016 Japanese Association of Occupational Therapists[10] and O’Brien and Bailey [11] compared three typesof splints, and both studies concluded that custom
thermoplastic splints, which are custom-made for eachpatient, were most effective.
Considering that sufficient improvement of extension lag has not been obtained through splinting of the
DIP joint alone, we believe that improved results could
be observed by studying splinting of the PIP joint [7−9]and splinting duration. We believe so because wethought that while splinting the PIP and DIP joints does
sufficiently draw together the ruptured tendon portions
and that this would be a favorable position for repair of
the terminal tendon, long-term immobilization would
result in PIP joint contracture. Thus, to minimize PIP
joint contracture, we thought that if we removed only
the PIP joint splint at 2 to 3 weeks and then retained
only the DIP splint, we could then correct the DIP joint
extension lag.
We also believe that the key to the success of thisapproach would be having a hand therapist create a custom-made thermoplastic splint for each patient.
The present study aimed to determine the therapeutic values of two methods of splinting that involved initial fixation at the PIP and DIP joint extension positions,followed by further fixation at the DIP joint extension
position, and then by hand therapy. Herein, we report
splint therapy cases in which favorable results were24

Therapeutic Value of Using Two-step Splinting for Mallet Finger

obtained by using the two methods of splinting. This
study was conducted after providing sufficient explanations to the subjects and obtaining their consent.

Methods
In this paper, we describe the splint therapy that wedesigned and the follow-up hand therapy, and report 2
cases, 1 each of tendinous and bony mallet fingers.
The protocols for the two-step splinting and handtherapy were as follows (Fig. 1):
1) Two-step splinting (Table 1)
Step 1 was performed up to 2 or 3 weeks after
injury; it involved creating the splint for DIP joint hyperextension and 45°-flexion position of the PIP joint.
The splint material used was a 1.6-mm Orfit soft-typematerial (Orfit Industries n.v. Belgium) and the splint

was created with a full-circumference mold. Then, 2- or
3-week fixation was performed (initial splinting).
Step 2 was performed from 2 or 3 weeks to 6
weeks; after 3 weeks’ fixation with the first splint,
we created a splint for the DIP joint slight extension
position. By using a 1.6-mm Orfit soft-type material,a figure-8 splint was created. Here, 3-week fixation(second splint) was performed (total splint-fixation duration: 6 weeks). Subsequently, a DIP joint (night splint)
was used for 12 weeks, with constant monitoring of thesubject’s condition. During this period, active range of
motion (ROM) was initiated, but because the extension
lag of the DIP joint became aggravated, splint use wasincreased from nighttime only to 24 hours [2, 4] (Fig. 1).
2) Hand therapy
Six weeks from the initiation of therapy, active exercise was initiated at the rehabilitation clinic. In cases

Fig. 1. Two-step splinting protocol and hand therapy.
Table 1. Two-step Splinting.
First step

Second step

Position

DIP joint mild extended position
PIP joint flexion 30−45°

DIP joint mild extended position

Splint typeCircumference type

Eight figure type

1.6 mm

1.6 mmAppearance

Material thickness
Term
Mounting time

2 or 3 weeks from initial visit

3 or 4 weeks after the first step splint
Total 6 weeks

Throughout the day

Throughout the daySaito K et al.

Asian J Occup Ther 12: 23−28, 2016

where swelling remained on the dorsal side of the DIP
joint, scar massage was performed from the proximal tothe distal area, after the swelling was reduced. DIP joint
blocking training was performed. The patient wore thesplint in the time when there was no training (Table 2).
Eight weeks from the initiation of therapy, other movement exercises and stretching were added. Muscularstrengthening exercises of the extensor tendon were
performed, with gradual increase of exercises. Muscularstrength training of the extensor tendon consisted of
gradually increasing the time and weight of pinch exercises, and extension resistance exercises, along withthe use of Ceraplast. At first, the resistance time wasshort and the load was light, and the subject was monitored for pain and fatigue when the soft-type Ceraplast
was used. Harder materials were gradually introduced(Table 2). Taping was performed mainly on the dorsalside of the DIP joint in a figure-8 configuration to offer
support to prevent hyperflexion of the joint (Table 2).
Taping was also instructed if the patient intended to thefinger ends during the daytime. The areas indicated by
the dotted line are sites subject to consultation with thephysician during monitoring of the improvement of theextension lag (Fig. 1).

Case Report
Case 1 was a severe DIP joint flexion deformity due
to tendinous mallet finger and a swan-neck deformity.
Case 2 was a bony mallet finger that was treated withconservative therapy.
Case 1 was observed in a woman aged 27 years.

Her left little finger was injured by a tape cutter that had
fallen from a high place. Two days thereafter, she was
examined at our hospital and diagnosed with a tendinous
mallet finger on radiography. She had no notable medical history. She presented a swan-neck deformity at theinitial examination (Fig. 2).
On day 2 after the injury, the first splint was created
and was affixed for 3 weeks. Thereafter, the second
splint was created and was affixed for 3 weeks (total
splint-setting period: 6 weeks), and ROM training consisting of DIP joint active movement was initiated. Scar
massage was performed, and at 8 weeks after injury,
other movement exercises, stretching, and muscularstrength training were initiated. The DIP joint ROM overtime in terms of extension/flexion was as follows: at thetime of injury, −60°/60°; 6 weeks after injury, 10°/30°;
and 12 weeks after injury, −5°/60° with pain withinmanageable bounds. The patient was able to return toher part-time job at a convenience store. Her condition
was classified as good according to the Crawford
evaluation criteria [11]; the results are shown in Table 3
and Fig. 2.
Case 2 was observed in a man aged 28 years. His
right ring finger was injured when it became stuck in
a refrigerator while working. Three days thereafter,
he was examined at our hospital and diagnosed with amallet fracture on radiography. According to the Wehbéand Schneider classification system [7], the injury wasclassified as a type IIB injury. The patient had no notable
medical history (Fig. 3).
On day 6 after injury, the first splint was created
and worn for 2 weeks. Thereafter, the second splint was

Table 2. Hand therapy for 6 weeks and 8 weeks (ring finger).
6 weeks

8 weeks

1. Active ROM exercise

1. Passive ROM exercise

2. Blocking exercise

2. Stretching
Hook fist

2. Scar massage
Proximal → distal

25

Full fist

3. Muscle strength exercise
Pinch exercise
Extensor exercise

3. Taping
During the daytime
at work
Direction of the arrow indicates the movement of the injured finger

26

Therapeutic Value of Using Two-step Splinting for Mallet Finger

Table 3. Case 1: Course of treatment (left little finger).

DIP Ex/Flex
Pain VASWork

1 week2 weeks

6 weeks

12 weeks

Outcome−50/60
7/10
Leave of absence

20/−203/10
Some return

10/30
1/10
Some return

−5/60
0/10
Full return

Crawford
evaluation criteria
Good

First treatment

Outcome after 12 weeks

Appearance

Extension

RadiographFlexionFig. 2. Case 1: First treatment and outcome after 12 weeks(Left little finger with tendinous mallet finger).

created and worn for 4 weeks (total splint-setting period:
6 weeks), and ROM training via DIP joint autonomous
movement was initiated. Scar massage was performed,
and at 8 weeks after injury, other movement exercises,
stretching, and muscular strength training were initiated.
The DIP joint ROM over time in terms of extension/
flexion was as follows: at the time of injury, −40°/50°;
6 weeks after injury, 20°/30°; and 12 weeks after injury,
5°/50°, with pain within manageable bounds and no pain
during carrying tasks. This injury was classified as perfect according to the Crawford evaluation criteria [12];the results are shown in Table 4 and Fig. 3.

Discussion
Anatomically, the balance between the central slipof the extensor hood at the PIP joint and the terminal
extensor tendon at the DIP joint is important for finger
function and appearance. Loss of the terminal extensor
tendon attachment leads to the central slip receiving all
tension. The PIP joint will thus have a resting tone inextension or even in hyperextension. With the flexed
posture of the DIP joint, this would present as a swanneck deformity [4, 12, 13]. In mallet finger, the extent
of the DIP joint flexion deformity is thought to be proportional to the extent of the separation of the ruptured
tendon ends in the ruptured tendon portion within the
DIP joint extension position [13].
As the first splint flexes the PIP joint and as the DIP

joint is considered the hyperextension position, the ruptured tendon is thought to be sufficiently entwined, morethan with the conventional splint at the DIP joint extension position. Considering the tendon repair process, aremarkable proliferation of fiber cells and fibroblasts
could be observed at the tendon cross-sectional area
at approximately 3 weeks, and tendon tensile strength
increased [14]. At this time, the splint was changed to aconventional splint at the DIP joint extension position.
This change allowed exercise of the PIP joint, and thereby, is thought to have minimized the PIP joint contracture.
Because case 1 had a severe terminal tendon injury,
the lateral band and oblique retinacular ligaments weretranslocated to the dorsal side, presenting a swan-neckdeformity [12]. Therefore, in order to sufficiently reposition the terminal tendon, we planned to fix the finger inthe DIP joint hyperextended position for 3 weeks to flex
the PIP joint and transpose the lateral band and obliqueretinacular ligaments to the volar side.
This suggests that in a case such as case 2, wherea bony mallet finger is classified as type IIA or lower
according to the Wehbé and Schneider classification
system [7], even if this is an obsolete case, good fixation
positions can be preserved and synostosis is possible.
In case 2, radiography showed DIP joint extension
only, indicating that repositioning of the bone fragment
could be achieved through PIP joint flexion and DIP
joint extension. The splint was fixed at that position,

Saito K et al.

Asian J Occup Ther 12: 23−28, 201627

Table 4. Case 2: Course of treatment (right ring finger).

DIP Ex/Flex
Pain VASWork

1 week2 weeks

6 weeks

12 weeks

Outcome−30/308/10Some return

20/−20
5/10
Full return

20/30
0/10
Full return

5/50
0/10
Full return

Crawford
evaluation criteria
Perfect

First treatment

Outcome after 12 weeks

Appearance

Extension

RadiographFlexionFig. 3. Case 2: First treatment and outcome after 12 weeks(Right ring finger with bony mallet finger).

which allowed fixation at a position where the terminal
tendon was sufficiently loose [2, 4, 12].
The success of the two-step splinting used in thisstudy was owing to the fact that anatomically, the tension
on and looseness of the extensor tendon was maintainedin the early stages. Thereafter, switching to a splint that
fixed the minimum amount of the digit prevented excess
contraction and led to improvement of ROM. For thecreation of the first splint, it is important to correctly
understand the characteristics of thermoplastics and be
familiar with the materials. Moreover, care in the castingis important to ensure that no pressure is applied at thesides of the finger or at the dorsal side of the DIP joint.
To increase the possibility of successful fixation of the
splint for a continuous period of ≥ 6 weeks, the splint
should be custom-fit for each patient. Custom-made,two-step splinting is thus thought to be effective. The
splinting therapy that we used, with its two splinting
methods, is thought to have enabled fixation and ROM
acquisition that were in tandem with the tendon healing
process. In the future, we will accumulate more cases ofusing this fixation method and investigate, for example,
the differences between the two splinting methods andfixation of the DIP joint only, as well as the applicationof our splinting method to residual mallet finger. This
treatment hints at the effectiveness of conservative therapy in the treatment of swan neck deformities and bonymallet finger.
In the future, we would like to continue our studyof this treatment but with larger numbers of subjects andwith attention paid to splint-related complications suchas dorsal skin maceration and necrosis [15]. We would
also like to compare conventional treatments withthe two-step splint method. Finally, we would like toinvestigate the applicability of our treatment method to
obsolete cases of tendinous and bony mallet fingers.

References[1] Clayton RA, Court-Brown CM. The epidemiology ofmusculoskeletal tendinous and ligamentous injuries.
Injury. 2008; 39: 1338−44.
[2] Handoll HH, Vaghela MV. Interventions for treating
mallet finger injuries. Cochrane Database Syst Rev. 2004;
1−25.
[3] Abouna JM. Splint for mallet-finger. Br Med J. 1965; 13:444.
[4] Cheung JP, Fung B, Ip WY. Review on mallet finger
treatment. Hand Surg. 2012; 17: 439−47.
[5] Stack HE. A modified splint for mallet finger. J Hand
Surg Br. 1989; 11: 83−9.
[6] Wilson SW, Khoo CT. The Mexican hat splint–a new
splint for the treatment of closed mallet finger. J Hand
Surg Br. 2001; 26: 488−9.
[7] Wehbé MA, Schneider LH. Mallet fractures. J Bone Joint

28

Therapeutic Value of Using Two-step Splinting for Mallet Finger

Surg Am. 1984; 66: 658−69.
[8] Evans RB. Therapeutic management of extensor tendon
injuries. Hand Clin. 1986; 2: 157−69.
[9] O’Connor JF. Mallet finger. Can Fam Physician. 1997;
43: 1725−6.
[10] Pike J, Mulpuri K, Metzger M, Ng G, Wells N, Goetz T.
Blinded, prospective, randomized clinical trial comparing
volar, dorsal, and custom thermoplastic splinting in treatment of acute mallet finger. J Hand Surg Am. 2010; 35:
580−8.
[11] O’Brien LJ, Bailey MJ. Single blind, prospective, randomized controlled trial comparing dorsal aluminumand custom thermoplastic splints to stack splint for acutemallet finger. Arch Phys Med Rehabil. 2011; 92: 191−8.

[12] Harris C Jr, Rutledge GL Jr. The functional anatomy ofthe extensor mechanism of the finger. J Bone Joint Surg
Am. 1972; 54: 713−26.
[13] Schweitzer TP, Rayan GM. The terminal tendon of thedigital extensor mechanism: Part II, kinematic study. J
Hand Surg Am. 2004; 29: 903−8.
[14] Peacock EE Jr. Biological Principles in the healing oflong tendons. Surg Clin North Am. 1965; 45: 461−76.
[15] Rayan GM, Mullins PT. Skin necrosis complicating
mallet finger splinting and vascularity of the distal interphalangeal joint overlying skin. J Hand Surg Am. 1987;
12: 548−52.

■ORIGINAL ARTICLE

An Occupational Performance Patternsof Family Members of Terminal Cancer Patients:
Typology of family palliative caregivers
and occupation performance patterns
Seigo Minami1, Ryuji Kobayashi212Faculty of Allied Health Sciences, Yamato University, Japan
Department of Occupational Therapy, Tokyo Metropolitan University, Japan

Abstract:
Objective/Background: In this study, we classified the psychological adjustments of family members of terminal cancer
patients using a conceptual structure based on recurring cases. We hypothesised that it is possible to determine the needfor intervention on the basis of the occupational performance patterns of the family members.
Methods: The subjects were bereaved family members of cancer patients who died more than a year ago. For our classification system, we adopted code matrix analysis using MAXQDA10 analysis software.
Results: We categorised the 9 cases into 3 types on the basis of functionality with regard to occupation: i) type of continued occupation; ii) type of resumed occupation; iii) type of interrupted occupation.
Conclusions: The categorisation of occupational types assumes that occupation has an effect on the family members’ability to progress through or alter mental states according to occupational performance patterns.
Keywords: occupational therapy, family caregivers, occupational performance(Asian J Occup Ther 12: 29−36, 2016)

Introduction
Caretakers of family members with terminal cancer
often experience both sorrow and grief following theloss of the patient. Lindemann [1] noted that grief does
not only occur only after bereavement; instead, it begins
upon the anticipation of death. He called this phenomenon ’anticipatory grief’.
It is normal to experience grief after the loss of a
loved one. However, if this grief continues for an excessive period or disrupts daily life, it is conceivable thatthe grieving person has fallen into a state of psychological crisis due to pathological grief. Caplan [2] definedsuch a psychological crisis caused by pathological grief
as a situation in which a person faces obstacles against
Received: 6 October 2014, Accepted: 17 July 2015
Corresponding to: Seigo Minami, Faculty of Allied Health Sciences,
Yamato University, Japan, 2-5-1 Katayamachou Suita-shi, Osaka, 5640082, Japane-mail: minami.seigo@yamato-u.ac.jp©2016 Japanese Association of Occupational Therapists

an important goal in life. In other words, the person isin a situation where he tries to solve the problem in theway that he has done habitually, but he cannot overcome
the problem.
Occupational therapy is a method to encourage thegrieving person to avoid a state of psychological crisis
through occupation [3]. To the best of our knowledge,
no previous report, other than ours [4], has shown theefficacy of occupational therapy as support for families
experiencing pathological grief. In the present study, we
studied families who took care of patients with terminal
cancer at home and clarified a conceptual structure
categorizing the effects of occupation on psychologicaladjustments of the families using a grounded theory approach [5]. However, our findings were comprehensive
and did not reflect the characteristics of individual cases
or support specific interventions. Accordingly, we decided to pursue additional data analysis on a case-by-casebasis because it is important to clarify relationships between occupational performance patterns and alterationsin the mental state. Thus, we supposed that it would bepossible to determine the need for intervention on the

30

An Occupational Performance Patterns of Family Members of Terminal Cancer Patientsbasis of occupational performance patterns observed ineach case.
This study coordinated the talk of subjects along
six categories obtained in the preliminary research that
Minami et al. [4] was contributed to Hong Kong Journalof Occupational Therapy. The purpose of the present
study was to clarify the occupational performancepatterns and types of occupation of family members ofcancer patients using the ‘case-category matrix method’in order to identify factors that contribute to alterationsin the mental state due to pathological grief.

Methods
Survey period
The survey period was 5 months, from February
2011 to June 2011.
Subjects
The study subjects were family members who provided in-home palliative care for patients with terminal
cancer and were selected using convenience sampling
methods. The subjects were spouses, children or grandchildren of the patients. They individually interviewed
by 4 medical staff members in order. . Each patient
received palliative care during the final stages of illness.
Palliative care focuses on pain management without theuse of anti-cancer agents, which are generally administered during intensive care. Moreover, we chose subjects
whose family members had died more than a year
before participation in this study because we considereda period within 6 months after death to be a ‘grief work’
period, although the duration of this period is reportedly
dependent on the age of the caregiver [6, 7]. The Schnabel method was used to qualitatively measure theoreticalsaturation conditions [8]. The Schnabel method can
express a trapping rate in a reasonable viewpoint. To
determine whether the theoretical sampling was successful, we calculated and evaluated the trapping rate when
new findings began to gradually cease. At this time,
if the label had an overall trapping rate of ≥ 90%, we
considered it to indicate theoretical saturation. The study
protocol was approved by the Ethical Review Board of
Kibi International University (approval number: 10−17).
Creation of a case–category matrix
To create a case–category matrix, we placed core
categories that were identified in our previous study on
the horizontal axis and the cases recruited in this study
on the vertical axis. In each of the cells, we provided
a paraphrased version of comments from the family
member who provided care; these comments were obtained during case interviews regarding the correspond-

ing core categories [9]. In addition to studying the case–
category matrix as a whole, we arranged the details ofeach case into a story centred on the core categories andclassified each case on the basis of similarities between
these stories. The core categories were ‘being overwhelmed by pressure’, ‘occupation while living with theillness’, ‘living without being overwhelmed by anxiety’,‘having difficulties in regulating emotions’, ‘comforting
memories of the occupational experiences’ and ‘leading
to a change in emotions’ [4].
Summary of subjects
In total, 9 cases were included in this study. The
Schnabel method yielded a result of 94.8%, indicatingthat these 9 cases provided theoretical saturation. The
attributes of the included cases were as follows: (i) the
average [± standard deviation (SD)] period of home palliative care was 7.2 ± 6.9 months; (ii) the average lengthof time since the patient’s death was 44.8 ± 28.2 months;(iii) the average age of the caregiver was 50 ± 19.9 years
and (iv) the average age of the deceased cancer patientwas 60 ± 10.8 years (Table 1).

Results
We obtained occupational performance patterns
from the ‘case–category matrix’ (abridged edition) on acase-by-case basis. As shown in Table 2, case no. 1 fell
into the category labelled ‘thoughts are continued’, no. 2
fell into ‘thoughts are continued’, no. 3 fell into ‘work is
insufficient’. no. 4 fell into ‘work is insufficient’, no. 5
fell into ‘thoughts are continued,’ no. 6 fell into ‘thoughts
are continued,’ no. 7 fell into ‘resumed former hobbies’,
no. 8 fell into ‘resumed former hobbies’ and no. 9 fell
into ‘work is insufficient’.
In addition, occupational performance patterns werecategorised into 3 occupational types: (i) ‘occupation
continued’, (ii) ‘occupation resumed’ and (iii) ‘occupation interrupted’. The distribution of occupational
patterns was as follows: (i) ‘occupation continued’: casenos. 1, 2, 5 and 6; (ii) ‘occupation resumed’: case nos.
7 and 8 and (iii) ‘occupation interrupted’: case nos. 3,
4 and 9 (Table 2). Moreover, we found that after thedeath of the patient, alterations in the mental state wereassociated with occupation types as follows: in both the‘occupation continued’ and ‘occupation resumed’ types,
alterations in the mental state were promoted, and in the‘occupation interrupted’ type, alterations in the mental
state were incomplete (Table 2).
Here, we specifically describe the occupational
performance patterns along with the story of each case,beginning before the cancer patients died.

Minami S et al.

Asian J Occup Ther 12: 29−36, 201631

Table1. Characteristics of family members and patients.
Subject

No. 1

No. 2

No. 3

No. 4

No. 5

No. 6

No. 7

No. 8

No. 9

Gender

W

M

W

W

M

W

W

M

W

Age

60s

30s

50s

50s

50s

60s

50s

90s

20s

Attribute
participant

wife

son

wife

wife

son

daughterwife

husbandGC

Attribute patienthusbandfatherhusbandhusbandmothermother

ML

wife

GF

Palliative careperiod at home

9 months

1 year14 days

1 month

6 months

2 months

6 months

5 months

2 years

After the death

1 years 10
months2 years 6
months1 year 5
months2 years 6
months7 years

1 year 6
months7 years

7 years

3 years

Diagnosis ofcancer

Not
Informed to Informed to Informed to Informed to
informed tothe patients the patients the patients the patientsthe patientsNot
informed tothe patientsNot
informed tothe patientsNot
informed tothe patientsNot
informed tothe patientsInterview time

97 minutes

44 minutes

47 minutes

88 minutes

114 minutes

41 minutes

59 minutes

91 minutes

38 minutes

GC: grandchild; GF: grandfather; M: man; ML: mother-in-law; W: woman

1) ‘Thoughts are continued’: case nos. 1, 2, 5 and 6
Case no. 1 was a woman who cared for her sickhusband. During his illness, the couple spent time gardening, walking, enjoying tanka (a 5-line, 31-syllable
Japanese poem) and reciting Chinese poems. ‘One
day’, the wife recalled, ‘the doctor told us, “Even if
your husband has surgery, I don’t expect that he cansurvive.” Therefore, my husband told the doctor that hedidn’t want to be hospitalised or have surgery. Instead,he wanted to receive home palliative care’. One of thereasons why this patient wanted to receive palliative
care at home was that he wanted to help care for his sickmother. His wife, who respected her husband’s decision,
devoted her time to care for her husband and his sickmother. After her mother-in-law died, she accompanied
her husband to the funeral.
At the funeral, however, her husband’s condition
was critical: his lips were blue and he was barely able
to stand. His wife supported him and monitored his
condition. In addition, she kept a notebook in which she
described his fight against his illness. After he died, she
re-read her notebook and composed it in tanka form,
which was her hobby, and turned this narrative into
an anthology for her children. She also worked in thegarden, which became her sole responsibility after her
husband became ill. She continues to take early morning
walks and compose tanka.
Case no. 2 was a man who cared for his sick father.
While his father was fighting his illness, he enjoyedgathering his family members around the dining tablefor casual conversations. The father reminisced about
his life and upbringing, requested that his son lookafter particular matters after his death, spoke to his

relatives about being good members of the society andmaintaining a strong family unit and so on. During theseheartfelt conversations, the son was able to embrace his
feelings towards his father, and this time offered them achance to become closer than they ever had been. The
father also shared his passion for photography with hisson, which had been one of his favourite activities. The
father told his son that he could not take pictures any
longer because his condition was becoming prohibitively worse. Thus, the son took his father’s camera, photographed scenes of a mountain they had once visited
together and shared them with his father. When thefather saw the pictures, he happily said, ‘My son continues to pursue my hobby’. The son values the camera till
date.
Case no. 5 was a son who cared for his sick mother.
Before his mother died, the son continued to live hislife normally, while also discussing his work and hischildren’s education with his mother. While the motherwas fighting her illness, the son was unable to visit her
during the final stage of her life because he was working
out of town. Therefore, when he returned, he supported
his children, wife and father who had been taking careof his mother. He appreciated the support of his immediate family, who served as primary caregivers, andacknowledged their tireless efforts and valued his relationships with them as it reflected in his mother’s care.
After his mother died, he realised the importance of the
support of his family members during times of illness.
He now feels that his family ties have deepened becauseof sharing the common experience of fighting against an
illness.
Case no. 6 was a daughter who cared for her sick32

An Occupational Performance Patterns of Family Members of Terminal Cancer Patients

Table 2. Abridged edition/case-category matrix.
categories (examples)

Switching of
mental statetype ofoccupation

Occupationalperformancepattern

Promotion

type of continued
occpation

Thoughts arecontinued

Nos. 1, 2, 5, 6

My husband often woke me up in
the middle of the night becauseof which I couldn’t get sufficient
sleep. I suffered from dizziness. I
was so tired that I went to the hospital without letting my husband
know. After my doctor told me
about his cancer, it was difficult
for me to accept the reality of thesituation. (No. 1)

My husband and I ate, went forwalks, took care of the garden,sang “kouta” (a ballad sung toshamisen accompaniment) andtogether cared for my mother-inlaw at home. My husband taught
me about gardening and bonsai.
Other family members continued singing tanka, which is ourhobby, and they accompanied us
for walks in the mornings. I wrote
about my husband’s condition andthe events of each day in detail in
my notebook. (No. 1)

type of resumed
occupation

Resumed former
hobbiesNos. 7, 8

My mother-in-law was often
scared at night, so she had someone to stay with her and hold her
hand. It was painful for me tosee my mother-in-law becoming
weaker every day. Although care
was needed at all times, mymother-in-law did not like the factthat she needed such care. I did
not know what to do. (No. 7)

I harvested in our field andcooked with my mother-in-law.
It was refreshing to continue
working. (No. 7)

type of interrupeted occupation

Work is insufficientNos. 3, 4, 9

My husband lost weight during
the week after his doctor told him
about his terminal cancer. I was
more scared than worried. My
husband could not get up on his
own at all. I had to pull him up
and help him go to the washroom.
Our family members were exhausted from taking care of him.
(No. 3)

Because my husband was
self-employed, I helped him withhis work. When my husband was
hospitalized, he wanted to smoke.
I would take cigarettes for him
at the hospital. I also helped him
move about when he was bedridden. (No. 3)

IncompleteNo.

mother. While her mother was fighting her illness, thedaughter provided in-home palliative care without
informing her mother of her cancer. Other family members worked hard to maintain her everyday life without
letting her realise that she had cancer, while providing
the most devoted care possible all the time. One day on
Tanabata (the Star Festival), the mother wrote a tanzaku(a strip of fancy paper to write wishes on) with herfamily, including her grandchildren. The mother wrote
on the tanzaku, ‘Everyone is very devoted to me thisyear. Thank you. Thank you. Thank you’. The family
members who saw that tanzaku were heartbroken. After
her mother’s death, the daughter still treasures thattanzaku as it portrays her mother’s feelings of gratitude.
Even now, she continues to embrace the feelings ofemotional support from the note.

being overwhelmed by pressure

occupation while livingwith the illness2) ‘Resumed former hobbies’: case nos.7 and 8
Case no. 7 was a woman who cared for her sickmother-in-law, who had no knowledge of her cancer.
Therefore, the woman continued to avoid letting her
mother-in-law realise that she had cancer. In spare
moments during her illness, the mother-in-law often
invited her daughter-in-law to her room and expressed
her feelings of gratitude. On the day when the motherin-law died, the woman was at work and was therefore
unable to see her during the final moments of life. She
experienced bitterness about this; however, the factthat she was able to offer her mother-in-law a sense offamily unity and the memories of her mother-in-law’s
expression of gratitude provided her emotional support.
The most cherished memory of the woman was that she
was able to spend time with her mother-in-law at home
until the end, while they mutually supported each otherMinami S et al.

Asian J Occup Ther 12: 29−36, 201633

living without being overwhelmedby anxiety

having difficulties
in regulating emotions

comforting memoriesof the occupational experiencesleading to a change
in emotions

Our family members could talkwith my husband about events
when we went for a walk in themorning. My husband encouraged
me to take walks on my own as
well, as they helped me feel calm.
Our family members also helped
each other. I supported my husband in what he wanted to do.
Even when my husband couldn’t
walk anymore, we went to buy a
new potted plant and had a suitmade together. (No. 1)

Once or twice a month, I experienced sudden shortness ofbreath and lack of motivation,and I am being treated for thisat the hospital now. When I
stayed home too much, I would
feel suffocated. Going out
rather than staying home all thetime is therapeutic for me, so I
try to go out. (No. 1)

I was able to care for both my husband and my mother-in-law at home. I
was also able to make a songbook that
I had promised my husband I would
make. This songbook also documented the events that were recorded in
my notebook. Even now, I still takegood care of the garden that my husband and I planted together. Without
these things, I would have been overwhelmed. Taking over my husband’s
hobbies helped me feel connected tohim because I started thinking likehim and following his lifestyle. (No. 1)

Some of my friends invited me
to go on a trip together. My
family members have stayedwith me. Some of my husband’s belongings are still here.
I still take good care of thepotted plant that my husbandbought during his final stage.
I still feel that my husband issomewhere close to me. (No. 1)

Our family ensured that mymother-in-law could do what she
wanted. My work improved mymood, and I eventually decided to
ask caregivers to take care of mymother-in-law. (No. 7)

My only regret is that I could
not be with my mother-in-law
during her final stage. (No. 7)

I was relieved because my motherin-law wrote to me about her feelingof gratitude while she was fighting
against the disease. Also, after mymother-in-law’s death, I was encouraged by my family members whogathered around me. (No. 7)

I have starting reading the picture books that I collected as ahobby and other picture books
that were given to me by myfriends. (No. 7)

I always hoped that I would be
able to work with my husband if
he were to recover completely. On
the day before my husband died,he said, “I want to eat anpan (around soft bread with azuki bean
jam in its center).” He ate all the
anpan, even though he later vomited it all. He told us that he wanted
to live. His doctor and nurses
offered him a lot of support. (No. 3)

It is painful to see pictures of
my husband around the house.
Even now, I sometimes cannot
focus on my daily life. (No. 3)

as a family. Till date, the daughter-in-law continues toappreciate that experience. Since then, she has resumed
collecting picture books, a long-standing hobby, because
she could not pursue this endeavour during her motherin-law’s illness. When the daughter-in-law was young,she wished to become a librarian. Since then, she hascontinued to borrow picture books to read. At present,
she is at last able to meet and talk to acquaintances whoshare her hobby of picture books.
Case no. 8 was a husband who cared for his sickwife. While his wife was fighting her illness, he decided
to not tell her about the disease and was committed tospend her remaining time together. His wife wrote about
her feelings of gratitude towards the people around her.
The husband also filled several notebooks with detailsof his wife’s life and the events of her illness, whilereflecting on her life. After her death, the husband wrote

My main activity is readingbooks. (No. 3)

a book detailing his wife’s last years. This book wasmeant to be a memorial to his wife that would offer a
glimpse of his role as a husband as well as his time withhis wife and family. The book described his wife’s stateof mind while she was fighting her illness and included
calligraphy that they had completed together, whichreflected the couple’s journey. At present, the husband
has resumed his former hobby of photography, which he
was unable to pursue during his wife’s illness. He travels in a friend’s car to capture pictures of mountains andneighbourhood scenery, which are shown in an annual
exhibition. He has also received some awards.
3) ‘Work is insufficient’: case nos. 3, 4 and 9
Case no. 3 was a wife who cared for her sick husband. One day, her husband visited a hospital because
of severe fatigue. After the doctor diagnosed him with

34

An Occupational Performance Patterns of Family Members of Terminal Cancer Patientscancer, his wife chose to remain a driving force in hislife. She and other family members provided in-homepalliative care for a period of 14 days. During that time,
the wife spent time with her husband by getting involved
in his favourite activities. She continued to encourage
him to participate in every activity as well as he could.
At the same time, she continued to organise a resume
for their printing business believing that he would
completely recover. He never gave up trying to recoverfrom cancer, and although he desperately fought andfaced his illness, he unfortunately passed away. After
his death, his wife closed the printing business and lived
at home, choosing to not work any longer. Till date, shesometimes finds it difficult to resume her normal life.
The only activities that sustain her are reading and thememory of what her husband said to her while he wasfighting his illness: ‘I married you and wanted us both tobe happy’.
Case no. 4 was also a wife who cared for her sickhusband. While the husband was fighting his illness, hisfamily members were united and supported his endeavours and needs by accompanying him during his drives
to the hospital, workplace and home. During these car
rides, they reflected on and talked about their family
life together, while travelling and walking. In addition,
when home palliative care began, the wife expressed aparticular fondness for the dining table that had given
them a place to enjoy familial interactions. While he
was fighting his illness, the husband and wife enjoyedgardening activities such as pruning plants together.
The wife stated that she would organise her own stateof mind while exchanging emails with her friends andhoped that her husband would continue to fight his
illness the following day. Immediately after her husband
died, she said, ‘It was great that our whole family cared
for him together’. After that, she continued to eat withher family members around the dining table and offeredthem flowers from the garden. Moreover, till date, she
continues to exchange emails with her friends, which
was a former hobby that she enjoyed before her husband
died.
Case no. 9 was a grandchild who cared for her sickgrandfather. While the grandfather was fighting his illness, no one told him that he had cancer. Moreover, thegrandmother devotedly cared for her husband, although
there were times when she broke down in tears whenleaving the hospital. Following this, since no therapeutic effect was expected, in-home palliative care wascommenced. As a goal of this in-home palliative care,the family planned to visit a field that the grandfather
loved. However, as the grandfather’s physical strength
was rapidly deteriorating owing to worsening pathology,
they were unable to travel. Even then, the grandmothercontinued to care for her husband with the hope that
he may be able to visit the field at another time. At thattime, one of their grandchildren experienced extreme
stress, became emotionally exhausted and was incapableof caring for her grandfather any further. Shortly thereafter, the grandchild’s mother was also diagnosed withterminal cancer. Although the mother was aware of her
cancer, she cared for the grandfather through his final
days. After the grandfather died, all his family members
reported feeling like ‘empty shells’. The situation got so
out of control that the family members stopped getting
along with each other. The grandchild became distressedover her family’s situation, which had fallen apart, andeven considered suicide to join her grandfather. Even
after the grandfather’s death, the grandmother continued
to work quietly on the field that he had loved. Three
years after his death, the grandchild got married and hada child, which reunited the family.

Considerations
Occupation was categorised into 3 types: (i) continued, (ii) resumed and (iii) interrupted. Based on thesecategories, we examined the impact that the occupational performance patterns and the occupation of familiesof patients with terminal cancer had on alterations in themental state as follows:[Occupation continued type] Activities such as
gardening, birthday parties, conversations, dining andleisure activities enjoyed with the patients with cancer
as they fought their illnesses was a factor in promoting
communication. These occasions provided social opportunities for families of patients with cancer, who tended
to become absorbed in providing care, and offered
opportunities to ameliorate stress [10]. In addition, continuing such occupation after the patients’ death lessened
excessive grief and the feeling of sudden change. The
immediate family’s image appeared to remain unbroken
in the minds of other family members, and the increased
improvement in grief suggested that these activities
contributed to strengthening familial relationships. Furthermore, it is thought that the experience of working
together with others in various ways such as writing adiary, taking pictures, or writing a songbook (not only
during but also after the battle with illness) helped
family members to embrace their feelings. In a reporton family and social functions and other activities thatprovide family members with a sense of identity andpurpose, Keesing et al. [11] noted that after the deathof a family member, looking back to the occupaton ofplanning the memorial service and otherwise expressing
their feelings appears to help the family members sortout their feelings.

Minami S et al.

Asian J Occup Ther 12: 29−36, 2016

[Occupation resumed type] The hobbies and interests that the families of patients with terminal cancer
gave up while the patient was fighting against the illness
were resumed after the patient’s death. During the illness, caregiving for the patient was the highest priority;
thus, hobbies and interests were abandoned. However,as they were no longer required to provide care after thepatient’s death, former hobbies and interests could beresumed. Words of gratitude from the patients before
death often served as a trigger for the resumption of pasthobbies and interests, along with a sense of accomplishment from having provided in-home care to the patient.
To have the opportunity to resume a former hobby, thefamily member must be able to resume occupation at
any time [12]. In other words, when abandoned activities
that had formerly been performed on a daily basis wereresumed, it offered some respite to the family members
after the patient’s death, which suggested an opportunity
to promote a sense of closure.
In the ‘occupation interrupted type’, family members of patients with terminal cancer were dedicatedto caring for the patients with the hope of recovery.
However, such care was not rewarded and these hopes
did not come true. In such cases, the bond between thefamily members and patients does not always become
stronger through occupation during the illness. In addition, there are no comforting memories of the caregiving
experiences to aid in alterations in the mental state
after death. For them, everything is lost. The resulting
long-term unexpected loss of occupational deprives thefamily members of something that is necessary for a
person to survive [13−15]. Therefore, we believe that weneed to provide people with occupation that can connect
these patients with their families before death, as a formof occupational therapy. Pickens and Pizur-Barnekow[16] referred to the significance of collaboration as follows: ‘People tend to characterise the meaning of life byinteracting with each other’. It is thought that facilitating
communication through cooperative occupation plays arole in deepening the bonds of patients and their families
and characterizing the meaning of the patients’ lives.
Furthermore, in occupational therapy, it is thought that
it is important to propose environmental adjustments sothat the families can continue their work even after thepatients’ deaths [4]. Clark [17, 18] pointed out that occupation plays a central role in the existence of humanbeings and adds meaning to life. It has been suggested
that offering work to family members provides the opportunity to prepare for and confront grief even after thepatients’ deaths [4].

35

Future challenges and limitations
We believe that it is necessary to further elucidate
occupational performance patterns, including pathological grief, experienced by families of patients with terminal cancer. Moreover, to confirm the generalizability androbustness of this model, it is necessary to perform further analysis in a quantitative study design and to measure triangulation. To achieve proper understanding ofsuch situations, it is necessary to implement a research
design with qualitative and quantitative measures.
Acknowledgements: We would like to sincerely thankeach of the families that participated in the study bygiving interviews about painful times in their lives.

References[1] Lindemann E. Symptomatology and management of
acute grief. American Journal of Psychiatry. 1944; 101:
141−48.
[2] Caplan G. An Approach to Community Mental Health.
Taylor and Francis Inc.; 1961.
[3] Dunton WR. Reconstruction therapy. Philadelphia: W.B,
Sauders; 1919; 10.
[4] Minami S, Kobayashi R, Kyougoku M, Matuda I. Occupational experiences of and psychological adjustment byfamily members of cancer patients. Hong Kong Journalof Occupational Therapy. 2013; 23: 32−8. Available
from: http://www.sciencedirect.com/science/article/pii/
S1569186113000259[5] Strauss A, Corbin J. Basics of qualitative research:
Grounded theory procedures and techniques. Newburg
Park, CA: Sage; 1998.
[6] Parkes CM. Complicated grief: The debate over a new
DSM–V diagnostic category. In KJ Doka (Ed.), Livingwith grief: Before and after the death. Washington DC:
Hospice Foundation of America; 2002; 139−51.
[7] Prigerson HG, Maciejeski PK. A call for sound empirical testing and evaluation of criteria for complicatedgrief proposed for DSM–V. Omega. 2006; 52(1): 9−19.
Available from: http://dx.doi.org/10.2190/ANKH-BB2HD52N-X99Y[8] Matsumura N. Theoretical sampling of text data. IEICESIG Notes. 2011; WI2-2011-53: 27e28.
[9] Sato I. Situteki de-ta bunsekihou (genri · houhou · jissen)(in Japanese). Tokyo: Shinyosha; 2010.
[10] Kielhofner G. A model of human occupation, Theory andapplication 3rd ed. Baltimore: Lippincott, Willams andWilkins; 2002.
[11] Keesing S, Rosenwax L, McNamara B. Doubly deprived:
A post-death qualitative study of primary carers ofpeople who died in Western Australia. Health and Social
Care in the Community. 2011; 19(6): 636−44. Available
from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-

36

An Occupational Performance Patterns of Family Members of Terminal Cancer Patients

2524.2011.01005.x/full[12] Wilcock AA. A theory of the human need for occupation. Journal of Occupational Science. 1993; 1(1): 17−24.
Avaiable from: http://www.tandfonline.com/doi/abs/10.1
080/14427591.1993.9686375#.VSZH0_AgwxI[13] Whiteford G. Occupational deprivation and incarceration.
Journal of Occupational Science. 1997; 4(3): 126−30.
Available from: http://www.tandfonline.com/doi/abs/10.1
080/14427591.1997.9686429#.VSZHCPAgwxI[14] Whiteford G. Occupational deprivation: global challenge
in the new millennium. British Journal of Occupational
Therapy. 2000; 63(5): 200−4. Available from: http://bjo.
sagepub.com/content/63/5/200.short?rss=1&ssource=mfc[15] Whiteford G. When people cannot participate: Occupational deprivation In Christiansen C, Townsend EA (Eds.),
Introduction to occupation: The art and science of living.

Upper Saddle River, NJ: Prentice Hall; 2004; 221−42.
[16] Pickens ND, Pizur-Barnekow K. Co-occupation: Extend­
ing the dialogue. Journal of Occupational Science. 2009;16(3): 151−6. Available from: http://www.tandfonline.
com/doi/abs/10.1080/14427591.2009.9686656#.VSZD_
fAgwxJ.
[17] Clark FA. Occupation embedded in a real life: Interweaving occupational science and occupational therapy: 1993
Eleanor Clarke Slagele Lecture. American Journal of
Occupational Therapy. 1993; 47(1): 1067−78.
[18] Clark FA. The concepts of habit and routine: A preliminary theoretical synthesis: Habits I conference. Occupational Therapy Journal of Research. 2000; 20: 123S−37S.
Available from: http://otj.sagepub.com/content/20/1_
suppl/123S.abstract

■ORIGINAL ARTICLE

The characteristics of the pencil gripof 6−7-year-old children in Japan
Satoshi Sasada
School of Rehabilitation, Kanagawa University of Human Services

Abstract: The purpose of this study is to clarify the patterns of 6−7-year-old children’s pencil grip in Japan, and to clarify the relationship between grip pattern and gender. The participants were 80 first graders in the regular class of an elementary school (40 boys, 40 girls). Of the 80 children, 20 percent implemented a standard pencil grip. Additionally, 60
percent of the children held their pencil with three fingers, and 70 percent held their pencil near the tip. Analyses wereconducted to determine factors related to gripping the pencil near the tip, and this practice was found to significantly
differ with respect to thumb IP joint flexion. There was no significant difference regarding the position of the thumb,gender, and the number of fingers that touch the pencil. The data revealed that about 20 percent of 6- and 7-year-old
children implemented an average pencil grasp.
Keywords: pencil grip, handwriting, position of holding a pencil(Asian J Occup Ther 12: 37−41, 2016)

Introduction
In Japan, the educational system for children withphysical and mental disabilities was converted from“Special Education” to “Special Needs Education,”starting in 2001. Ministry of Education, Culture, Sports,
Science and Technology (MEXT) [1] is described asfollows. Formerly, special schools had been establishedseparately by type of disability, such as “Schools for
the Blind,” “Schools for the Deaf,” and “Schools for
the Intellectually Disabled, the Physically Disabled andthe Health Impaired.” However, the number of children
with multiple disabilities has been increasing, and inorder to appropriately meet their needs, the School Education Law was partially amended and enacted in 2007.
Under the new “Schools for Special Needs Education”
system, one particular school can accept children withseveral types of disabilities. “Special Needs Education”
is for students with disabilities, in consideration of theirindividual educational needs; it aims to fully develop
each child’s capabilities, independence, and social
Received: 13 January 2015, Accepted: 22 Junuary 2016
Corresponding to: Satoshi Sasada, School of Rehabilitation, Kana­
gawa University of Human Services, Heiseicho 1-10-1, Yokosuka
City, Kanagawa Prefecture, Japane-mail: sasada@kuhs.ac.jp©2016 Japanese Association of Occupational Therapists

participation. “Special Needs Education” is carried out
in various forms, including resource rooms and specialclasses within regular schools, and in special schools
named “Schools for Special Needs Education.” “Special
Needs Education” provided in regular schools serves
children with many disabilities, including speech impairments, autism, emotional disturbances, low vision,
hearing impairments, learning disabilities (LD), andattention-deficit/hyperactivity disorder (ADHD). Withthe “Special Needs Education” system, research inschool-based occupational therapy settings has increased[2, 3]. Handwriting is indicated as an example of a topic
requiring consultation between occupational therapists
and teachers [4, 5]. From the author's experience, requests from teachers for occupational therapy services
for handwriting involved more boys than girls. This isdue to the fact that many boys are writing characters bygripping the point of the pencil. As was exhibited in aprevious study, there is research that has analyzed how
typical children and children who exhibit a developmental delay hold a pencil [6−15]. There are, however, few
prior studies in occupational therapy that involve how aJapanese child should hold a pencil [16, 17]. Therefore,
the purpose of this study is to clarify the pattern of
pencil grip of children from 6- to 7 years old in Japan,
and to clarify the relationship between grip pattern andgender. This study also seeks to obtain fundamental datafor developing a handwriting intervention program in

38

The characteristics of the pencil grip of 6−7-year-old children in Japan

Japan.

MethodParticipants
The participants were 80 first graders from theregular class of an elementary school (40 boys, 40 girls).
The age range was from 6- to 7 years old. Consent for
research was obtained from the school’s principal andteachers.
The criteria for pencil grip
The criteria for optimal pencil grip were based on
the model in a Japanese textbook, and are shown in Fig.
1.
• Three fingers are used to hold the pencil.
• These are the thumb, index finger, and middle finger.
• The pulp of the thumb presses down on the pencil.
Hold position (distance from pencil tip)
When the hold position was 1 inch from the tipof the pencil, it was judged as being suitable. Two unsuitable hold patterns were also identified. If the conepart of the pencil was held, it was judged as proximity.
When the pencil was held from the core at more than 1
inch from what is considered suitable, it was judged as
distality (Fig. 2).
ProtocolEach child sat in a chair and wrote a line on A4
paper with a pencil. As the children wrote, each child’shand was photographed with a digital camera.
Survey Items
The following aspects were noted for each child during
the handwriting task:
1) The number of fingers holding the pencil
2) The position of the fingers holding the pencil
3) The position of the thumb on the pencil

Fig. 1. The standard way to hold a pencil.

• The position of the thumb was checked, and it wasnoted whether or not the pulp of the thumb pressed
down on the pencil.
• It was also noted whether the angle of the IP joint of
the thumb was flexed too much.
Two therapists, employing the above criteria,
analyzed each photograph to determine whether the
standard pencil grip was used.
Statistical analysis
The number and rate were computed for each item.
A chi-squared test and multiple linear regression wereapplied to the data.

Results
Grip pattern and gender
As shown in Fig. 3, about 20 percent of the children
used a standard pencil grip.
A non-standard pencil grip was observed in almost
80 percent of the children, regardless of gender (Figs. 4& 5).
There was no significant difference between boys
and girls in regard to pencil grip (χ2(1) = .478, ns).
Three- and four-finger grip
Sixty-two percent of the children held the pencil
with three fingers (Fig. 6).
More girls than boys gripped the pencil with four
fingers (Figs. 7 & 8).
The use of a three- versus four-finger grip did not
significantly differ between genders (χ2(1) = .471, ns).
Position of fingers holding the pencil
Seventy-four percent of the children gripped near
the tip of the pencil (Fig. 9).
The position of the fingers did not significantly
differ with respect to gender (χ2(2)= 1.898, ns). The

Fig. 2. The position of the fingers of holding the pencil.

Asian J Occup Ther 12: 37−41, 2016

Fig. 3. Pattern of pencil grip (n = 80).

Sasada S

Fig. 6. Number of fingers used to hold pencil (n = 80).

Fig. 4. Pattern of pencil grip for girls (n = 40).

Fig. 7. Number of fingers used to hold pencil for girls (n = 40).

Fig. 5. Pattern of pencil grip for boys (n = 40).

Fig. 8. Number of fingers used to hold pencil for boys (n = 40).

39

40

The characteristics of the pencil grip of 6−7-year-old children in Japan

Fig. 9. Distance of fingers touching pencil (n = 80).

frequency of holding a pencil too close to the tip did
not significantly differ in regard to the position of thethumb, gender, and the number of the fingers touching
the pencil. However, it significantly differed with respect to thumb IP joint flexion ( p < .05).
Position of the thumb
The position of the thumb did not significantly
differ with respect to the number of fingers touching the
pencil (χ2(1) = 1.083, ns).

Discussion
For the first grader, handwriting is a skill that must
be mastered [18]. Regarding the relationship between
pencil grip and gender, anecdotally, it appears that boys
are more likely than girls to exhibit an immature pencil
grip. During the course of this study, it was observedthat the rate of girls exhibiting the correct pencil grip
was slightly higher than that of boys. When analyzed
statistically, however, the data revealed that pencil grip
and gender are not related. Pencil grip, therefore, cannot
be judged by gender in the sense that “boys have atendency, more so than girls, toward exhibiting an immature pencil grip.” We need to warn school personnel
and others against judging an awkward pencil grip as
simply a gender difference. Regarding the developmental progression of pencil grip, 3−4-year-old children use
a static 3-finger grip, and gain a dynamic 3-finger gripby 4- to 5 years. Therefore, it seems logical to assume
that most children should have mastered the 3-finger
pencil grip by the age of 6 or 7 years. However, the data
revealed that only 21% of the children studied were im-

plementing the dynamic three-finger grip, which was a
low rate compared to what was expected. As is shown in
Fig. 6, about 40 percent of the children held the pencil
using four fingers; these children were not fully capableof holding the pencil with three fingers. Schneck andHenderson [7] point out that about six- to seven-tenthsof 6-year-olds use a dynamic three-finger grip. On theother hand, the dynamic three-finger grip is not usedamong 6- to 7-year-old children. It is speculated thatthe three-finger and four-finger grips are intermingled
among 6- to 7-year-old children. Factors related toholding a pencil near the tip were not clarified in thisresearch. Future studies should investigate conduct
longitudinal investigations from the first to sixth grade.
About 70 percent of the children were holding the pencil
too close to the tip. This shows that the child is writing
such that the characters and the fingers are very near.
Proximal hold of the pencil was related to bending the IP
joint of the thumb. This is due to the fact that when thecone part of a pencil is held, in order to write well, children have to press down on the cone part by the finger
pad of the thumb. Furthermore, the child may lean the
body in order to write a character,. It is said that it has apencil in 1 inch of distance from the core of a pencil [19].
But, the influence by hold of the cone part of a pencil
is not described. A limitation of this research is that itwas not able to clearly describe the relationship between
grip method and posture. Handwriting is influenced by
not only finger motion but also the position of the trunkand legs. Therefore, for future research, it is necessary
to investigate the relationship between the method ofgripping a pencil and body posture.
Acknowledgement: The author thanks the children
who cooperated with this study, as well as the school
officials.

References[1] Ministry of Education, Culture, Sports, Science and Technology (MEXT). 2014. Special Needs Education. Available from: http://www.mext.go.jp/english/elsec/1303763.
htm[2] Yoshikawa M, Sasada S. Roles and points of view as
occupational therapists working in school for children
with special needs. (in Japanese) The Japanese Journal of
Occupational Therapy. 2012; 46: 1034−6.
[3] Iwanaga R. Therapy and Support for Children with
Developmental Disabilities –A Sensory and Motor Approach–. (in Japanese) The Journal of Child Health. 2013;
72: 473−9.
[4] Nagai N, Sasada S, Arikawa M, Sugiyama I. Needs investigation of the occupational therapist in Kanagawa inthe visit to an elementary school. (in Japanese) The Jour-Asian J Occup Ther 12: 37−41, 2016

nal of Kanagawa Occupational Therapy Reserch. 2013; 3:
21−5.
[5] Sasada S. Intervention of OT to the Developmental
Coordination Disorder child by the visit to an elementary
school. (in Japanese) The Japanese Journal of Occupational Therapy. 2014; 48: 394−8.
[6] Bergmann KP. Incidence of atypical pencil grasps among
nondysfunctional adults. The American Journal of Occupational Therapy. 1990; 44: 736−40.
[7] Schneck CM, Anne Henderson A. Descriptive analysis of
the developmental progression of grip position for pencil
and crayon control in nondysfunctional children. The
American Journal of Occupational Therapy. 1990; 44:893−900.
[8] Schneck CM. Comparison of pencil-grip patterns in first
graders with good and poor writing skills. The American
Journal of Occupational Therapy. 1991; 45: 701−6.
[9] Dunn W. Models of occupational therapy service provision in the school system. The American Journal of
Occupational Therapy. 1988; 42: 718−23.
[10] Ziviani J. Qualitative changes in dynamic tripod grip
between seven and 14 years of age. Developmental Medicine and Child Neurology. 1983; 25: 778−82.
[11] Van Waelvelde H, Hellinckx T, Peersman W, SmitsEngelsman BC. SOS: a screening instrument to identify
children with handwriting impairments. Physical & Occupational Therapy in Pediatrics. 2012; 32: 306−19.
[12] Engel-Yeger B, Rosenblum S. The effects of protracted
graphomotor tasks on tripod pinch strength and handwrit-

Sasada S

41

ing performance in children with dysgraphia. Disability
and Rehabilitation. 2010; 32: 1749−57.
[13] Koziatek SM, Powell NJ. Pencil grips, legibility, andspeed of fourth-graders’ writing in cursive. American
Journal of Occupational Therapy. 2003; 57: 284−8.
[14] Overvelde A, Hulstijn W. Handwriting development ingrade 2 and grade 3 primary school children with normal,
at risk, or dysgraphic characteristics. Research in Developmental Disabilities. 2011; 32: 540−8.
[15] Schwellnus H, Carnahan H, Kushki A, Missiuna C,
Polatajko H, Chau T. Effect of pencil grasp on the speed
and legibility of handwriting in children. American Journal of Occupational Therapy. 2012; 66: 718−26.
[16] Ikeda C, Nakajima S, Gotou Y, Nakamura Y, Takizawa S,
Sengoku Y. The relation between subjective and quantitative evaluation and handwriting legibility. (in Japanese)
Japanese Journal of Occupational Therapy in Pediatrics.
2013; 2: 39−45.
[17] Sakamoto K, Nakajima S, Sera G, Ohyanagi T, Sengoku
Y. Relationship between the ability to draw a line andother abilities of clumsy children with developmental
disorders. (in Japanese) Japanese Journal of Occupational
Therapy in Pediatrics. 2012; 1: 39−45.
[18] Smits-Engelsman BC, Niemeijer AS, van Galen GP. Fine
motor deficiencies in children diagnosed as DCD basedon poor grapho-motor ability. Human Movement Science.
2001; 20: 161−82.
[19] Katho Y. (Eds.) Shougaku shosya1. Tokyo: kyouikusyuppann; 2010.

■ORIGINAL ARTICLE

Development of a task-specific occupational therapy
training menu for the improvementof upper limb function in stroke patients
Kunji Shirahama1, Masatoshi Gocyou2, Tomomi Morita3, Taeko Kitahashi4,Tomonori Yasuda5
1

Kanagawa University of Human Service, Faculty of Health & Social Services, School of Rehabilitation,
Division Occupational Therapy
2
Kawasaki Rinko General Hospital
3
Shonan Central Hospital4
IMS Itabashi Rehabilitation Hospital
5
Kumamoto Health Science University

Abstract: Rehabilitation for stroke patients requires a large amount of high-quality, intensive training. However, formost patients, use of the paralyzed upper limb is avoided in daily life outside of rehabilitation therapy. The purpose ofthis study was to devise a menu of tasks for improving upper limb function in patients with hemiplegia after stroke. Participants included 39 occupational therapists with experience in treating patients with hemiplegia after stroke. The tasks
were organized and rewritten as 26 items on a questionnaire. Participants were asked to consider the tasks for inclusionin the upper limb function task menu. The participants identified the lowest possible Brunnstrom recovery stage (BRS)
for the upper limb and fingers required to complete each task. In accordance with the Delphi method, this study was
conducted in three rounds. The final round included 32 occupational therapists with an average of 4.40 ± 3.00 years ofexperience. The mean score (±SD) for evaluation of the tasks in this round was 3.85 ± 0.63 and the median value was
3.85. The same mean value of 3.0 was chosen to represent recommendation to adopt a task. In the final round, 100.0%(26/26) of the tasks were selected for adoption. The mean value (±SD) for the lowest BRS for the paralyzed upper limb
was 4.26 ± 0.41 (median, 4.15) and that for the fingers was 4.57 ± 0.46 (median, 4.62). Results indicated that these tasks
would be useful for upper limb functional training for stroke patients. The most important aim of occupational therapy
is to make patients aware of what movement is possible. The role of occupational therapists is to provide task-specifictraining by using a feasible upper limb function task menu that demonstrates ability to improve upper limb function inpatients undergoing occupational therapy after a stroke.
Keywords: task specific training, training menu, stroke(Asian J Occup Ther 12: 43−51, 2016)

Introduction
Stroke rehabilitation for patients with hemiplegia
after stroke involves incorporation of facilitation techniques. Traditional neurological treatment approaches
have been used to construct an efficacious motor recovery intervention strategy [1]. However, meaningful
Received: 12 April 2014, Accepted: 2 February 2016
Corresponding to: Kunji Shirahama, Kanagawa University of Human
Service, Faculty of Health & Social Services, School of Rehabilitation, Division Occupational Therapy, 1-10-1, Heiseicho, Yokosuka,
Kanagawa, 238-8522, Japan.
e-mail: shirahama-k@kuhs.ac.jp©2016 Japanese Association of Occupational Therapists

task-specific programs (such as reaching for an object
that is presented) are reportedly more effective thantherapy using these traditional approaches [2]. Furthermore, rehabilitation after stroke is intensive; however,functional training using range of motion exercises andspecific facilitation techniques involves only passive
participation. Task-specific therapeutic intervention
provides practical, daily behavioral training in which
positive changes can actually be experienced. Currently,
there are a number of reports involving various rehabilitation approaches after stroke [3], including virtual
reality-based rehabilitation systems [4]. Rehabilitation
for stroke patients requires a large amount of high-quality intensive training [5]. Patients undergoing intensive

44

Development of a task-specific occupational therapy training menu

training received at least 16 hours more treatment timein the first 6 months after stroke compared to patients
receiving traditional therapies [6], and the amount oftraining was increased incrementally each day [7].
However, in most cases, the frequency of use of theparalyzed upper limb is extremely low in patients withhemiplegia after stroke, and use of the paralyzed hand isavoided in daily life outside of rehabilitation therapy.
The feasibility of use of high repetition exercises(reaching, grasping, manipulating, transporting, andreleasing) as part of a task-specific approach has beenreported in investigations involving therapies that are
different from those currently delivered in routine clinical practice [8]. This new rehabilitation strategy wasdeveloped based on the results of animal experiments[9] and human motor learning and psychology studies[10]. The task-specific approach focuses on repeatedpractice of tasks in which the subject is conscious of
specific learning objectives and has strong motivation to
improve functional performance. This training method
involves focusing on the performance of specific tasks.
It is superior to simple, repetitive practice of mechanicalactions, such as flexion of the elbow joint, which havebeen shown to have no effect on functional performance
and/or cortical reconstruction [11, 12]. Performing specific tasks for the purpose of rehabilitation aids functional recovery in the upper limbs, affects brain activation
patterns [13], and facilitates functional reconstruction of
the cortex [14].
The effectiveness of constraint-induced movement
therapy (CI therapy) for upper limb functional training
after apoplexy has been widely reported [15]. Rehabilitation therapy can involve combining CI therapy
with the task-specific approach and other intervention
methods. Eating, grasping, using a spoon, and picking
up objects [16] have been among the tasks utilized inthis approach. However, voluntary extension of thewrist joint and fingers is an adaptive criterion in CI
therapy; thus, the application of this special therapy islimited to subjects with mild paralysis. Furthermore, CI
therapy constrains the non-paralyzed limb, which raises
concerns about ethical issues and may increase stress onpatients.
On the other hand, task-specific therapy involves
repetition of multiple tasks. Significant functional improvement in the paralyzed upper limb was observed
after repetition of eight different tasks [17], corticalreconstruction was seen after performance of six different tasks [18], and reconstruction of the activation site
was seen after performance of a tracking task [19]. In
addition, intensive performance of task-specific training
associated with activities of daily living reportedly
changes cortical activity [20]. Finally, task-specificupper limb functional training has an effect on restructuring and restoration of brain function.
Therefore, the purpose of this study was to devise
a task menu for improving upper limb function fortherapeutic purposes for use in treatment of patientswith hemiplegia after stroke. This upper limb function
task menu was designed to include tasks that could be
performed with daily items.

Methods
Participants
The participants included 39 occupational therapists
from nine hospitals with experience in treating patientswith hemiplegia after a stroke.
In this research, the subjects were selected bysnowball sampling from among occupational therapists
belonging to the Japanese Association of Occupational
Therapists.
Sample size
In order to detect significant differences within
our data, it was necessary to calculate the sample size
required for the chi square test. We determined that
we needed a minimum sample size of 32 to satisfy thefollowing conditions: a significance or alpha (α) level of
0.05, a statistical power of 0.8, and an effect size of 0.5(high) [21] by G*power 3 [22]. A total of 39 participants
were recruited to compensate for possible dropouts (10%of the estimated sample size).
Questionnaire method
A questionnaire was distributed to the occupational
therapists in order to acquire information about tasks
that would facilitate improvement of upper limb function in the paralyzed limb in patients with hemiplegia
after stroke. This research was conducted between September 2012 and January 2013 in accordance with theDelphi method [23]. The Delphi method is a qualitative
research method that merges the opinions of subjects
with specialist knowledge in a given field by referring toeach subject’s views several times.
In this study, we distributed our questionnaire forself-completion by mail. The consensus process required
the questionnaire to be completed three times (Rounds
1−3). Thus, the results of previous iterations regardingtask-specific training items were adopted or rejected byindividual participant members in later iterations basedon their ability to review and assess the comments andfeedback provided by the other participants. Round 1:
In the first round, the questionnaire provided the list of
twenty-seven tasks and asked each participant to list
as many responses as possible. Round 2: In the second

Asian J Occup Ther 12: 43−51, 2016

round, each participant received a second questionnaire
and was asked to review the items summarized by
the investigators based on the information provided
in the first round. Round 3: In the third round, the listof remaining items, their ratings, and items achieving
consensus were distributed to the participant. This roundprovided a final opportunity for participants to revise
their judgments (Fig. 1).
The tasks being evaluated for inclusion on theupper limb function training menu were selected fromprevious studies. The tasks chosen were those whose
therapeutic effects had been confirmed in previous
studies: arm ability training, or AAT [17], task-oriented
training, or TT [18], shaping tasks from CI therapy [24],and tracking training [19]. We reorganized the adoption
criteria from the 80 tasks into the following categories:
AAT: 8 tasks, TT: 6 tasks, Tracking tasks: 1 task, Shaping tasks: 60 tasks, other: 5 tasks.
Inclusion criteria were the following: the tasksneeded to be performed while sitting down, to involve
repeated handling of objects, and to use the paralyzed
upper limb. In addition, each task had to be performablewithin a time limit of 1minute.The tasks were organized
and rewritten as 26 items on the training menu. Participants were asked to consider the tasks for inclusion in
the upper limb function training menu. The tasks required patients to reach the lowest Brunnstrom recovery
stage (BRS).

Fig. 1. Delphi method.

Shirahama K et al.

45

First RoundIn the first round, the participants were asked toanswer two questions about the proposed tasks to be
included in the upper limb function training menu
The first question asked the participants to identify the
degree of movement ability required to carry out eachtask (the lowest BRS for the upper limb and fingers; I,
II, III, IV, V, or VI). They were then asked to evaluate
the appropriateness of each task for use with patients
experiencing hemiplegia after a stroke (1: adopted; 2:
rejected).
Second RoundFor the second round, the results from the firstround were mailed to all participants, who also received
a newly created training implementation manual. Participants re-examined the tasks with reference to the opinions of other participants from the first round. Because
many of the tasks were adopted in the first round, in thesecond round participants were asked to choose fromfive options regarding the suitability of the items on thelist for inclusion on the upper limb function training
task menu. Items were scored on a scale from 5 (verysuitable) to 1 (not suitable). Tasks were rated as follows:
1; not suitable, 2; suitability uncertain, 3; somewhat
suitable, 4; suitable, 5; very suitable. The results of thesecond round questionnaire were used to determine thata value of 3 would determine whether the task would be
adopted. Other questionnaire items remained unchanged.

46

Development of a task-specific occupational therapy training menu

Third RoundThe third round consisted of the same questionnaire
items as the second round, in the same answer format.
Participants re-examined the list of upper limb function
training tasks with reference to the opinions of the otherparticipants from the second round.
Analytical methods
Scores were obtained for all tasks in all threerounds. Mean values, standard deviations (SD), andmedian values for adoption or rejection of tasks and thelowest BRS required for the upper limb and fingers were
calculated and analyzed. The task evaluation score data
were statistically analyzed using the binomial test. Statistical analysis was performed using SPSS version 20.0.
In all analyses, p < 0.05 was considered statisticallysignificant.
Ethical considerations
Written explanations were mailed to all participants
regarding the purpose of the study. Participation was
voluntary. Participants were informed that withdrawal
from the study was permitted at any time. The occupational therapists selected as participants were those who
understood the content of the study and gave writtenconsent for participation. Approval for this study was
obtained from the Kanagawa University of Human
Sciences Research Ethics Committee (approval number:
23-045).

Results
The number of participants in the survey
In the first round, 34 participants (87% response
rate, 13 men and 21 women) with an average of 4.35
± 2.66 years of experience (mean ± SD) completed thequestionnaire. The second round included 33 participants (97% response rate, 13 men and 20 women) withan average of 4.38 ± 2.62 years of experience. The thirdround included 32 participants (97% response rate, 12
men and 20 women) with an average of 4.40 ± 3.00
years of experience.
Task evaluation
First RoundIn the first round, participants decided either toadopt (1 point) or reject (2 points) the upper limb function training tasks from the list provided in the questionnaire. The mean value (± SD) for the 26 items was 1.11
± 0.09 and the median value was 1.10. Of the 26 items,
24 (92.31%) were scored between 1.00 and 1.25, andtwo items (7.69%) were scored between 1.26 and 1.50.
Thus, in the results of the first round, most participantschose to adopt the listed tasks.
Second RoundIn the second round, the mean score (± SD) for theevaluation of task suitability was 3.79 ± 0.39 and the
median value was 3.86. Scores between 4 and 5 were recorded for 38.46% of the items (10/26), while scores ofbetween 3 and 4 were recorded for 57.69% of the items(15/26) and scores between 2 and 3 were recorded for
3.58% (1/26). The mean cutoff score of 3 was chosen to
represent recommendation to adopt the item on the taskmenu. Thus, 96.15% (25/26) of the tasks on the list wereselected for adoption. The task that was not adopted was“flipping a switch.”
Third RoundThe third round consisted of the same questionnaire
items and answers as the second round. The mean score(± SD) for evaluation of the tasks in this round was
3.85± 0.63 and the median value was 3.85. Scores ofbetween 4 and 5, between 3 and 4, and between 2 and 3
were recorded for 38.46% (10/26), 61.54% (16/26), and
0% (0/26) of the items, respectively. In the third round,
100.0% (26/26) of the tasks were selected for adoption(binominal test, p < 0.05). In all, 79 (100%) of the tasks
were adopted, since they received an evaluation score of
3 or more. The tasks were listed in Table 1 and Table 2
shows detailed results.
The task evaluation score data were statisticallyanalyzed using the binomial test (Table 3). There were
statistically significant differences in adoption rates.
Lowest BRSFirst RoundIn the first round, the mean value (± SD) for thelowest BRS for the paralyzed upper limb was 4.40 ± 0.58
and the median value was 4.27. The lowest BRS ratingsof IV–V were observed for 96.15% of items (25/26), andratings of III–IV were recorded for 3.85% (1/26). For
the fingers, the mean value (± SD) for the lowest BRS
was 4.62 ± 0.63 and the median value was 4.67. The
lowest BRS ratings of V–VI were observed for 19.23%
of items (5/26), while 76.92% were rated IV–V (20/26),
and 3.85% were rated II–III (1/26). The lowest BRS
rating of IV or above accounted for the majority of theitems requiring use of both the upper limbs and fingers.
Second RoundIn the second round, the mean value (± SD) for thelowest BRS for a paralyzed upper limb was 4.31 ± 0.48
and the median value was 4.15. The lowest BRS ratingsof IV–V were observed for 96.15% of items (25/26) andratings of II–III were seen for 3.85% (1/26). The meanvalue (± SD) for the lowest BRS for the fingers was 4.60
± 0.55 and the median value was 4.65. The lowest BRS
ratings of V–VI were observed for 23.08% of items

Shirahama K et al.

Asian J Occup Ther 12: 43−51, 201647

Table 1. Tasks list.
1 Pick up bean bags and lift them to your mouth, then place them on the table
2 Wipe a bowl with a cloth
3 Pick up clips and place them in a container
4 Solve computational problems on a calculator
5 Pick up five of one, five, and 10 yen coins and place them in a box
6 Pick up small iron balls and place them in a container (2 types: 1.2 cm and 0.6 cm)
7 Draw hiragana, numbers and shapes
8 Flip switches
9 Fasten acrylic sheets together from different angles with clothes pegs
10 Wipe a table back and forth with a towel or place your forearm on a towel and move it back and forth and in circles
11 Fold a bath towel
12 Trace a 20-cm diameter circle clockwise and anti-clockwise with your index finger
13 Go through a maze with your index finger
14 Go through a maze with a pen
15 Stack Jenga blocks
16 Turn over and stack playing cards
17 Cut paper with scissors following a maze
18 Create a knot (a bow) and untie it
19 Move and stack four plastic cups
20 Reach for and grab plastic bottles, then move them. Unscrew and close the cap.
21 Pick up pens and place them in a penholder
22 Line cancellation test
23 Pick up tennis ball s and place them in a container
24 Roll tennis balls around on a tray without dropping them
25 Unscrew, take them apart, and tighten three types of bolts and nuts
26 Turn the page of a book

Table 2. Task evaluation.
Round 1Task

1: adopt;
2: reject

adop
(%)

dopt
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

32
33
30
26
33
30
31
25
34
33
31
28
27
28
31
31
30
34
29
33
33
25
33
27
34
33

94.1
97.1
88.2
76.5
97.1
88.2
91.2
73.5
100.0
97.1
91.2
82.4
79.4
82.4
91.2
91.2
88.2
100.0
85.3
97.1
97.1
73.5
97.1
79.4
100.0
97.1

Round 2Round 3

1: not suitable, 2: suitability uncertain,
3: somewhatsuitable, 4: suitable,
5: very suitable.
1

2

3

4

5

0
0
0
1
0
1
1
7
0
0
0
1
1
1
0
0
1
0
0
0
0
1
0
1
1
0

1
0
3
7
2
5
1
7
0
0
0
3
5
5
4
2
4
0
0
1
2
9
0
2
2
2

6
6
8
14
3
7
4
8
3
2
5
10
5
6
8
5
5
5
7
2
6
13
7
7
7
3

16
20
18
9
19
17
19
11
23
15
20
17
19
16
17
21
18
18
18
17
20
9
20
18
18
23

10
7
4
2
9
3
8
0
7
16
8
2
3
5
3
5
5
10
8
13
5
1
6
5
5
5

over3
(%)
97
100
91
76
94
82
94
58
100
100
100
88
82
82
85
94
85
100
100
97
94
70
100
91
91
94

1: not suitable, 2: suitability uncertain,
3: somewhatsuitable, 4: suitable,
5: very suitable.
1

2

3

4

5

0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0

0
0
0
0
0
1
0
4
0
0
0
3
1
2
0
0
1
0
0
0
1
7
0
0
0
0

2
2
5
24
2
7
7
24
4
2
2
12
12
9
7
5
6
4
4
1
4
20
7
8
5
2

23
24
24
7
26
23
21
4
24
22
25
17
20
20
21
26
21
21
23
23
24
5
23
23
26
25

8
7
4
1
5
2
5
1
5
9
6
1
0
2
5
2
5
8
6
9
4
1
3
1
2
6

over3
(%)
100
100
100
97
100
97
100
88
100
100
100
91
97
94
100
100
97
100
100
100
97
79
100
97
100
100

48

Development of a task-specific occupational therapy training menu

Table3. A Statistical analysis of task evaluation
Task

Ave

SD

Median

P

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

4.22
4.15
3.96
3.22
4.11
3.74
3.93
3.07
4.04
4.30
4.15
3.37
3.48
3.59
3.93
3.89
3.89
4.15
4.07
4.33
3.93
3.00
3.85
3.63
3.89
4.11

0.58
0.60
0.59
0.75
0.51
0.66
0.68
0.68
0.59
0.61
0.53
0.74
0.58
0.75
0.68
0.51
0.75
0.66
0.62
0.55
0.68
0.78
0.60
0.74
0.51
0.58

4.00
4.00
4.00
3.00
4.00
4.00
4.00
3.00
4.00
4.00
4.00
3.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
3.00
4.00
4.00
4.00
4.00

< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.02< 0.001< 0.001< 0.001< 0.001(6/26), 73.07% were rated IV–V (19/26), and 3.85%
were rated III–IV (1/26). The lowest BRS ratings of IV
or above accounted for the majority of items that had
been considered suitable according to the results of thequestionnaire. The only lower-rated task that had been
considered suitable was the towel task (BRS < IV).
Third RoundIn the third round, the mean value (± SD) for thelowest BRS for the paralyzed upper limb was 4.26 ± 0.41
and the median value was 4.15. The lowest BRS ratingsof IV–V and III–IV were observed for 96.15% (25/26)
and 3.85% (1/26) of the items, respectively. The meanvalue (± SD) for the lowest BRS for the fingers was 4.57
± 0.46 and the median value was 4.62. The lowest BRS
ratings of V–VI were observed for 7.69% of items (2/26),
80.77% were rated IV–V (21/26), 3.85% were rated III–IV (1/26), and 3.85% were rated II–III (1/26). Tables 4
and 5 give the detailed results for our study.

Discussion
In this study, three rounds of questionnaire administration were conducted using the Delphi method.
The occupational therapists participating in the study
were asked to evaluate tasks for improving upper limb
function for inclusion in a task-specific approach totreatment of patients with hemiplegia after stroke. The

results indicated that many occupational therapists choseto adopt the upper limb function tasks listed in the questionnaire as possible therapeutic techniques.
Task evaluation
The 26 tasks investigated in this study were used inprevious studies. However, the reason why these tasks
were adopted was not clear, for there were no inclusion
criteria given. These studies [17−19, 24] do not describe
how the tasks were selected for treatment of stroke patients. In our study, the participating occupational therapists determined the tasks to be appropriate according toinclusion criteria. Our results indicated that there were
statistically significant differences.
Among the 26 tasks, less than 90% of replies indicated that the switch task and the line cancellation test
should be adopted. The switch task is the only task involving an “ON/OFF” switch, which probably led to thedetermination that this task was too simple. On the other
hand, the line cancellation test requires use of a pen andwas determined to be difficult for stroke patients. In
addition, the score for the calculation tasks (No. 4), andthe task involving tracing a circle or a maze with theindex finger (No. 12 and No. 13) often received a scoreof 3 (somewhat suitable). The calculation task is difficult
because it requires complex movements of the finger
that are difficult for stroke patients; on the other hand,
the tracking task involved gross motor movement.
Most of the tasks were deemed suitable for taskspecific upper limb function training in all three rounds.
This suggests that these tasks would be useful for upper
limb function training for stroke patients.
Lowest BRS
The occupational therapists judged the 26 tasks
listed in the questionnaire to be suitable for rehabilitation of patients with moderate to mild paralysis (BRS
IV–VI). However, these tasks were deemed unsuitableas part of a training program for patients with severe
paralysis [24]. Inclusion of CI therapy shaping tasks in
the list may have influenced these results. CI therapy
shaping tasks are considered suitable for stroke patientswith mild paralysis of the upper limb and fingers. In
addition, task-specific upper limb function training involves moving items repeatedly, which requires a certain
amount of dexterity to reach out for and handle objects.
Further study is required regarding selection of suitable
tasks for stroke patients with low BRS.
The need for repetitive training
Many of the 26 tasks in this study were determinedby our participating occupational therapists to be appropriate for a stroke rehabilitation program. All of theShirahama K et al.

Asian J Occup Ther 12: 43−51, 201649

Table 4. Lowest BRS (U/E).
Task
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Round 1Round 2Round 3Ave

SD

Median

Max

Min

Ave

SD

Median

Max

Min

Ave

SD

Median

Max

Min

4.03
4.35
4.32
4.24
4.44
4.44
4.50
4.13
4.79
3.82
4.39
4.42
4.53
4.63
4.65
4.44
4.69
4.44
4.15
4.50
4.47
4.42
4.21
4.65
4.30
4.41

0.58
0.65
0.59
0.75
0.50
0.50
0.71
0.57
0.54
0.90
0.56
0.50
0.51
0.49
0.54
0.61
0.47
0.56
0.44
0.56
0.51
0.56
0.54
0.66
0.68
0.56

4.00
4.00
4.00
4.00
4.00
4.00
5.00
4.00
5.00
4.00
4.00
4.00
5.00
5.00
5.00
4.00
5.00
4.00
4.00
4.00
4.00
4.00
4.00
5.00
4.00
4.00

5.00
5.00
5.00
5.00
5.00
5.00
6.00
5.00
6.00
6.00
6.00
5.00
5.00
5.00
6.00
6.00
5.00
5.00
5.00
6.00
5.00
6.00
5.00
6.00
5.00
6.00

3.00
3.00
3.00
2.00
4.00
4.00
2.00
3.00
3.00
1.00
4.00
4.00
4.00
4.00
4.00
3.00
4.00
3.00
3.00
4.00
4.00
4.00
3.00
3.00
2.00
4.00

4.15
4.31
4.06
4.32
4.28
4.25
4.35
4.10
4.64
3.76
4.61
4.32
4.45
4.39
4.52
4.34
4.71
4.30
4.24
4.19
4.25
4.26
4.22
4.48
4.34
4.31

0.44
0.47
0.25
0.48
0.46
0.44
0.49
0.31
0.49
0.50
0.50
0.48
0.51
0.50
0.51
0.48
0.53
0.59
0.50
0.40
0.44
0.51
0.42
0.51
0.65
0.47

4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
5.00
4.00
5.00
4.00
4.00
4.00
5.00
4.00
5.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00

5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
6.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
6.00
5.00

3.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
3.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
3.00
3.00
4.00
4.00
3.00
4.00
4.00
3.00
4.00

4.07
4.30
4.04
4.19
4.11
4.07
4.30
4.04
4.59
3.74
4.59
4.07
4.19
4.26
4.63
4.30
4.74
4.37
4.30
4.19
4.26
4.37
4.15
4.48
4.19
4.15

0.27
0.47
0.19
0.48
0.32
0.27
0.54
0.19
0.50
0.53
0.50
0.27
0.40
0.45
0.49
0.47
0.45
0.49
0.47
0.40
0.45
0.49
0.36
0.51
0.48
0.36

4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
5.00
4.00
5.00
4.00
4.00
4.00
5.00
4.00
5.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00

5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
4.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00

4.00
4.00
4.00
3.00
4.00
4.00
3.00
4.00
4.00
2.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
3.00
4.00

BRS: Brunnstrom recovery stage, stage I = 1, stage II = 2, stage III = 3, stage IV = 4, stage V = 5, U/E: Upper Extremity
Table 5. Lowest BRS (Finger).
Task
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Round 1Round 2Round 3Ave

SD

Median

Max

Min

Ave

SD

Median

Max

Min

Ave

SD

Median

Max

Min

4.06
4.47
4.85
4.67
5.15
4.97
4.91
4.23
4.97
2.56
4.35
4.52
4.56
4.88
4.65
5.00
5.16
5.06
4.18
4.79
4.65
4.94
4.38
4.39
5.00
4.68

0.65
0.61
0.56
0.74
0.56
0.52
0.62
0.97
0.30
1.48
0.85
0.71
0.72
0.49
0.54
0.43
0.45
0.49
0.58
0.73
0.54
0.43
0.65
0.76
0.43
0.64

4.00
5.00
5.00
5.00
5.00
5.00
5.00
4.00
5.00
2.50
4.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
4.00
5.00
5.00
5.00
4.00
4.00
5.00
5.00

5.00
5.00
6.00
6.00
6.00
6.00
6.00
6.00
6.00
6.00
6.00
6.00
6.00
5.00
6.00
6.00
6.00
6.00
5.00
6.00
6.00
6.00
5.00
6.00
6.00
6.00

2.00
3.00
4.00
2.00
4.00
4.00
2.00
2.00
4.00
1.00
1.00
2.00
2.00
3.00
4.00
4.00
4.00
4.00
3.00
3.00
4.00
4.00
3.00
2.00
4.00
4.00

4.12
4.44
4.69
5.00
4.94
5.03
4.90
4.47
4.85
2.36
4.58
4.55
4.90
4.55
4.70
5.00
5.03
5.00
4.21
4.63
4.69
4.84
4.25
4.32
5.00
4.59

0.42
0.56
0.54
0.37
0.44
0.47
0.47
0.57
0.36
1.25
0.50
0.89
0.47
0.89
0.53
0.36
0.41
0.35
0.48
0.66
0.59
0.45
0.51
0.75
0.51
0.56

4.00
4.00
5.00
5.00
5.00
5.00
5.00
4.00
5.00
2.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
4.00
5.00
5.00
5.00
4.00
4.00
5.00
5.00

5.00
5.00
6.00
6.00
6.00
6.00
6.00
6.00
5.00
5.00
5.00
6.00
6.00
6.00
5.00
6.00
6.00
6.00
5.00
5.00
6.00
6.00
5.00
5.00
6.00
5.00

3.00
3.00
4.00
4.00
4.00
4.00
4.00
4.00
4.00
1.00
4.00
1.00
4.00
1.00
3.00
4.00
4.00
4.00
3.00
2.00
3.00
4.00
3.00
3.00
3.00
3.00

3.93
4.37
4.93
4.85
4.89
4.81
4.96
4.26
4.85
2.26
4.48
4.48
4.15
4.81
4.74
5.00
5.00
4.96
4.15
4.78
4.78
4.93
4.15
4.44
5.04
4.74

0.38
0.56
0.27
0.36
0.32
0.40
0.19
0.53
0.36
1.06
0.58
0.51
1.03
0.48
0.45
0.28
0.28
0.34
0.53
0.51
0.42
0.38
0.46
0.64
0.19
0.53

4.00
4.00
5.00
5.00
5.00
5.00
5.00
4.00
5.00
2.00
5.00
4.00
4.00
5.00
5.00
5.00
5.00
5.00
4.00
5.00
5.00
5.00
4.00
5.00
5.00
5.00

5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
6.00
5.00
6.00
6.00
6.00
6.00
6.00
5.00
6.00
5.00
5.00
6.00
6.00

3.00
3.00
4.00
4.00
4.00
4.00
4.00
3.00
4.00
1.00
3.00
4.00
1.00
4.00
4.00
4.00
4.00
4.00
3.00
4.00
4.00
4.00
3.00
3.00
5.00
4.00

BRS: Brunnstrom recovery stage, stage I = 1, stage II = 2, stage III = 3, stage IV = 4, stage V = 5.

50

Development of a task-specific occupational therapy training menu

following tasks were determined to be appropriate by allof the occupational therapists: beanbags task, wiping thebowl, clip task, the coin task, writing a letter, clothespintask, towel task, bath towel task, Jenga, trump task,
string task, cups task, PET bottles task, tennis balls task,
and bolts task. However, the usefulness of those specifictasks is limited to patients experiencing the degree ofparalysis found in relatively mild stroke patients.
In previous studies, reports demonstrating theeffects of task-specific training indicate that a large
amount of training must be performed [20]. The benefitsof a high intensity program are well established, withthe most important benefit being that rehabilitation
clinicians provide repetitive task training. It was an important finding that therapies involving high repetition
must involve feasible tasks [25]. Repetitive training that
includes practice of a particular movement involving
achievement of a specific goal during functional task
practice may improve specific impairment [26]. The
repetitive training is based on the fundamental principlethat repeated practice is the best way to learn a particular
task [14].
The importance of task training in occupational therapy
Patients may decide that functionality in the limb
has permanently declined and that rehabilitation is “notpossible.” The most important aim of occupational therapy is to make patients aware of what is “possible.” Therole of occupational therapists is to provide task-specifictraining using a feasible upper limb function task menu,
which may enhance patients’ sense of competency andability to bring meaningful functional gains. A taskspecific approach should include a variety of tasks thattake individual patient needs into account [27].
However, the practical application and therapeutic
effects of upper limb function tasks for stroke patients
must be investigated based on the results obtained fromthis study.

Conclusions
A group of occupational therapists was asked toevaluate upper limb function tasks for inclusion in arepetitive training task menu designed for treatment ofpatients with hemiplegia after stroke.
The role of occupational therapists is to provide
repetitive training using a feasible upper limb function
task menu.
Acknowledgements: I would like to give my special
thanks to other research members and occupational therapists who participated in our survey studies.

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■ORIGINAL ARTICLE

Prefrontal Cortex Activation during Writing and
Hand-Shape Changing Dual-Task Performance:
A Near-Infrared Spectroscopy Study
Noriko Yamaguchi1, Sayaka Okahashi2, Priscila Yukari Sewo Sampaio3,
Toshiko Futaki2
1

Division of Occupational Therapy, Department of Rehabilitation Medicine, Kobe Rehabilitation Hospital, Kobe, Japan
Division of Occupational Therapy, Department of Human Health Sciences, Graduate School of Medicine, Kyoto University,
Kyoto, Japan3
School of Physical Education, University of Campinas, Campinas, Brazil
2

Abstract: Aim: To clarify the characteristics of desktop dual tasks that cause dorsolateral prefrontal cortex (DLPFC)
activation. Methods: Subjects (29 young adults and 22 middle-aged adults) performed three different combinations ofdual tasks composed of a pencil and paper task (copying numbers or calculation) and a hand-shape changing task (inresponse to visual hints or self judgment). We measured brain activation using near-infrared spectroscopy. Results:
Right DLPFC activation was significantly higher for the simplest dual task than the complex dual task with the younger
group, whereas there was no significant difference between tasks with the middle-aged group. Task performance washigher in the younger group than the middle-aged group, whereas there was no difference in brain activation between
the two age groups. Conclusion: A dual task including two of each task performed automatically could be used fortraining frontal lobe functions, and the difficulty level should be adjusted depending on age.
Keywords: dual task, near-infrared spectroscopy, prefrontal cortex(Asian J Occup Ther 12: 53−60, 2016)

Introduction
In Japan, which is becoming a super-aged society,care for patients with dementia is one of the main issues
for mental health and rehabilitation services. A significant symptom of dementia, the behavioral and psychological symptoms associated with dementia (BPSD),
prevents patients from doing many activities of dailyliving (ADL) by themselves in their home and community life. Therefore, it is important not only to inhibit
the disease progression but also to prevent and care for
BPSD. One of the countermeasures for these illnesses is
cognitive rehabilitation, which is a non-pharmacotherapy approach and is well-recognized to prevent or delay
dementia.
Received: 9 December 2013, Accepted: 17 October 2015
Corresponding to: Toshiko Futaki, Human Health Sciences, Graduate
School of Medicine, Kyoto University, 53 Kawahara-cho, Syogoin,
Sakyo-ku, Kyoto 606-8507, Japane-mail: futaki.toshiko.2c@kyoto-u.ac.jp©2016 Japanese Association of Occupational Therapists

So far, several studies have reported the effectiveness of cognitive training in improving patients’ qualityof life [1−5]. Cognitive rehabilitation programs for
activating the prefrontal cortex (PFC) help to prevent
dementia and mild cognitive impairment (MCI) [3].
However, there is not enough evidence for clinical applications.
Nowadays, there are various functional neuroimaging methods to measure human brain activation, forexample magnetic resonance imaging, single photon
emission computed tomography, positron emission tomography, and so on. Near-infrared spectroscopy (NIRS)
has benefits for subjects because it is not invasive or
restrictive of body movement, so that the flexibility ofthe method is high [6], and we have used this technique
to investigate the difference on task performance, brain
activation and subjective assessment in relation to thedifficulty levels of a virtual shopping test [7]. In thepresent study, we tried to clarify what kind of task activates the PFC highly by comparing hemodynamic data
during different types of dual-task performance using
NIRS.

54

Prefrontal Cortex Activation during Dual-Task Performance

It was reported that elderly people maintain theability to perform ADLs such as eating and getting
dressed for a long time by increasing their neuralnetwork, regardless of neurodegeneration caused byaging or disease [8]. There are many possibilities thatcognitive training using a dual task that needs working
memory and alternating attention in relation to PFC
activation could lead to an increase in neural networks
and help to maintain independent personal/social life.
Working memory plays an important part in the functioning of alternating attention [9]. A neuropsychological model of attention: the supervisory attention system(SAS) was proposed as a central executive of working
memory in PFC [10, 11]. The dorsolateral prefrontal
cortex (DLPFC) plays a major role in modulating working memory [12].
Additionally, it was reported that dual-task performance required working memory in relation to the
DLPFC, in particular, the left DLPFC was activatedduring mental calculation performance [13]. It has also
been reported that performing a dual task (e.g. doingarithmetic and a physical activity task at the same time)
was effective for maintaining cognitive functions inelderly people [14]. Therefore, we adopted a type ofasthmatic task as part of our dual tasks to investigate
DLPFC activation.
We designed dual tasks that could be used conveniently at home or in occupational therapy sessions
in various facilities. We combined two simple andfamiliar desktop tasks together as a dual task: a writingtask based on the hundred square calculation task, anda hand-shape changing task based on the “rock-paperscissors” game [15]. The hundred square calculation involves simple addition, and is widely used with elementary school students to improve their basic learning skills
including attention and memory. “Rock-paper-scissors”
is a popular children’s game using the hand in Japan.
We considered that Japanese people could perform thehand gestures in this game automatically regardless of
their age, using both procedural memory and declarative
memory.
This study aimed to clarify the characteristics of thedesktop dual task in relation to working memory and alternating attention, which causes DLPFC activation, andto verify the difference between healthy younger adultsubjects and middle-aged adult subjects in dual-task
performance and DLPFC activation.

Methods
1. Subjects
Subjects’ characteristics are described in Table 1.
A total of 51 subjects participated in this study. They

Table 1. Subjects characteristics.

Male : female
Age
Education years
MMSE (/30)
FAB (/18)
TMT (s)TMT-A (s)TMT-B (s)Young group(n = 29)
Mean (SD)

Middle-aged group(n = 22)
Mean (SD)11 : 18
23.4 (2.98)
16.1 (1.94)
29.6 (0.77)
17.1 (0.83)
6.9 (12.33)
60.0 (17.22)
66.9 (16.59)

9 : 1353.2 (3.59)
15.1 (1.96)
28.9 (1.02)
16.2 (1.65)
17.3 (19.16)
72.7 (17.37)
90.0 (18.08)

*
*
ns
*
*
*
*

* significant different between young group and middle-aged group byt-test ( p < 0.05).
MMSE: Mini-Mental State Examination. FAB: Frontal Assessment
Battery. TMT: Trail Making Test.
TMT = time required to complete TMT-B−time to required complete
TMT-A

were divided into two groups: a younger adult group (n= 29, age range: 20−35) and a middle-aged adult group(n = 22, age range: 48−60). Frontal assessment battery(FAB) and trail making test (TMT) were conducted asneuropsychological assessments. There were significant
differences in age, years of education, MMSE, FAB, andTMT between the two groups.
The selection criteria were persons who lived
independently in the community without mental and/or neuropsychological diseases such as cerebrovasculardisease; and those who were right hand dominant asevaluated using the Edinburgh inventory (laterality
quotient > 0) [16]. The exclusion criteria were 1) individuals who had visual impairment; 2) individuals withmotor deficits that affected dual-task performance; 3)
Mini-Mental State Examination (MMSE) score of ≤ 26
points.
All cognitive functions decrease consistently withaging. In particular, processing speed starts decreasing
rapidly around the age of 50 years [17]. For this reason,
we set subjects in the middle-aged group as people aged
over 45 years old. The study protocol was approvedby the Kyoto University Graduate School of Medicine
Ethics Committee (E-1114, 2011).
2. Three dual tasks using both hands
We utilized three original dual tasks (e.g. Tasks A,
B, and C) consisting of a “hundred square calculationtask” performed with the right hand and a “hand-shapechanging task” with the left hand placed on a table.
Fig. 1 shows the task sheets used in Tasks A, B, andC (in Fig. 1a, 1b, and 1c, respectively). Subjects wereasked to fill in the blank squares with numbers by referring to the top and left edges of the table while using
their right hand. They completed each row of the table

Asian J Occup Ther 12: 53−60, 2016

Yamaguchi N et al.

55

Fig. 1. A4 sized task sheets used in threetasks.

starting from left to right and then working from top tobottom. Subjects were asked to add the two numbers
shown at the top and the left side of the table, then write
the answer in the intersection square between them.
In addition, subjects were also asked to switch theshape of their left hand whenever they filled in a squarewith a thick border in Tasks A and B. Conversely, inTack C they were asked to switch the shape of theirhand whenever they wrote an odd number after writing
an even number (or an even number after writing an odd
number) in the previous square. Subjects started witha “rock” pattern, in which the fist was clenched, thenchange to the “scissors” shape by extending only two
fingers (index and middle fingers like scissor blades)and finally “paper” by extending all five fingers out flat.
Subjects were instructed to perform the dual tasks
as accurately and quickly as possible. The evaluation
items were the number of answers written in 60 seconds,
and the number of completed switches of the left handshape.
3. Procedure
The experimental protocol is shown in Fig. 2. In advance, we provided the instructions and a small practiceFig. 2. Experimental protocol.

task for subjects to understand how to execute the dual
tasks, then NIRS data during the tasks were measured
for a total of six 60-second sessions (3 tasks × 2 trials)
continuously. We set a rest period between sessions toallow brain activation level to subside after the previous
task. Subjects were instructed to sit in a comfortable andrelaxed position, placing both hands on the armrests forthe rest periods while looking at the white paper in frontof them.
4. NIRS data collection
As shown in Fig. 3, subjects sat in a chair with theirfeet on the ground during task performance, and they
were asked not to talk or move their body or head except
for the hand movements required in task execution. Subjects filled in a sheet for the hundred square calculation
on a document stand by using their right hand, and they
kept their left hand placed on the left side of the document stand on the desk.
We used a multichannel NIRS instrument, FOIRE3000 (SHIMADZU Co. LTD, Kyoto, Japan) to measure brain activation status from the point of view of
hemodynamic changes during dual-task performance.
As shown in Fig. 4, we set 27-channel NIRS probes on

56

Prefrontal Cortex Activation during Dual-Task PerformanceFig. 3. Experimental setup.

the forehead of the subject corresponding to the international 10−20 system, and the lowest probes were placedalong Fp1-Fp2. We set a total of 18 probes including
emitters and detectors, in which the distance between
each probe was 3 cm.
The NIRS system calculated relative changes in theconcentrations of oxygenated hemoglobin ([OxyHb]),
deoxygenated hemoglobin ([DeoxyHb]), and totalhemoglobin. We used the changes in [OxyHb] values toinvestigate changes in regional cerebral blood volume
in this study, based on the report that [OxyHb] is moresensitive than [DeoxyHb] as a parameter to measure
blood flow changes associated with brain activation [18].
We reset hemodynamic data at the start of each task andrecorded the change in [OxyHb] for 60 seconds during
the performance of each task.
The system used a sampling time of 260 milliseconds. The intensity of the light detected at three
wavelengths (780, 805, and 830 nm) was measured, andchanges in the optical density were calculated.

Fig. 4. NIRS channel arrangement on the forehead.

5. Data analysis
We selected one of five specified channels in each
DLPFC area (e.g. channels 6/12/17/18/23 for right
DLPFC, channels 11/16/21/22/27 for left DLPFC) on
the basis of the waveforms. We determined these channels as the DLPFC region, which was nearly the sameas the Brodmann area 46 involving executive functions,by referring to a previous study [19]. The positions of
two channels adopted were symmetrical and fixed on
all tasks individually. A dual-task type (Task A, B, orC) × Group (younger, middle aged) analysis of variance(ANOVA) was conducted to evaluate behavioral dataand changes in [OxyHb] in DLPFC using SPSS Version
19. Differences were reported as significant when p <0.05.

Results
1. Comparison of task performance between younger
and middle-aged adult groups
Regarding the hundred square calculation task, themean (SD) accuracy scores were 100% (0) in Task A,
99.02% (1.31) in Task B, and 99.41% (0.93) in Task C
in the younger group, while they were 99.97% (0.12) inTask A, 97.25% (3.54) in Task B, and 99.00% (1.57) inTask C in the middle-aged group.
Fig. 5a shows the comparison of writing task
performance between the two age groups. The task
performance score indicated the total number of written
answers, including correct and incorrect ones. The resultof ANOVA (3 tasks × 2 age groups) showed a significant
main effect of the task ( p < 0.0001) with no interaction.
There was also a significant main effect of age group( p < 0.0001). The scores were higher in Task A than inTasks B and C ( p < 0.001); scores were also higher inYamaguchi N et al.

Asian J Occup Ther 12: 53−60, 201657

a significant main effect of the task ( p = 0.005) with nointeraction.
There was also a significant main effect of the agegroup ( p < 0.0001). The score was higher in Task B
than in Task A ( p = 0.007) and Task C ( p < 0.001) inthe younger adult group, whereas it was higher in Task
B than in Task C ( p = 0.016) in the middle-aged adultgroup.

Fig. 5. Comparison of the task performance between tasks inage groups.

Task B than in Task C ( p < 0.001) in both groups.
Fig. 5b shows a comparison of hand-shape changing performance between the two age groups. The task
performance score indicated the total number of left
hand movements including correct and incorrect ones.
The result of ANOVA (3 tasks × 2 age groups) showed

2. Comparison of DLPFC activation between younger
and middle-aged adult subjects
Fig. 6 shows sample NIRS data on changes in[OxyHb] during Task A. Right DLPFC (e.g. channel17) and left DLPFC (e.g. channel 22) activation wasobserved during task performance.
Fig. 7 shows a comparison of DLPFC activation
between tasks in the two age groups. Fig. 7a shows theright DLPFC, and Fig. 7b shows the left DLPFC. The
result of ANOVA (3 tasks × 2 age groups) on [OxyHb]
change showed a significant main effect of the task in
the right and left DLPFC ( p = 0.003 and p = 0.019, respectively) with no interaction. There was no significant
main effect of age group in any area of DLPFC. The
right and left DLPFC were activated more highly during
the performance of Task A than during Task C ( p = 0.002
and p = 0.007, respectively, after Bonferroni correction).
Analysis using the Holm method showed the following. The right DLPFC was activated more highly
during the performance of Task A than during Task C
in the younger adult group ( p = 0.007). There was no
significant difference between Task A and Task C in
the middle-aged adult group ( p = 0.030) in the right
DLPFC. On the other hand, there were no significant

Fig. 6. A sample NIRS data on change of [OxyHb] during Task A performance.

58

Prefrontal Cortex Activation during Dual-Task PerformanceFig. 7. Comparison of the DLPFC activation between tasks
in age groups.

differences between Task A and Task C in either group ( p= 0.037 and p = 0.034, respectively) in the left DLPFC.

Discussion
This study aimed to clarify the characteristics of adesktop dual task to determine which caused DLPFC
activation more easily, and to verify the difference between younger and middle-aged adults during dual-task
performance and with regard to DLPFC activation.
Participants performed three dual tasks composed of a
pencil and paper task using their right hand (copying
numbers in Task A; calculation in Tasks B and C) and ahand-shape changing task using their left hand (on cue
from visual hints in Tasks A and B, and by self judgement in Task C).
Regarding the characteristics of DLPFC activation,
it found that the right DLPFC activation was significantly higher with the simplest task (Task A) compared withthe complex task (Task C) in the younger adult group,
whereas there was no significant difference between
tasks in middle-aged adult group. We considered that
Task A was a dual task composed of the easiest tasksof the three, which should not interfere with each otherdirectly, and it was possible for the subjects to perform
this task without much difficulty. On the other hand,
Task C was a dual task combined of two tasks requiring
both calculation and self-judgment, which could inter-fere with each other. On the basis of data from younger
subjects, it was suggested that the simple dual task composed tasks performed using both hands automatically
had a tendency to activate the DLPFC highly.
As a reason for the fact that there was no significant
difference in DLPFC activation between tasks for the
middle-aged group, we considered that all dual tasks
used in this study, even Task A, imposed too high aload for middle-aged subjects to activate their brain. So
far, it has been reported that the compensation-related
utilization of neural circuits hypothesis (CRUNCH) has
a relationship with age-related brain activation [20].
According to this hypothesis, more neural resources areengaged by older brains to accomplish computational
goals completed with fewer resources by younger
brains. Therefore, older adults were more likely than
younger adults to show over-activation at low load, andunder-activation at high load.
The task performance results varied depending onage: younger adult subjects performed better on each
dual task than the middle-aged subjects. In contrast,
there was no significant difference in brain activation
during each task execution, although the activation
patterns in [OxyHb] change were similar between thegroups. As shown in Table 1, there were differences incognitive test scores (e.g. TMT representing attention
and FAB representing frontal lobe function) between
the two age groups. There is a possibility that the differences in basic cognitive functions were related to thedifference in the tendency on task performance between
the two groups.
In addition, the characteristics of attention requiredin the execution of a specific task influenced the taskdifficulty [21]. We considered that all of the three dual
tasks would need attention capacity but have their own
characteristics. With respect to the hand-shape changing
task performance, subjects could execute the motion
switching itself automatically in all dual tasks. However, Tasks A and B required the processing of visual
information as a trigger for the hand-shape change byusing divided attention and procedural memory mainly.
Task C required higher functioning such as SAS [10, 11]involved in working memory, as described in Introduction section, by judging the number in each answer incomparison with the previous one. We considered thatthese various aspects of cognitive functions requiredin each dual task could influence task performance andbrain activation.
A previous study reported that young and oldparticipants showed significantly greater PFC activation during dual-task performance than single-task
performance by using stepping and mental arithmetic
called “serial 7”, which are simple tasks using automatic

Asian J Occup Ther 12: 53−60, 2016

processing [22]. Although the type of dual task usedhere was different from the previous study, we foundthat the dual task using both hands but composed of two
tasks that subjects performed automatically activated the
DLPFC similarly.
Our study had some limitations. The brain activation data varied even in a single age group owing toindividual differences. We plan to collect a larger data
set to resolve the relationship between task performanceand brain activation as a subsequent study. After revisions to make our dual tasks easier, a further study
investigating brain functions according to task characteristics is needed to improve cognitive rehabilitation for
elderly people and patients with dementia or MCI.

Conclusion
This study examined the impact of the characteristics of dual tasks on prefrontal lobe activation inyounger and middle-aged adult subjects. As a result, a
simple dual task composed of two tasks each performed
automatically caused higher DLPFC activation than amore complex dual task requiring judgment in younger
subjects. The task performance was higher in the younger adult group than in the middle-aged adult group. It
was suggested that a desktop dual task including theperformance of two easy tasks using both hands simultaneously could provide a cognitive training task topromote DLPFC activation, and the task level should be
adjusted for each person’s ability considering age.
Acknowledgments: We thank the subjects who participated in this experiment. We are grateful to Professor
Motomi Toichi of the Graduate School of Medicine,
Kyoto University, Associate Professor Hiroshi Sakai of
the Graduate School of Medicine, Nagoya University,
and Associate Professor Katsumi Inoue of the Graduate
School of Medicine, Kanazawa University. This research was supported by KAKENHI; a Grant-in-Aid for
Scientific Research (C) (24500643).

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de Mendonca A. Quality of life in patients with mild cognitive impairment. Aging Ment Health. 2013; 17: 287−
92.
[2] Glanz BI, Healy BC, Rintell DJ, Jaffin SK, Bakshi R,
Weiner HL. The association between cognitive impairment and quality of life in patients with early multiple
sclerosis. J Neurol Sci. 2010; 290: 75−9.
[3] Matuda O. Cognitive rehabilitation. (in Japanese) Jpn J
Geriatr Psychiatry. 2006; 17: 736−41.

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Improved quality of life and cognitive stimulation therapy in dementia. Aging Ment Health. 2006; 10: 219−26.
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2009; 37: 324−29.
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M, Nagano A, Seki K, Futaki T, Luo Z. An fNIRS-based
study on prefrontal cortex activity during a virtual shopping test with different task difficulties in brain-damaged
patients. J Behav Brain Sci. 2014; 4: 247−55.
[8] Park DC. Psychological issues related to competence:
Cognitive aging and instrumental activities of dailyliving, Mahwah, New Jersey, Erlbaum. 1997.
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Sci. 2007; 62: 1134−41.
[10] Shallice T. From neuropsychology to mental structure.
Cambridge: Cambridge University Press; 1988.
[11] Norman DA, Shallice T. Attention to action. Willed andautomatic control of behavior. New York: Plenum Press;
1986.
[12] Berman KF, Ostrem JL, Randolph C, Gold J, Goldberg
TE, Coppola R, Carson RE, Herscovitch P, Weinberger
DR. Physiological activation of a cortical network duringperformance of the Wisconsin Card Sorting Test: apositron emission tomography study. Neuropsychologia.
1995; 33: 1027−46.
[13] Burbaud P, Camus O, Guehl D, Bioulac B, Caille J,
Allard M. Influence of cognitive strategies on the patternof cortical activation during mental subtraction. A functional imaging study in human subjects. Neurosci Lett.
2000; 287: 76−80.
[14] Ohsugi H, Ohgi S. The potential of dual task Training fordementia. (in Japanese) J Rehabil Sci Seirei Christopher
Univ. 2010; 6: 57−67.
[15] Yamaguchi N, Osaki S, Futaki T. The activation in a prefrontal area at the time of alternating tasks enforcement
related to the age, performance and task: a study in theused of near-infrared spectroscopy. (in Japanese) HealthSci. 2012; 7: 9−16.
[16] Oldfield RC. The assessment and analysis of handedness:
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Prefrontal Cortex Activation during Dual-Task Performance

Kohno S, Oda I, Isobe S, Suzuki T, Kohyama K, Dan
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[21] Sohlbarg MM, Mateer CA. Effectiveness of an attention-training program. J Clin Exp Neuropsychol. 1987; 9:
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2013; 14: 10.

■CASE REPORT

Driving risk in a stroke patient with mild cognitive
deficit could not be predicted by neuropsychologicaltesting: a case report
Tatsunori Sawada1, Yoshio Fujita2, Mika Shiratori1, Masanao Shibuya1
1
2

Department of Rehabilitation, IMS Itabashi Rehabilitation Hospital
Division of Occupational Therapy, Faculty of Health Science, Mejiro University

Abstract: Neuropsychological, off-road, and on-road testing were used to assess the driving skill of a stroke patient todetermine whether he could drive safely. Driving risk could not be detected by neuropsychological testing, but was detected with the Useful Field of View (UFOV) test and a driving simulator and confirmed with on-road testing. Although
it may be more effective to use on-road testing or a driving simulator to assess whether a stroke patient is competent todrive, our results suggest that UFOV may be more a more accessible and cost-effective method for detecting driving
risk due to mild cognitive dysfunction.
Keywords: driving skill, cognitive dysfunction, useful field of view (UFOV)(Asian J Occup Ther 12: 61−66, 2016)

Introduction
Rehabilitation of stroke survivors often requires
medical staff to decide whether the patient is competentto drive. This decision must be made carefully to avoid
the possibility of driving accidents caused by strokerelated impairments. Cognitive dysfunctions are often
more serious factors than motor deficits for stroke patients who wish to drive because driving an automobile
requires a high level of cognitive skills [1−4]. On-road
driving is the gold standard for assessing fitness to drivefor people with disabilities [5]. However, on-road driv­
ing assessment may be expensive and require muchtime for patients [3]. Furthermore, traffic laws in somecountries restrict stroke patients from driving on publicroads for evaluation of their skills. In cases where onroad testing is not feasible, neuropsychological testing,
the Useful Field of View (UFOV) test, and driving simulators are frequently used alternatives. Because the costof the driving simulators prevents many hospitals from
Received: 21 April 2014, Accepted: 18 Feb 2015
Corresponding to: Tatsunori Sawada, Department of Rehabilitation,
IMS Itabashi Rehabilitation Hospital, 3-11-1 Azusawa, Itabashi, Tokyo
174-0051, Japane-mail: sawada.tatsunori@ims.gr.jp©2016 Japanese Association of Occupational Therapists

using this device, neuropsychological testing is mostfrequently used for driving assessment.
Many researchers have reported a relationshipbetween neuropsychological testing and driving skill,and meta-analyses and systematic reviews have revealed
such a correlation [3, 6]. Understandably, clinicians
desire valid and reliable tools to accurately and easily
assess the driving risk associated with cognitive dysfunction [2, 7].
In this article, we report that driving risk in a stroke
patient could not be detected with neuropsychologicaltesting and that the use of a driving simulator and the
UFOV test revealed visuospatial and attention deficits.
The driving risk of this patient was confirmed with onroad driving assessment. As required by the Ethics
Committee of our hospital, written consent was obtained
from this patient for publication of this article.

Case introduction
A 52-year-old man experienced sudden onset ofloss of consciousness and developed a cerebral infarction after atrial fibrillation. He was diagnosed with cardiogenic cerebral infarction of the right middle cerebral
artery region, with damage from the putamen to coronaradiata confirmed by magnetic resonance imaging.
He received conservative treatment in an acute hos-62

Driving risk in a stroke patient with mild cognitive deficit could not be predictedpital and was discharged from a rehabilitation hospital
3 months after onset. Simple Test for Evaluating Hand
Function scores (right upper extremity 90, left upper
extremity 83) revealed no motor or sensory deficits. The
patient’s functional independent measure score was 125
when he was discharged from the rehabilitation hospital.
He experienced no problems or complications duringhospitalization. He received a medical driving-skill
evaluation at our hospital as an outpatient.

Protocol for driving skill evaluation at our
hospital
The driving assessment protocol used at our hospital is summarized in Fig. 1. Initially, we interview apatient to determine driving history, car model, and thepatients’ plans to drive in the future. In addition, thepatient attends a lecture of approximately 1 h regarding
traffic law and legal procedures before returning to driving, which raises awareness of issues facing drivers after
brain injury. Subsequently, the patient is evaluated with
off-road testing, including neuropsychological testing,visual acuity testing, and performance in a driving simulator. The patient’s abilities to adjust the seatbelt andside mirror and to operate the steering wheel and brakeand acceleration pedals are evaluated in a parked car.
The on-road driving assessment (Fig. 1) is used only incases of considerable doubt, as the ability of the medical
staff to evaluate a patient’s driving skills with on-road
testing in Japan is limited institutionally and financially.
We refer to previously reported cut-off points (Table 1)for each neuropsychological testing [2, 8]. In addition,competency to drive is not determined with only a single
abnormal result, but instead is comprehensively assessedusing many results from multiple tests.

Fig. 1. Protocol for driving assessment used at our hospital.
The patient attends the lecture and is assessed using
many evaluations.

Interview
The patient demonstrated strong motivation todrive, as he had a son still in high school and a wife
to support. He hoped to be able to drive a car again tomaintain his employment at an apartment managementcompany, which required him to transport staff by car.
His job required him to drive 5−6 h per working day. He

Table 1. Cut-off scores for testing.
We referred to previously reported cut-off point based systematic review for neuropsychological testing.
Type of testing

acceptable

doubtful

unacceptable

Mini-Mental State Examination
Rivermead Behavioral Memory Test
screening
standard profile
Rey-Osterrieth Complex Figure Test (copy)“A” Random letter Test
Trail Making Test-A
Trail Making Test-B
Behavioural Inattention Test
conventional test of scorebehavioral test
Kohs block design test
Japanese road signs (original assessment in our hospital)

28 or more

27-23

22 or less7 or more
16 or more
34 or more
042 sec or less
148 sec or less

−
−
30−34
43−54 sec
149−180 sec

5 or less14 or less29 or less1 or more
55 sec or more
181 sec or more

131 or more
68 or more
IQ 90 or more
10 or more−−
IQ81−898−7

130 or less67 or less
IQ 80 or more
6 or lessAsian J Occup Ther 12: 61−66, 2016

Sawada T et al.

63

was eager to return to his work as soon as possible, as hefeared being fired due to the current difficult economic
condition. He had committed some mild traffic violations. Although he had never caused a traffic accident
resulting in injury, he had caused an accident resulting
in property damage. According to his wife, he exhibitedno particular changes in comparison to his behavior,personality, and abilities prior to the stroke.

Off-road testing results
The patient had no hemianopia. The following are
the results of several off-road tests completed by thepatient: Mini Mental State Examination score was 28;
Rivermead Behavioral Memory Test screening score
was 12 and standard profile score was 18; Rey-Osterrieth Complex Figure Test (only copy) score was 35; “A”
Random letter test error value was 0; Trail Making Test
(TMT) A was completed in 46 s; TMT-B was completed
in 48 s; Behavioral Inattention Test (BIT) conventional
test score was 146 and behavioral test score was 77; andKohs Block Design Test IQ was 85.4. In addition, thepatient correctly identified 19 out of 20 Japanese roadsigns in an original assessment used by our hospital, andhis vision in both eyes was 0.8 while wearing his glasses. Although these results were not perfect, our medical
team could not confirm driving risk.
When tested in a parked car, the patient did notexhibit any notable problems while opening and closing
the car door, adjusting the seatbelt and mirrors, inserting
the key, or adjusting the speed when operating the steering wheel or stepping on the brake or acceleration pedal.
In this test as well, our medical team could not confirm
driving risk.

UFOV testing result
The Visual Field with Inhibitory Tasks (VFIT) software was used to assess the UFOV or functional visual
field (FVF) using dual tasks (Fig. 2) [9]. During theassessment, the useful field of view is measured as theseated patient watches a computer monitor placed on thedesk in front of him or her. The VFIT comprises threepretests (simple task, go/no go task, and peripheral task)
and a dual task of combined pretests. We adopt tasks excluding the peripheral task. At first, subjects must gazeat the center of the monitor during all tasks.
Four target marks (4 types) on the monitor are
indicated for 2500 msec–3000 msec, and subjects mustpush a button immediately according to various tasks.
The simple task is that the subject must always push the
button when the target marks appeared on the monitor.
If the subject pushes the button before the target marks

Fig. 2. Visual Field with Inhibitory Tasks (VFIT) setup.
VFIT software is used to assess the UFOV. Subject
sits on the front of PC monitor. They need to push the
button for correct reaction.

appear, the result will be a “false alarm (FA)” (same asother tasks). If the subject cannot push the button correctly, the result is an error. The go/no go task requires
the subject to push the button only when all target marks
are different from each other. If the subject pushes the
button when some target marks are the same, the result
will be FA (same as dual task). In the dual task, a single
target mark (a surrounding mark) appears around fourtarget marks, and the subject must push the button only
when all target marks in the center of the monitor are
different. After that, the subject must push a predetermined button corresponding to the surrounding marktypes. There are four versions (I, II, III, and IV) of thedual task depending on the distance between the target
marks and the surrounding mark.
The percentage of correct answers for each stage(peripheral task; indicates the width of the useful fieldof view) and the number of FAs are recorded. Although
no defined clear cut-off scores have been established for
VFIT, VFIT developers indicated that the average score
for people of the same age as the patient was approximately 90%, and the cut-off score was estimated to beapproximately 80% [9].
The patient’s performance on the VFIT was as follows: the percentage of correct answers was 100% in thesimple task, 100% in the go/no-go task, and, in the dualtask, 84% in stage I, 93% in stage II, 84% in stage III,and 75% in stage IV. The number of FAs was 6% in thego/no-go task, and, in the dual task, 9% in stage I, 6%
in stage II, 6% in stage III, and 0% in stage IV. He mademistakes on both left and right sides (slightly more often
on the left side) during VFIT (Fig 3).

64

Driving risk in a stroke patient with mild cognitive deficit could not be predicted

to drive on the left side of the road, and crossed over a
guard rail and a side walk. Several times an occupational
therapist directed him to drive in the center of the lane,
after which he initially drove in the center but eventuallytended to drive on the left side. No other problems wereobserved.

On-road testingFig. 3. Result screen from the VFIT (dual task Stage III).
This screen indicates the dual task Stage III of the
VFIT. Our patient made mistakes on both left andright sides (only left or middle side in this figure).

Driving simulator
We adapted the UC-win/ROAD software version 3.4(FORUM8 Co., Ltd) as a driving simulator (Fig. 4). The
software provides a steering function that is similar toa TV driving game and is not similar enough to a car toassess steering. Therefore, other driving skills, such as
the ability to stay in the center of the lane and to remain
stationed at a red traffic signal, are assessed using thissimulator.
During assessment with this driving simulator, thepatient could not keep to the center of the lane, tending

The results of the driving simulation and VFIT
raised doubts on the patient's competency to drive andan on-road assessment was deemed necessary. We
adopted ordinary driving skill evaluation items (e.g.,the outer circumference of the course road, slope, andcrank) for which healthy driving students are tested. In
the 1-h on-road assessment, a driving instructor sat in
the front passenger seat, and an occupational therapist
sat in the back seat. The patient exhibited no difficulties
when instructed to start the car on a hill, stop on a line,
and turn a corner. However, when he carefully attempted
to stop the car on the left side of road, he scratched theleft tire on the curb. Although the occupational therapist
and instructor warned him repeatedly, he scratched theleft tire in six out of nine attempts to park on the left
side of the road.
From the results of this series of driving assessments, we concluded that the patient was not yet readyto drive due to suspected attention deficits. As thepatient showed improvement since the stroke and the
impairment was mild, the clinician informed the patientand his wife that there was a possibility that he might
be competent to drive in the future. In addition, thephysician provided the patient with a medical certificate
stating that, with the exception of driving, he was able toreturn to work. The patient returned to work as a clericalstaff without driving responsibilities, and he completed
regular ambulatory care at our hospital.

Discussion

Fig. 4. Driving simulator.
UC-win/ROAD software version 3.4 (FORUM8
Co., Ltd). This simulator can reflect the virtual roadon three computer screens. But this software is notsimilar enough to a car to assess steering.

In this study, the assessment of a stroke outpatient
using neuropsychological tests and off-road assessmentin accordance with our protocol did not reveal driving risk. Because visuospatial Meyers, Volbrecht, &Kaster-Bundgaard [10] and attentional Parasuraman &Nestor [11] functions are critical to driving skill, BIT
and TMT were performed and did not reveal driving
risk. However, on-road assessment revealed that thepatient experienced difficulty in stopping the car on theleft side of the street, and it was concluded that the riskof driving was sufficiently high to indicate he was notready to drive yet. The patient's driving risk could not
be detected by neuropsychological testing, and this wasSawada T et al.

Asian J Occup Ther 12: 61−66, 2016

likely due to the presence of very mild cognitive disorder. A previous study showed that it was easy to detectdriving risk for patients with moderate or heavy cognitive disorders, but that it was more difficult to assess thedriving risk for patients with mild cognitive disorders [3].
In a study that found a correlation between visuospatial
or attention and driving skill, cognitive dysfunction
could not be detected with neuropsychological testing[10, 11]. Another study indicated that there is no correlation between neuropsychological testing and driving
skill [12], and our results support this conclusion.
Although it is possible that our study is a rare case inwhich driving risk could not be assessed with neuropsychological testing, it should not be dismissed as the riskof accident was considerable.
VFIT and driving simulator assessment also revealed the driving risk of the patient. Previous studies
indicated that the UFOV test can be used to assess various cognitive functions (e.g., attentional, visuospatial),that it was superior for detecting the driving risk ofelderly drivers, and that the results correlate well with
on-road assessment as well as TMT and Rey-OsterriethComplex Figure Test results [2, 13]. The fact that we
could detect a mild cognitive disorder using VFIT anddriving simulator suggests that these assessments may
be useful for assessing driving risk that cannot be detected with neuropsychological testing. Although driving
simulators may be prohibitively expensive, cognitive
disorders contributing to driving risk can be assessedin a hospital using only VFIT and a personal computer,because the developer of VFIT offers the test for freewith some requirements.
Ultimately, on-road testing is still the most usefulassessment of driving risk in cognitive disorder patients
after brain injury. However, many therapists cannot use
on-road testing due to economic and institutional restrictions. Marshall et al. [2], in describing institutional
differences in countries with respect to on-road testing,noted that on-road assessment is used primarily in
Canada because most physicians must declare the driving competency of patients and, correspondingly, notused as often in the USA because American physicians
are not required to report driving competency, usually.
At present, only a few hospitals in Japan use on-road
testing. Although Japanese physicians do not have theauthority to decide whether a patient can drive or not,driving license authorities often seek medical advice
for granting driving privileges, because on-road testingis rarely performed by this organization. Physiciansrequired to assess the driving competency of patientsare faced with the disadvantages of neuropsychologicaltesting and a lack of cooperation from driving schools.
To address these issues in Japan, we suggest that driving

65

license authorities should employ individuals, such as
occupational therapists, who have the knowledge ofneuropsychology and driving skill assessment. Until
such policy is implemented, driving risk can be assessedin hospitals using the UFOV test or driving simulators.

Conclusion
We used neuropsychological, off-road, and onroad testing to determine the driving skill of a stroke
patient. Although driving risk could not be determinedby neuropsychological testing, it could be determined by
the UFOV test and a driving simulator. Although it may
be most effective to use a combination of neuropsychological, off-road, and on-road testing to determine thedriving competency, our results suggest that the UFOV
test may be a useful alternative when on-road testingand driving simulation is unavailable.

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A survey of clinical practice in aged care assessment
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Brosseau L, Finestone HM, Lamothe C, Korner-Bitensky
N, Wilson KG. Predictors of driving ability following
stroke: a systematic review. Topics in Stroke Rehabilitation. 2007; 14: 98−114.
[3] Reger MA, Welsh RK, Watson GS, Cholerton B, Baker
LD, Craft S. The relationship between neuropsychological functioning and driving ability in dementia: ameta-analysis. Neuropsychology. 2004; 18: 85−93.
[4] Sundet K, Goffeng L, Hofft E. To drive or not to drive:
neuropsychological assessment for driver’s license
among stroke patients. Scandinavian Journal of Psychology. 1995; 36: 47−58.
[5] Driving and Parkinson’s disease. Lancet. 1990; 336: 781.
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Assessing fitness to drive after head injury: A survey ofclinical psychologists. Neuropsychological rehabilitation.
2001; 11: 45−55.
[7] French D, Hanson CS. Survey of driver rehabilitation
programs. American Journal of Occupational Therapy.
1999; 53: 394−7.
[8] Kato T, Suetsuna T, Ninomiya E, Kishimoto S, Sato T,
Inobe J. Driving assessment for patients with higher brain
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driving school. (in Japanese) Sogo Rehabilitation. 2008;
36: 1003−9.
[9] Fujita Y, Mimura M, Iijima S. Correlating driving fitness
and functional visual field in the elderly. (in Japanese)
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[10] Meyers JE, Volbrecht M, Kaster-Bundgaard J. Driving

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Driving risk in a stroke patient with mild cognitive deficit could not be predicted

is more than pedal pushing. Applied Neuropsychology.
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in aging and Alzheimer’s disease. Human Factors. 1991;
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[13] Owsley C, Ball K. Assessing visual function in the older
driver. Clinics in Geriatric Medicine. 1993; 9: 389−401.

■ORIGINAL ARTICLE

Reasons for the Lack of Practice using Public
Transportation at Sub-acute Rehabilitation Hospitals
in a Japanese Urban Community
Masahiro Ogawa1, Tatsunori Sawada2, Chinami Ishizuki3, Sayaka Okahashi1,
Toshiko Futaki1
1

Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
Department of Rehabilitation, IMS Itabashi Rehabilitation Hospital, Tokyo, Japan
3
Health Sciences Major, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
2

Abstract: Using public transportation is crucial for people living in urban communities. However, a previous study
suggested that approximately one-third of sub-acute rehabilitation hospitals in Japan could not practice using public
transportation. Here we aimed to quantitatively and qualitatively examine why these hospitals did not practice. Managerial occupational therapists working in sub-acute rehabilitation hospitals in urban Japan were enrolled. Using a postal
survey, some questions regarding the practice of using public transportation were asked. Two hundred and twenty-eight
responses were analyzed. The frequency of practicing the use of public transportation was weakly correlated with thehospital bed number, therapist number, and average therapy duration. The qualitative data concerning reasons for notpracticing were integrated into four categories: barriers of social system, specific factors of the task, existence of complementary method, and lack of necessity and awareness. It may be important to improve these inhibiting factors forproviding appropriate occupational therapy.
Keywords: practice, public transportation, sub-acute rehabilitation hospital(Asian J Occup Ther 12: 67−74, 2016)

Using public transportation is important for people
living in an urban community to participate in activities
outside, e.g., using the railway to commute or taking abus to shop. A lack of outdoor mobility for the elderly
can lead to isolation, poor health, high mortality, andlow quality of life [1−4]. Moreover, acquired disability
and aging accelerate the disuse of public transportation,
which limits their outside participation and narrows theirlife spaces [5−8]. In an urban community, such as a metropolitan region in Japan, where public transportation
has matured, it is a social problem that handicapped andaged people cannot use public transportation.
Occupational therapy can contribute to enhancing
the use of public transportation in handicapped andaged persons. Riding public transportation is a physicalReceived: 12 March 2015, Accepted: 2 February 2016
Corresponding to: Masahiro Ogawa, Department of Human Health
Sciences, Graduate School of Medicine, Kyoto University, Kyoto, 53
Syogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japane-mail: ogawa.masahiro.4w@kyoto-u.ac.jp©2016 Japanese Association of Occupational Therapists

and cognitive practice, and it also encourages patientsand clarifies their problems on using public transportation. A previous post-stroke randomized controlled
trial suggested that occupational therapy intervention
increased outdoor mobility in the intervention group [9].
Therefore, enhancing outdoor mobility for handicapped
and aged people, including the practice of using public
transportation, is part of an occupational therapist’s
remit.
Representative diseases known to cause mobility
restriction for the elderly include stroke and hip fracture.
For example, Wendel, Stahl, Risberg, Pessah-Rasumussen and Iwarsson [10] reported that one-third of patients
after stroke decreased or stopped the use of buses andtrains. In Japan, there are unique wards that provide
intense rehabilitation for people with such diseases inthe sub-acute phase from approximately 2 weeks to
2−6 months after the onset. They are called Kaifukuki
Rehabilitation Wards (Kaifukuki means recovery phasein Japanese). More than 80% of patients in these wards
had a stroke or fracture and their average age was 75.2
years [11]. Thus, most of the inpatients in the hospitals

68

REASONS FOR LACK OF PRACTICING PUBLIC TRANSPORTATION

are elderly and easily get housebound after handicapped.
Moreover, according to our previous research, even if
there are many inpatients hoping to use public transportation after discharge and are approved to use it, 29.4%
of hospitals cannot practice it [12]. Other studies also
indicated that many patients with physical disability
who lived at home wished to get out more often [13−14].
Although aging of society has been progressing worldwide, particularly in Japan, studies have revealed undesirable conditions concerning the supply and demand ofoccupational therapy needs.
Barriers to outdoor mobility for stroke patients havebeen studied. A previous qualitative study found that thebarriers were fear of falling or injury, lack of confidence,and inadequate information about transport services[14]. To reduce these barriers it could be vital to practiceriding public transportation as a rehabilitation practice.
Why can occupational therapists in some sub-acuterehabilitation wards not practice using public transportation? Investigation of the reasons would give us
some meaningful information for adjusting appropriate
occupational therapy practices. Moreover, this research
could be applied to urban areas of the world to provide
knowledge about rehabilitation of public transportation.
The purpose of this study was to quantitatively andqualitatively examine why occupational therapists working in sub-acute rehabilitation wards cannot practiceusing public transportation in a Japanese urban community. The quantitative method was used to examine
correlations between the extent of the practice of using
public transportation and the characteristics of subacute rehabilitation wards. Furthermore, the qualitative
method was used to ask occupational therapists about
reasons for not practicing using public transportation.

Methods
Subjects
Using purposive sampling, subjects in the study
included managers of occupational therapy departments
in hospitals that were selected from a list of sub-acuterehabilitation hospitals in Japan, which were made by
the Kaifukuki Rehabilitation Ward Association [15].
The subjects were all associated with hospitals that had
sub-acute rehabilitation wards in the regions and cities
with a greater than 5% utilization rate of railways duringholidays on investigation of the national urban traffic
condition [16]. Based on the selection criteria, 453
facilities in the metropolitan region including the Kinki
region and Chukyo region as well as Sapporo, Sendai,
Hiroshima, and Fukuoka city were selected for the investigation.
A postal questionnaire was sent to the manager ofthe occupational therapy department in each facility.
A document attached to the postal questionnaire provided information about the research purpose, researchmethod, and protection of personal information. The
explanation in this document was carefully written to
not affect question responses. The questionnaire wasfilled out anonymously. Returning the questionnaire wasregarded as obtaining respondent’s consent for participation in the study. The study was approved by the ethics
committee at IMS Itabashi Rehabilitation Hospital (approval number: A-006).
Recruitment and data collection
The data collection method was a postal survey
with a self-administered questionnaire. The reply
deadline was three weeks later. After this deadline had
passed, a letter of appreciation including a reminderof their response was sent to all of the subjects and thedeadline was extended for two more weeks.
As a precaution, before answering the questionnaire
an operational definition of the following terms was
explained. In this study, public transportation meant
railway and bus and excluded taxies. Practice of using
public transportation was defined as practice riding
transportation outside the hospital during rehabilitationor an assessment.
Information about the respondents, such as years ofclinical experience and managerial position, was gathered. General information regarding the facility included
the number of hospital beds, number of therapists(occupational therapists, physical therapists, and speechtherapists), average therapy duration for a patient perday, and distance from the hospital to the nearest station
and bus stop.
Regarding practice of using public transportation,a question about the frequency was asked. The question
was, “How many patients practice using public transportation during rehabilitation, among those who areapproved to use it after discharge?” The response wasgiven on a 5-point scale: all of the patients, majority ofpatients, half of the patients, few patients, and none ofthe patients. If few patients and none of the patients wereanswered, an open-ended question was asked regarding
the reason for not practicing it. If the practice was not
performed, this question was sure to be answered.
Data analysis
Descriptive statistics were calculated for the characteristics of respondents and their facility. Spearman’srank correlation coefficient was used to examine therelationship between the frequency of practice and othervariables, including number of hospital beds, number ofstaff, average therapy duration, and distance between theAsian J Occup Ther 12: 67−74, 2016

hospital and station and bus stop. SPSS 22.0 was used
for statistical analysis. The level of significance was set
at 0.05.
A qualitative analysis was performed for descriptive
data from the open-ended question regarding the reasonsfor not practicing the use of public transportation using
the KJ method [17]. First, the answers that were impossible to understand or misunderstand were examined, forexample “can you apply health insurance for paymentof rehabilitation outside a hospital such as using public
transportation? (counter-question)” These answers were
excluded from the analysis. The answers were split
into labels so that each label had only one meaning fora question. The labels were gathered by their similarity to make the first-level categories and each of thecategories was named so the meaning of the category
was represented. Furthermore, following similarity of
the categories the second-level categories were made.
The same procedure was repeated until the forth-level
categories were finally made. To ensure consistency inthe analysis, two researchers who had experience withqualitative studies repeatedly confirmed until no further
revisions were found. They were occupational therapists
and co-authors who had clinical experience more thanten years.

Results
Two hundred and thirty subjects replied. Two of the
returned questionnaires had many omissions and were
excluded. Therefore, 228 responses were used for the
analysis (response rate, 50.3%).
The number and ratio of participants is shown in
Table 1. Information regarding the respondents andtheir facilities is shown in Table 2. Some responses
were excluded for each question in the analysis because
no answer or an inappropriate answer was given. The
average and standard deviation of years of clinicalexperience was 10.9 years (SD = 5.7) and 81.5% of the
respondents held a managerial position. The average
number of hospital beds was 70.5 (SD = 54.8). The
average number of therapists was 34.8 (SD = 30.2). The
average therapy duration for a patient per day was 127.5
min (SD = 32.5; including physical therapy and speechtherapy). The average distance from the hospital to thestation was 2.0 km (SD = 2.2) and to the bus stop was
0.44 km (SD = 0.51).
Results of the frequency of practice using public
transportation are shown in the bottom right of Table 2.
Correlation coefficients between the frequency of practice and other variables are provided in Table 3. Correlation coefficients between the frequency of practice
are presented with the number of hospital beds (r = .25,

Ogawa M et al.

69

n

ratio
(%)

Table 1. Charactristics of respondents.

Years of clinical experience1−5 y6−10 y11−15 y≥ 16 yNo answer

25
103
61
34
5

11.2
46.2
27.3
15.3

Managerial position
Vice-principal, general manager, assistant manager
Section manager, chief therapist, senior manager
Section chief, chief clerk
Other managerial position
Staff (non-managerial position)
No answer

4
36
111
3
35
39

2.1
19.1
58.7
1.6
18.5

p <.001), number of therapists (r = .28, p <.001), andaverage therapy duration (r = .18, p = .005).
Qualitative analysis of reasons for not practicing public
transportation use
Eighty-three respondents provided reasons for notpracticing public transportation use with the narrative
form. From these answers 239 labels were extracted.
The average and standard deviation of the number oflabels per respondent was 2.8 ± 1.5 labels (range: 1−7
labels). Italics in the following results are quotes of
respondents’ answers. The numbers in parentheses correspond to the label number.
The data were integrated into 4 categories withthe forth-level category as the highest category: 1)
barriers of social system (37 labels), 2) specific factorsof the task (89 labels), 3) existence of a complementary
method (44 labels), and 4) lack of necessity and awareness (69 labels). Based on these categories (Fig. 1), excluding 4) lack of necessity and awareness, the reasonsfor not practicing public transportation use were 1) barriers of social system and 2) specific factors of the task.
These two categories have given rise to 3) existence ofcomplementary method.
1) Barriers of social system
Twenty-nine respondents (34.9%) felt that there
were barriers of social system preventing therapists fromthe practice. This category comprised two lower categories (third-level categories): A) not permitted by hospitaladministrations (13 labels) and B) imperfections in thesocial system (24 labels).
A) Not permitted by hospital administrations
Some occupational therapists wanted to practiceoutside their hospitals, but they had some problems with

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REASONS FOR LACK OF PRACTICING PUBLIC TRANSPORTATION

Table 2. Facility information and frequency of practice.

Location
Metropolitan region
Kinki region
Chukyo region
Local central cities(Sapporo, Sendai, Hiroshima and Fukuoka city)
No answerabnratio (%)

91
72
25
37

40.5
32.0
11.1
16.4

3

Number of hospital beds
1−49 beds
50−99 beds
100−149 beds
150+ beds
No answer

98
78
27
19
6

44.1
35.1
12.2
8.6

Number of therapistsa
0−19 therapists
20−39 therapists
40−59 therapists
60−79 therapists
No answer

83
72
24
43
6

37.9
32.9
11.0
18.2

Average therapy duration for a patient per day
0.00−0.99 hours
1.00−1.99 hours
2.00−2.99 hours
3.00 hoursb
Inappropriate answer
No answer

10
442
129
13
4
28

5.1
2.5
65.8
6.6

n

ratio (%)

Distance from hospital to the nearest station
0.0−0.9 km
1.0−1.9 km
2.0−2.9 km
3.0 kmNo answer

65
63
43
48
9

29.7
28.8
19.6
21.9

Distance from hospital to the nearest bus stop
0.00−0.19 km
0.20−0.39 km
0.40−0.59 km
0.60+ km
No answer

91
48
47
28
14

42.5
22.4
22.0
13.1

The frequency of practice using public transportation
All
AlmostHalf
SeldomNone
Inappropriate answer
No answer

34
67
26
55
41
1
4

15.2
30.0
11.7
24.7
18.4

Number of therapists is the sum of occupational therapists, physical therapists, and speech therapists.
In Japan, up to three hours of rehabilitation per day for an inpatient in sub-acute rehabilitation wards is permitted by the payment system for
medical services. This rehabilitation duration includes occupational therapy, physical therapy, and speech therapy.

* Number of therapists is the sum of occupational therapists, physicaltherapists, and speech therapists.

B) Imperfections in the social system
In some cases rehabilitation outside the hospital
was restricted because it is not profitable owing to thelack of health insurance coverage, for instance, “because
rehabilitation outside the hospital is not covered byhealth insurance (3a)” and “practice of public transportation give little profit (23c).”
The other barrier was problems of guarantee if
any accidents would be happened. This category was
extracted from the following representative label, “if any
accidents like falling and medical emergency occurred,
it will be difficult for our hospital to guarantee patients.
(50d)” The restriction was caused by problems in oursocial system regarding insurance and guarantee system.

hospital administers and hospital policy, for example,“hospital administers do not permit therapists to practice outside the hospital (17d)” and “as our hospital’s
policy, going out with patients is not preferred. (62a)”
They were restricted by the administration in the hospital.

2) Specific factors of the task
Fifty respondents (60.2%) pointed out that there
were specific factors involved in practicing public
transportation use. This category had four third-level
categories: C) high risk of practice (30 labels), D) problems with environment around the hospital (19 labels), E)
problems of manpower and time (28 labels), and F) Not

Table 3. Correlation coefficients between frequency of practice andother variables.
frequency ofpractice

Number of hospital beds (n = 217)
Number of therapists* (n = 214)
Number of occupational therapists (n = 215)
Number of physical therapists (n = 214)
Number of speech therapists (n = 206)
Average therapy duration (n = 182)
Distance to the nearest station (n = 212)
Distance to the nearest bus stop (n = 204)

r

p

.25
.28
.22
.21
.21
.18
.05
−.05

< .001< .001< .001‘ .001< .001‘ .005‘ .488‘ .468

Ogawa M et al.

Asian J Occup Ther 12: 67−74, 201671

Fig. 1. Qualitative analysis of reasons not to practice using public transportation.
Note: Parentheses in the table indicate number of label

established necessary manuals and rules (12 labels).
C) High risk of practiceThis category included high risk of traffic accidents
and falling, emergency for patients outside, and difficult
to cope with accidents and emergencies away from thehospital. A respondent suggested that “we are worry
about how to cope with an emergency away from our
hospital. It is would be difficult (50c).” Therefore, many
therapists recognized that the practice had a lot higher
risk factors than those in the hospital.
D) Problems of environment around hospitalSome occupational therapists felt that there werebarriers regarding the environment around the hospital,such as undeveloped public transportation, long distancefrom station or bus stop, and danger around the hospital.
For example “we spend a lot of time waiting for a train
because only one train comes every hour (55c)” and “thepavement to the station is narrow and bumpy aroundour hospital (19c).” Therefore, the environment aroundthe hospital affected whether practice was performed ornot.
E) Problems of manpower and time
It took extensive manpower and time to practiceusing transportation in several hospitals. Examples of
their responses were “impossible to come back to thehospital after practice on the train within the given rehabilitation time (17a),” taking too much time for prac-

tice. (9a),” and “we have more number of patients thantherapists (30b).” Using transportation takes more timethan usual rehabilitation in their hospital. Moreover, ashortage of manpower restricted the practice of usingtransportation.
F) Not established manuals and rules
Some hospitals have not made necessary manuals
and rules such as practice protocol, payment for the costof transportation, and countermeasures for accidents or
emergencies outside. The representative opinions were,“in our hospital, rules for the practice haven’t been
established yet (81a)” and “there is a problem: who will
pay for the expense of using transportation? Sometimes
therapists pay the fee by themselves (78g).”3) Existence of complementary method
Forty-four respondents (41.0%) mentioned using acomplimentary method as the reason for not practicing
public transportation use. Complementary methods
included two lower categories: G) applying supplementary method (35 labels) and H) practice with simulated
method (9 labels).
G) Applying supplementary method
Instead of the actual practice by therapists a supplementary method was used. The representative labels
were, “when an inpatient returns home for a while, we
ask his or her family to use the transportation that will
be used after discharge and to assess their behavior

72

REASONS FOR LACK OF PRACTICING PUBLIC TRANSPORTATION

with a checklist (19f )” and “after discharge, we ask
home-visiting therapists to follow-up with them (63b).”
The therapists made use of the patients’ family, otherservice, or other professional if they had not given theirpatient practice.
H) Practice with simulated method
Without riding a train or a bus, simulated activities
are also used, such as “in the rehabilitation room, we
assess a patient using steps as high as those of the bus
entrance (55e)” and “we took a patient to the nearest
station to pretend to buy a ticket as a practice (12c).”
Patients did not actually ride public transportation but
the therapist simulated similar conditions for their patients.
4) Lack of necessity and awareness
Thirty-nine respondents (47.0%) answered thatpractice was not necessary and it had a lower priority
than other necessary things. In this category, therapists,patients and their families thought that practice was notnecessary: I) few patients need practice using public
transportation (64 labels) and J) negative attitude towardpractice (5 labels).
I) Few patients need practice using public transportation
Patients did not need to practice because “ourpatients are in such a bad medical condition that theycannot go out and they are old aged (59b)” and “driving
a car is the main form of outdoor mobility so in this area
it is more necessary than using public transportation(53a).” The demand for public transportation depended
on the area. In a rural area, driving a car is a morecommon form of outdoor mobility compared with using
public transportation.
J) Negative attitude toward practiceSome answers insisted that therapists, patients, andfamilies had a negative attitude toward the practice.
Some examples were, “we have never thought practicing use of public transportation in our hospital (26e)”and “patients and families refused the suggestion topractice from their therapists. (71c).”

Discussion
We studied the reasons for not practicing the use of
public transportation using a postal survey. Interviews
are often used in qualitative studies as a study method[18]. Alternatively, few researches use a postal survey.
While thinking of reasons for not practicing the useof public transportation before the present study, wehypothesized various reasons that depended on the areaand site in which the hospitals were located. Therefore,
the survey was not performed for a widespread area inmajor urban places of Japan. Moreover, a postal survey
is one directional communication and can sometimes
cause misunderstanding. In the present study, we
omitted data if it was difficult to interpret the meaning.
However, we believe that the more than 200 labels inthis study are enough to analyze reasons not to practice.
The result suggested that one of the reasons wasa barrier in hospital administration and social system
policies such as health insurance and guarantee for
accidents outside of the hospital. In Japan, it is unclear
whether we can or cannot apply health insurance to occupational therapy cost when it is performed outside of
the hospital site. It could have a dramatic effect on the
judgment of occupational therapists for performing thepractice. To resolve these issues it would be necessary to
clarify the evidence of practice. Logan et al. [9] reported
a significant effect of home-based occupational therapy
for people with stroke for the purpose of outdoor mobility. Alternatively, there has been no evidence regarding
practicing the use of public transportation for inpatients.
Therefore, it would be important to verify the practiceeffect and to appeal the necessity of the practice to provide appropriate occupational therapy corresponding topatient needs.
Some factors in the hospital affected the pros andcons of practice. For example, the number of therapists
and number of hospital beds was correlated with theextent of practice. These results suggest that a large
population of therapists and large hospitals can easily
make time and establish a manual for practice. Hiring
more therapists and making a manual is not easy but isrequired for practicing the use of public transportation.
Hospital environment was one of the reasons for
not practicing. A previous study suggested that theperceived neighborhood environment affected theamount of walking in the elderly [19]. Infrequent public
transportation, such as one train in one hour, was also
one of the barriers. Ogawa et al. [12] found that making
courses for the practice helped to shorten the durationof the practice. Therefore, setting up the courses anddeparture time would solve the problem, particularly inJapan as most of the trains operate on time. Consideringthat practicing actual condition leads to reacquired occupations, it would be essential to remove these barriers.
In cases where therapists could not practice using
public transportation, simulation of the practice close
to “real life” in the hospital was used instead of actual
situation. Doig, Fleming, Cornwell and Kuipers [20]reported that rehabilitation in an actual situation such as
patients’ home was more satisfying and effective from aAsian J Occup Ther 12: 67−74, 2016

quantitative study analyzing patient interviews. Recently, home-based and community rehabilitation has been
examined because it may effectively enhance community reintegration [21−23]. Therefore, actually practicing
using public transportation would be close to real life,
for example at home, and more effective for patients tolearn the motion and to be motivated. However, it would
be necessary to show the effectiveness of actually using
public transportation compared with the simulated practice.
The results of this study are not always generalizable because all of the subjects worked on sub-acuterehabilitation hospital in urban community of Japan.
Therefore, future studies may seek to explore the present
situation in other setting such as an acute hospital andhome-visiting rehabilitation. We found many reasonsfor lack of practice; however, we also have limitationsof this study that need to be addressed, for example, thesocial system and difference in environment surrounding public transportation , which depends on the country
and area, e.g., urban or rural [5]. In some countries andareas, driving a car would be more important than using
public transportation [24, 25]. Alternatively, 28.7% of
people use public transportation for outdoor mobility inthe metropolitan area of Japan [16]. Therefore, in theseregions, the quality of life of people with disabilities
who could not use these public transportations would be
affected. The goal of rehabilitation has been described to
be to “maximize the patient’s role fulfillment and his independence in his environment, all with the limitations
imposed by the underlying pathology and impairments
and by the availability of resources” [26]. Occupational
therapists should resolve the inhibiting factors of thepractice and facilitate the use of public transportation for
the elderly and those with a disability to acquire theirimportant occupations.

Conflicts of interest
The author declares no conflict of interest.
Acknowledgments: We acknowledge the significant
support for this study by Atsushi Komoto, Shinichi
Aoyama and occupational therapists in IMS Itabashi
Rehabilitation Hospital.

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■ORIGINAL ARTICLE

The effect of the challenging two handed rhythm
tapping task to DLPFC activation
Mutsumi Abiru1, Hiroshi Sakai2, Yasuhiro Sawada3, Hiroshi Yamane2
1

Human Health Science, Graduate School of Medicine, Kyoto University, PhD program
Human Health Science, Graduate School of Medicine, Kyoto University
3
Department of Occupational Therapy, College of Life and Health Science, Chubu University
2

Abstract: Using functional near infrared spectroscopy (fNIRS), we have been researching the effect of musical attention control training (MACT) on the prefrontal lobe, which is involved in attention control. We detected significant
dorsolateral prefrontal cortex (DLPFC) activation during music-based tasks that included “dual task” elements. In thisstudy, to elucidate which musical elements influence DLPFC activation, we focused on the effects of tempo of both
handed Rhythmic tapping tasks (RTT), which including “dual task” elements. RTT with 3 different tempos, the easy(E) (slow tempo), intermediate (I) (moderate tempo), and difficult (D) (fast tempo) tasks, were developed. Then, theactivation of the DLPFC was measured during each task. Our results detected a significantly stronger DLPFC activation
during the (D) task than during the (E) task ( p < 0.01) or the (I) task ( p < 0.01). These results indicate that the difficultyof RTT can be adjusted by altering the tempo. Music-based tasks could be useful for cognitive training programs, eventhose for poorly motivated people with severe attention deficits through changing the difficulty level by changing the
tempo.
Keywords: Music, Dual task, DLPFC, Rhythm, Attention functions, Cognitive rehabilitation(Asian J Occup Ther 12: 75−83, 2016)

Introduction
Higher brain dysfunctions, such as attention deficits, memory deficits, and executive function deficits caninhibit activities of daily living and prevent individuals
from returning to employment. In particular, executivefunctions can cause problems with reintegration into
society [1]. In order to perform executive functions
appropriately, individuals have to be able to efficiently
and appropriately recruit attention functions, which areconsidered to form the basis of all cognitive functions[2]. Therefore, improving attention functions is essential
to the success of rehabilitation [3].
Attention processing training (APT) mainly involves searching tasks and is considered to be a typicaltraining method for attention function deficits [4]. Although the efficacy of these methods has been verified,
Received: 6 March 2014, Accepted: 10 February 2015
Corresponding to: Mutsumi Abiru, Human Health Science, Graduate
School of Medicine, Kyoto University, 53 Kawaramachi Syougoinsakyou-ku Kyoto city, 606-8397, Japane-mail: muchanabiabi@yahoo.co.jp©2016 Japanese Association of Occupational Therapists

sufficient motivation and certain attention functions are
required to perform them. Therefore, training methods
that motivate the participants to focus on the task andwhose difficulty levels can be adjusted for each participant are required.
It is reported that music tasks that mainly involve
auditory stimulation promote attention functions more
efficiently than tasks that mainly involve visual stimulation [5]. Therefore, music-based tasks could promoteattention functions more efficiently than conventional
training tasks, which mainly involve visual searchingtasks. Moreover, music-based tasks motivate the participants more than other desk-based training tasks, and thisis especially true for people with low self-motivation,
attention function deficits, and severe cognitive deficits.
Furthermore, Music-based tasks would also be easy toadjust the difficulty levels by changing the tempo andrhythm of the music involved.
Thus, we have been researching the effect of musicon attention function through both clinical and basic
studies.
In healthy participants, we have been researching
the relationship between the characteristics of musicaltasks and cerebral blood flow (CBF) by measuring the

76

The effect of the challenging two handed rhythm tapping task to DLPFC activation

change in CBF in the dorsolateral prefrontal cortex(DLPFC) region of the prefrontal lobe, which controls
attention functions, by using functional near infrared
spectroscopy (fNIRS) [6]. In this study, we found thatmusical tasks involving “dual task” elements, such as
singing during a rhythmic tapping task (RTT), strongly
influence DLPFC activation [6]. However, we are notsure which elements of music, such as melody, tempo,
harmony, and rhythm etc, influence DLPFC activation in
fact. Among those basic elements of music, we thoughtrhythm can be easily understood for everybody since it
is easy to play even by individuals without any musicalexperience and easy to include dual task elements.
Therefore, we focused on rhythm to study. As basic
rhythm pattern, bilateral rhythmic tapping tasks (RTT),
which include dual task element by using both hands
differently, was selected. Then, the difficulty level of
RTT was adjusted by changing its tempo.
In this study, we researched the relationship between activation of the DLPFC region and the difficultyof rhythm-based dual tasks by adjusting the tempo in a
step-by-step manner as a means of altering its difficultylevel.

a) Octapad Digital Percussion Pad (ODPP) and the basic
rhythm pattern of Rhythmic tapping task (RTT)

Methods
1. Participants
Thirty healthy participants with no physical ormental problems (9 males, 21 females; mean age: 22.03± 2.39; 26 right-handed), who met requirements in thefollowing preliminary test, were selected from 34 undergraduate students, who applied in this study.
The preliminary tests by using the basic rhythmic
tapping task (RTT) were implemented before this study
since the difficulty level of rhythm varies from person
to person. The basic RTT are shown in Fig. 1-a). Fourparticipants were excluded in the preliminary test due
to: 1) failure to reach 90% success rate on the easy task(E) even after 3 minutes’ practice or 2) ability to easily
complete the difficult task (D), such as experienced musician.
Informed consent was acquired before study procedures began. This study was approved by Kyoto University Graduate School and Faculty of Medicine, Ethics
Committee (C593). All participants were required tosign consent forms, which explained the purpose, methods, benefits, and disadvantages of this study and that
their participation was voluntary, before participating inthis study.

b) Each level of RTT

Fig. 1. a) Upper part of Figure 1-a) showed an electronic rhythm instrument, an Octapad Digital Percussion Pad: ODPP (Roland SPD30), was set up in front of the participant. The ODPP had been set up so that the right and left sides produced different sounds.
The participants just hit the 2 pads of ODPP which circled with white line. The lower part of Figure 1-a) showed the basic rhythm
pattern of RTT. ●Indicates that an examiner hits the percussion Pad and ○ indicates the examiner does not hit the ODPP. The
basic rhythm pattern of RTT was the same for all levels.
b) 30, 60, and 80 RTT sets were performed per minute for the easy (E), intermediate (I), and difficult task (D), respectively.

Asian J Occup Ther 12: 75−83, 2016

2. Rhythmic tapping task (RTT)
The basic rhythm pattern of RTT is shown in Fig.
1-a). ●Indicates that an examiner hits the percussion Pad
and ○ indicates the examiner does not hit the percussion
Pad. To select the basic RTT, the RTT, which is the mostparticipants were able to perform perfectly at a slow
tempo but difficult with a faster tempo, was selected as
RTT preliminarily.
Three different difficulty levels of RTT, were created according to the accuracy rate data obtained in the
preliminary experiment:(1) The easy task (E), in which 30 sets of the RTT
were performed per minute at an accuracy rate of
approximately 100%.
(2) The intermediate task (I), in which 60 sets of the
RTT were performed per minute at an accuracy rateof approximately 80%.
(3) The difficult task (D), in which 80 sets of the RTT
were performed per minute at an accuracy rate of
approximately 50% (Fig. 1-b).
The all participants watched each level of RTT
task (E, I, and D) being performed on a monitor, which
set up in front of them. In the monitor, the examiner’s
hands were visually and auditory showed, as an example. They then performed each task on an electronic
rhythm instrument, an Octapad Digital Percussion Pad:
ODPP (Roland SPD-30). ODPP had been set up in
front of the participant so that the right and left sidesof the ODPP produced different sounds. Preliminary
sufficient practice of each task was implemented before
the measurement of fNIRS. With watching the monitor,

Abiru M et al.

77

the participants then performed each task on the ODPP,
while fNIRS measurements were obtained (Fig. 2).
To avoid the learning process affecting their results,
the researchers ensured that all participants understoodthe basic rhythm of the RTT and had practiced it fully
before the experiment.
3. The percentage of correctly played RTT
In this study, gradual blood flow changes during
each task (60 seconds) and the percentage of correctly
played RTT were measured simultaneously. Calculationof the percentage of correctly played (E), (I), and (D)RTT tasks was recorded by a video camera. The numberof correct RTT responses was counted by reviewing thevideo records after the experiments. As described in Fig.
1-a), each RTT set was composed of 7 beats (○ or ●),and the beats to be played with the right and left handwere indicated by (○) and (●), respectively. All levels of
RTT were performed with watching the monitor whichshowed the performance of examiner. Therefore, as acriterion of correct RTT, when all 7 beats were not delay
and/ or when the number of RTT sets that were playedcorrectly from example RTT showed through the monitor, the RTT were counted as the correct RTT set. Then,the number of RTT sets that were played correctly per
minute was divided by the total number of RTT played
per minute for each task level. Then, the quotient was
multiplied by one hundred.
4. Prefrontal cortex measurement fields
It is reported that a circuit involving the DLPFC,

Fig. 2. Measurement environment and the relationship between the locations of the probes and areas of the brain.

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The effect of the challenging two handed rhythm tapping task to DLPFC activation

prefrontal lobe, and cerebellum controls the accuracyof movements [7]. In this experiment, it was importantthat the participants implemented the task precisely
as instructed to activate attention control functions.
Therefore, we expect a circuit involving these areas ofbrain. However, we had to narrow down the target areaof the brain since it is hard to observe the entire brain
using our fNIRS system. Therefore, we focused on the
DLPFC, which is considered to control movement accuracy through both motor control and cognition [8, 9].
5. Measurement of prefrontal area activation
The activation of the prefrontal lobe during eachtask was compared by assessing the changes in brain
blood flow induced by using fNIRS. We used the
FOIRE-3000 fNIRS system (Shimazu Corporation,
Japan). The units of this fNIRS are shown as arbitrary
unit (a.u.). The different size and shape of each participant’s head changed the length of the light path. Therefore, the relative changes in the oxyHb concentrationin the resting stages were set as 0 a.u. The stage of justbefore the each task was set as a criterion of restingstages. Through these quantitative measurements, thevalidity of comparison between subjects was reported[10]. The fNIRS measurement interval was set at 115
ms. The lowest line of probes was horizontally alignedwith the frontopolar point [Fpz] of the International
10-10 System of Electrode Placement, which is the standard system for electroencephalographic measurements.
Three probes each were placed on the right and left ofthe [AFz], and then a second line of probes was placed
30mm above the initial line of probes. Therefore, a totalof 14 probes (19 channels); i.e., two rows of 7 probes,
were employed (Fig. 2).
Brodmann area 46, which is involved in the central
executive system of working memory, was chosen as
the target area within the DLPFC. However, the size andshape of each participant’s head were differed; therefore,
it was difficult to confirm the area of the brain that had
been activated using a head chart. Thus, the F3-F5 area
(left DLPFC area) and F4-F6 area (right DLPFC area)
were subjected to analysis since Okamoto et al. [11]reported that these areas were considered to be closest toBrodmann area 46.
In addition, the channels in each area displayed thesame waveforms. Therefore, the channel that displayed
the lowest amount of noise among nearby channels was
selected for the analysis (Fig. 2). Therefore, once thetarget channels for each participant were set, it did notchange among the different tasks for the same participant.
The change in the oxyHb concentration was used
as a measure of neural activation, and the mean oxyHb

concentration changes induced by each task were compared. Since the change in the oxyHb concentration
indicates the degree to which a particular brain region is
activated, a greater change in oxyHb indicates stronger
activation of the relevant brain area [10].
It would have been difficult to set up a control task
since various factors influence DLPFC activation duringsimple tasks (or resting). Minati et al. [12] reported
that the first trial could easily have been influenced bymental tension and thus produced different results fromthe procedural trials. Therefore, we used the first trial asa dummy trial (DT) (tapping with the right and left handin an alternating manner). The tempo of DT was sameas E-level. Thus, the DT was set to help participants getused to the research procedure. Then, the accuracy rate
and blood flow data were compared between the (E), (I),and (D) tasks.
A block design (10 sec. (rest) – 60sec. (task) –10 sec. (rest)) was used for the measurement sessions.
A total of 4 blocks (60sec. × 4 blocks; total: 240 sec),
which were composed of one DT and the three RTT
tasks (E, I, and D) were performed one after the other(Fig. 3).
To avoid learning effect and fatigue, preliminary
sufficient practice of each task was implemented before
the measurement of fNIRS. Since the three tasks (E, I,
and D) were all composed from the same basic RTT, andthe difficultly level of each task (E, I, and D) was determined by its tempo. In addition, to avoid the influence oftask’s order, 30 participants were allocated to 3 groups(Pattern 1, 2, and 3), which first order was different eachother (Fig. 3).
6. Analysis of data
The collected blood flow data were systematicallytransformed according to standardized methods using
the analysis software included with the fNIRS system.
Then, the data for each task were saved in text format
and opened in MS Excel. The point, when the DT finished, was revised to [0] on the total data line, and thenmean values were calculated.
SPSS version 20 (IBM, Japan) was used for statistical analyses ( p < .05). Friedman test was used for thepercentage of correct played RTT in each task. Twoway ANOVA was used for the comparison of the brain
activation and order. Tasks and orders were as fixedfactor. Activations were as dependent factor. As multiple
comparison, Tukey’s test was applied.
7. Limitation of fNIRS
The fNIRS data would have been influenced by various factors other than the tasks. Therefore, the tasks anddata collection would have to have been performed in a

Asian J Occup Ther 12: 75−83, 2016

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79

Fig. 3. The order of the task.

strictly controlled manner in order to allow the investigators to determine which factors were associated witheach change detected by the fNIRS system. However, it
is unlikely that data obtained from such a strict research
environment would be applicable to clinical situations.
Therefore, in this study, creating a research environmentthat closely mirrored the clinical setting was considered
to be the highest priority.
In addition, unlike other measurement methods,
such as fMRI, there are no well-established methods
for analyzing fNIRS data. The method we employedin this study was chosen because it allows quantitative
comparisons of fNIRS data. However, the spatial resolution of fNIRS is lower than that of fMRI, and there
are difficulties with the strict localization of brain areas,such as locating individual Brodmann areas of the brain.
Furthermore, it is impossible to compare fNIRS data
between participants since the distance from the surfaceof the head to the cortex of the brain and the percentage
of light absorbed differs depending on the angle of thedevice. However, after considering these limitations we
decided to use fNIRS for our measurements due to its
advantageous characteristics, such as the reduced burden
it places on participants and the fact that it allows
measurements to be obtained continuously during tasks
involving movement.

Results
1. The percentage of correct played Rhythmic Tapping
Task (RTT) in each task
The percentages of correctly played RTT in eachtask are shown in Fig. 4. The median was 99 (range
from 92 to 99) in (E), and 98 (70 to 98) in (I), and 83 (26to 92) in (D).
In the Friedman’s test, the percentages of correctly

Fig. 4. The percentage of correctly played rhythmic tappingtask (RTT). The box plot of the bottom and top of thebox indicate the first and third quartiles, and the band
inside the box indicates the median. Then ends ofthe whiskers represents the minimum and maximum
value within the half time of the top and bottom valueof box. ○ indicates outlier. **p < 0.01.

played RTT were significantly different ( p < 0.01), andfollowing paired test was also significantly different
between (E) and (I) ( p < 0.01), (E) and (D) ( p < 0.01),
as did the comparison between (I) and (D) ( p < 0.01)(Fig. 4).
2. A representative participant’s waveform data of eachtask and pattern
A representative participant’s waveform data forthe oxyHb changes observed during each task (E, I, andD) on each pattern (1, 2, and 3) are shown in Fig. 5. As

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The effect of the challenging two handed rhythm tapping task to DLPFC activation

Fig. 5. Waveform data of DLPFC for the OxyHb changes of a representative participant observed during each task.

the tempo of the rhythm increased, the waves associatedwith it became a larger-mountain-shape, and increasing
the tempo also resulted in wider activation of both theright and left DLPFC, regardless of the order in which
the tasks were performed (patterns 1, 2, and 3).
3. Comparison of the brain activation induced by eachtask
The comparisons of the brain activation induced byeach task are shown in Fig. 6.
In the Left DLPFC, the mean oxyHb concentration± standard error of mean (SEM) of E task was 0.18 ± 0.16
a.u. in (pattern 1), 0.14 ± 0.27 a.u. in (pattern 2), and 0.58
± 0.39 a.u. in (pattern 3). I task was 0.54 ± 0.13 a.u. in(pattern 1), 0.45 ± 0.16 a.u. in (pattern 2), and 0.35 ± 0.33
a.u. in (pattern 3). D task was 1.93 ± 0.14 a.u. in (pattern1), 1.59 ± 0.27 a.u. in (pattern 2), and 1.57 ± 0.39 a.u.
in (pattern 3). The main effect of task was statisticallysignificant (F(2,81) = 24.58, MSE = 17.60, p < 0.01,
η2 = 0.37). The main effect of order was not significant(F(2,81) = 0.30, MSE = 0.22, p = 0.74, η2 = 0.01). Theinteraction of task and order was not significant (F(4,81)= 0.61, MSE = 0.43, p = 0.66, η2 = 0.02) (Fig. 6). The

multiple comparison demonstrated significant differences between E and D ( p < 0.01), I and D ( p < 0.01), but
not between E and I.
In the right DLPFC, the mean oxyHb concentration± SEM of E task was 0.40 ± 0.12 a.u. in (pattern 1), 0.93
± 0.30 a.u. in (pattern 2), and 0.37 ± 0.32 a.u. in (pattern3). I task was 0.80 ± 0.13 a.u. in (pattern 1), 0.70 ± 0.18
a.u. in (pattern 2), and 0.12 ± 0.42 a.u. in (pattern 3). Dtask was 2.05 ± 0.11 a.u. in (pattern 1), 2.08 ± 0.22 a.u.
in (pattern 2), and 1.67 ± 0.24 a.u. in (pattern 3). The
main effect of task was statistically significant (F(2,81)= 31.57, MSE = 19.05, p < 0.01, η2 = 0.41). The main
effect of order was not significant (F(2,81) = 0.35, MSE= 0.21, p = 0.71, η2 = 0.01). The interaction of task andorder was not significant (F(4,81) = 2.20, MSE = 1.33,
p = 0.08, η2 = 0.06) (Fig. 6). The multiple comparison
demonstrated significant differences between E and D ( p< 0.01), I and D ( p < 0.01), but not between E and I.

Discussion
The relationships between the percentage of correctly played RTT and DLPFC activation in each task

Fig. 6. The mean OxyHb concentration changes during each task. Error bar indicates SEM.

Asian J Occup Ther 12: 75−83, 2016

are discussed below.
In a comparison of the percentages of correctly
played RTT between each task, significant differenceswere detected between (E) and (D) ( p < 0.01), (E) and (I)( p < 0.01), and (I) and (D) ( p < 0.01).
In a comparison of the DLPFC activation inducedby each task produced the almost same results except
between (E) and (I). In a comparison of (E) and (I), there
was no significant difference between the activationof the right or left DLPFC. However, in comparisonsof (E) and (D) ( p < 0.01), and (I) and (D) ( p < 0.01),
significantly increased activation was observed in both
the right and left DLPFC individually during the moredifficult tasks (D) (Fig. 6).
It is considered that the activation of DLPFC,
observed in this study, is induced by executive attention
system of working memory, since many studies have reported that the increase of simple repetitive movements
does not activate DLPFC [13−16].
Due to the characteristics of fNIRS, it is hard toderive rigorous conclusions from our data; however,in this restricted situation, we would like to consider
the following topics: how the characteristics of eachtask activated the DLPFC, why both the right and left
DLPFC were activated, and the challenges for future
clinical research thrown up by our findings regarding therelationship between the percentage of correct RTT and
DLPFC activation during each task.
1. The characteristics of the rhythmic tapping task (RTT)that activated the DLPFCThe RTT used in this study required the participants
to simultaneously tap different rhythm with their rightand left hands, which indicates that the basic RTT was
included “dual tasks” element in this study. According
to Low et al. [17], “dual tasks” activate the DLPFC bygradually increasing the workload placed upon it. In thisstudy, the percentage of correctly played RTT was lowerin (D) than (E) or (I), even though all tasks included“dual task” elements. This indicates that (D) increased
the workload by faster the tempo, and which leads more
activation of the DLPFC.
In addition, Shallice [18] explained that the earlystage of learning (in high difficulty situations) activatesthe supervisory attention system (SAS), which controls
the precise execution of tasks through active attention
control, and then activates the DLPFC. In this study,
we considered that (D) also activated the SAS since (D)required the participants to produce accurate movement
execute the RTT precisely under the situation of thefaster the tempo which requires active attention control.
Therefore, we considered that (D) activated the
DLPFC, which is involved in the executive attention

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system and the SAS, due to its characteristic of thecontrols the precise execution of tasks through active
attention control.
2. Why were both the right and left DLPFC activated?
Vogh et al. [19] reported that the main roles of theleft DLPFC are observing new information and making
preparations for movement and that the main role of
the right DLPFC is supervising movement during tasks,
such as playing the guitar. In this study, the left DLPFC
would have been activated when the subjects wereobtaining information about the new rhythm throughobserving the monitor and preparing for tap the rhythm,
and the right DLPFC would have been activated when
the subjects were supervising their tapping themselves
during each RTT.
In addition, Hatakenaka et al. [20] reported thatthe early stage of learning new movements (in difficult
situations requiring concentration) is considered to
involve strong activation of the entire prefrontal lobe.
In this study, (D), which most strongly activated the
DLPFC, required the participants to tap 80 sets of
the RTT per minute. In other words, (D) involved thegreatest amount of complex movements, in addition toobserving, preparing, and supervising of the movement,in the strict time regulation. Therefore, it indicated thatthe combination of complex motor learning, executive
attention system of working memory in the certain time
regulation for (D) also resulted in the strong activationof both the right and left DLPFC.
However it was impossible to compare the eachtask’s value of right and left DLFPC directly since theindividual probe was not measured same value between
right and left DLPFC in measurement method of NIRS
in this study. As challenges for the future, it is required
to consider direct comparison of right and left DLPFC
by setting basic ratio between frontal lobe and temporallobe.
3. Summary and clinical challenges for the future
According to the results of this study, tasks witha faster tempo and not high accuracy rate activate the
DLPFC more than slower and easier tasks. It is considered that tasks that require great focus to increase
accuracy would activate the DLPFC, which is involvedin the executive attention system of working memory
and the central executive system of the SAS, more thantasks that are so easy that they quickly become routine.
During the performance of (D), in addition toobserving new information and preparing for movement, which engaged the left DLPFC, and the elementof supervision, which engaged the right DLPFC, theincreased amount of motion also resulted in the strong

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The effect of the challenging two handed rhythm tapping task to DLPFC activation

activation of both the right and left DLPFC.
Nittono et al. [21] reported that the capacity ofworking memory, which controls the DLPFC, varies
from person to person although tasks with a high difficulty level activate the frontal lobe more strongly thantasks with a low difficulty level. Thus, to ensure that the
DLPFC is effectively activated in each participant, it isimportant to set a difficulty level for them. However, if
the task was too difficult to perform, even after making
an effort, they would just give up. Therefore, it is important to set the task which is comfortably difficult foreach participant.
To adjust the difficulty level in “dual tasks” for eachparticipant, music-based tasks would be easy to do. It isbecause music-based tasks are easy to add and decrease
the element to adjust, such as the tempo or whether they
only require one hand, etc. This make possible therapists
to develop a task that most participants will be able toperform with effort comfortably.
The difficulty level in this study was set by acceleration of tempo of RTT but that also lead the increase of
the amount of motion to beat RTT in each task. Therefore it was actually not clear which factor increases
the activation of DLPFC, whether it was the amount of
motion or acceleration of tempo. Therefore, re-examining the task setting would be required in the future.
Although simple comparison between the amount of
motion and acceleration of tempo would not make sensedue to the characteristic of DLPFC.
In addition to adjusting the difficulty level of a task,
individual personality traits and attitudes toward tasks
also influence DLPFC activation. For example, somepeople work through tasks at maximum effort, evenduring very easy tasks; on the other hand, other people
employ the minimum effort, even during difficult tasks.
Therefore, to decrease the effects of such factors, it isimportant to observe individual personal traits. Preliminary observations would help to recognize individual
personal traits, such as the type of directions that would
encourage individual participants to expend a sufficientamount of effort or focus on a task. It is important to
do as much as possible to adjust the difficulty levelsof tasks so that they match the personality traits of theparticipants.
In this study, the participants were all young andhealthy. Therefore, our findings might not be applicableto the clinical setting because the difficulty level of eachtask would also be influenced by the disease status of
the participants, such as whether they were sufferingfrom higher brain dysfunction or dementia. With clinicalpopulations it would be necessary to adjust the difficultylevel of attention training tasks for each participant in
the future.

Conclusions
Training programs for higher brain dysfunction
have to be performed in a low stress environment andbe enjoyable and interesting. Music is stimulating, evenfor poorly motivated individuals with low cognitive
function. In addition, it is comparatively easy to set thedifficulty level of music-based tasks for each participant
by adjusting the tempo, rhythm, and/or the number ofhands, etc. Therefore, we consider that music-basedtasks would be useful for frontal lobe rehabilitation
since it is motivating, and easy to set the comfortabledifficulty level to stimulate this area of the brain morethan other easy fun tasks.
Through continuous clinical research, we would
like to develop an attention-training program that issuitable for a wide range of participants and makes useof the effects of music on the prefrontal lobe, which is
closely involved in attention functions.

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■ORIGINAL ARTICLE

Clinical response of dynamic splintusing functional scales for the extension contractureof the metacarpophalangeal joint
Jun Nakayama1, Mituru Horiki2, Kakuro Denno2, Kazunori Ogawa3,
Hisao Oka4, Kazuhisa Domen5
1Department of Rehabilitation, Kansai Rosai Hospital
Department of Orthopaedics Surgery, Kansai Rosai Hospital
3
Daiya Gum Industry.CO
4
Graduate School of Health Sciencse, Okayama university
5
Department of Physical Medicine and Rehabilitation, Hyogo College of Medicine
2

Abstract: Collateral ligament shortening causes extension contractures of the metacarpophalangeal (MCP) joint, anddynamic flexion splinting (DFS) has been widely used to treat these contractures; however, there are various problems
with these approaches. We developed a novel, pneumatic-type dynamic traction and flexion (DTF) splint to solve these
problems. Twenty-one patients were treated with either the DTF or DFS for 8 weeks. Every 2 weeks, the average MCP
joint flexion angle, total active motion (TAM), grasp strength, and pain scores were assessed. The flexion angle, in the
DTF, was significantly greater than that in the DFS, starting after 6 weeks of treatment ( p < 0.05). Similarly, the TAM
results were significantly better following DTF treatment. Compared to treatment with DFS, our results showed thatDTF treatment promoted earlier recovery of joint flexion angle and whole finger function in patients.
Keywords: extension contracture, dynamic splint, MCP joint(Asian J Occup Ther 12: 85−91, 2016)

Background
Because finger function is important for holding
and pinching objects, the metacarpophalangeal (MCP)
joint is critical for the proper functioning of the hand.
Contracture of these joints, often resulting from trauma
and burns [1, 2], cause significant disorders in the activities of daily living (ADL), including eating, excretory
functions, grooming and bathing. Thus, treatment of thistype of contracture is extremely important for regaining
normal hand function. Contractures of the MCP joints
are common clinical conditions [3] that may be causedby shortening of the collateral ligament. Since the MCP
joint is associated with a collateral ligament, unlike
other joints, regaining flexibility of the collateral ligaReceived: 20 January 2015, Accepted: 10 December 2015
Corresponding to: Jun Nakayama, Department of Rehabilitation,
Kansai Rosai Hospital, 69-1, Inabaso, Amagasakishi, Hyogo, 6608511, Japane-mail: nakayama-kanrou.hp@live.jp©2016 Japanese Association of Occupational Therapists

ment is necessary to improve the joint’s range of motion.
However, treatment of severe contractures is often very
difficult.
Appropriate treatment of this type of contracture is
extremely important. The therapy used to treat the joint
contracture should be both integrative and problem-focused. Therefore, the therapist should avoid worsening
the joint problem through inappropriate rehabilitation,such as long-term fixation and malpositioning of thejoint after a fracture. Pressure therapy, active mobilization, and passive mobilization, using remedial orthotic
positioning, should be started as soon as a problem is diagnosed. Continuous stretching is an effective treatment
for these contractures [4], and the treatment efficacy isimproved through the use of a dynamic orthosis [5−7],
which is a well-accepted modality used to regain joint
motion in an injured hand [8]. The clinical success ofdynamic orthotic positioning is better and results in lessjoint stiffness if the interval between injury and treatment is kept short [9].
The dynamic flexion splint (DFS-splint) has been
widely used for the treatment of MCP joint extension

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Clinical response of dynamic splint

contractures [10, 11]. This conventional type of flexion
splint can, however, negatively impact the articular surface of the joint, leading to pain when the finger is flexed
for an extended period [3]. As a result, range of motion
improvements are difficult to obtain [11]. Therefore,
we devised a new dynamic traction splint using curved
rubber, also known as pneumatic artificial muscle (PAM),
as part of a novel dynamic splint. PAM is used forrehabilitations involving remedial neuromuscular andgate exercises [12−14], including for providing power
assistance to paralyzed muscles [15]. Also, PAM is usedin conjunction with various joints as an adjunct for weakor paralyzed muscles, according to preliminary research[16]. However, the use of PAM splints has not beenpreviously reported for improving joint contracture.
We devised a novel pneumatic-type dynamic
traction and flexion (DTF-splint) splint [17] that pulls
the articular surface and corrects flexural direction by
combining PAM with a dynamic splint. This study investigated the flexion angle, total active motion (TAM)
score, grasp strength, and pain (using a Visual Analog
Scale [VAS] score) associated with wearing the splint
by patients with MCP joint extension contractures;
patients were randomly assigned to use either the DTF
or conventional DFS-splint. Additionally, we examined
the patients’ clinical responses to the use of both splints

Methods
Study design and ethics
The trial protocol was approved by our hospital’s
ethics committee on human research. Written informed
consent was obtained from all patients who agreed toparticipate in the research protocol was obtained prior totheir enrollment in the study.
Patients
We evaluated 21 patients (52 fingers) with extension contractures of the MCP joints, less than six months
after the contractures developed. A total of 13 men (29fingers) and 8 women (23 fingers) were treated witheither DFS or DTF-splints. The average age of the patients treated with DFS-splints was 42-years-old (range,
28−59-years old), and 49-years-old (range, 33−62-yearsold) for those treated with DTF-splints. The contracturesdeveloped as a result of proximal phalanges fractures(5 patients, 6 fingers), metacarpal bone fractures (2patients, 2 fingers), proximal phalanges and metacarpal
bone fractures (4 patients, 8 fingers), extensor tendon
injuries (3 patients, 8 fingers), distal radius fractures(4 patients, 16 fingers) and complex regional pain syndrome type II (3 patients 12 fingers). The subject fingers
included 15 index, 7 middle fingers, 8 ring fingers and22 little fingers. The affected fingers were treated withosteosynthesis (15 patients, 32 fingers) or conservatively(6 patients, 20 fingers) (Table 1).
The patients were directed to wear the assigned
splint for their range of motion exercises. In all cases,
the patients started wearing the splints when their elastic
traction was 200 gf [4, 18−20]. The authors assisted patients to put it on every day for eight weeks. The splint
had to be worn by the patients thrice in a day, in themorning, noon and night, for 30 minutes each. An occupational therapist checked each patient’s traction power
and appropriate wearing of the splint every 2 weeks.
Measurements
The subjects were randomly assigned to use either
the GDS or DTF-splints. I carried out blind in Block
Randomization. We evaluated the progress of the TAM
scores (Total flexion angles – extension lag) and MCP
joint flexion angles, every two weeks, over an eightweek period. TAM is used as one of the evaluation
methods of the finger dysfunction. Further, we compared
Table 1. Characteristics of the patients with extension contractures ofthe MCP joints
DTF

DFS

Patients(n)Fingers(n)

Patients(n)Fingers
(n)

5
4
9

11
14
25

8
4
12

18
9
27

46.4
51.2
49
(33−62)

NA
NA
NA

43.8
46.3
42
(28−59)

NA
NA
NA

2

5

2

3

1
2
1
9

4
8
4
25

2
2
2
12

4
8
8
27

Treatment type
Osteosynthesis
Conservative
total

6
3
9

13
12
25

9
3
12

19
8
27

Subject
Index
MiddleRing
Little
total

NA
NA
NA
NA
NA

7
3
4
11
25

NA
NA
NA
NA
NA

8
4
4
11
27

Sex
Male
Femaletotal
Age (yrs)
Male
Femaleaverage
Disease
Proximal phalanges andMetacarpal bone fracture
Extensor injure
Distal radius fracture
CRPS type1
total

Asian J Occup Ther 12: 85−91, 2016

Nakayama J et al.

87

the two groups for their ability to grasp and their experience with sharp pain (VAS score) when they started
treatment with their assigned splint, and after 8 weeks
of progress. The evaluator was an occupational therapist
blinded to the purpose of the research. In addition, we
carried out three times of evaluations. We calculated
three times of means.
Structure and characteristic of the DFS and DTF-splints
DFS-splint. The DFS-splint comprised a thermoplastic support (3 mm, no hole; OG Giken, Okayama,
Japan), a Velcro strap and an elastic band (Figure 1A).
The cock-up splint fixed the location of the wrist joint
and metacarpal bones; the subject finger was positioned
inside a glove that allowed the tip of the finger to be directly pulled, using the power of the elastic band, to flex
the finger at the MCP joint.
DTF-splint. The DTF-splint comprised a wrist joint
dorsiflexion instrument, a curved PAM and wrist jointarthrodesis belt (Daiya Industrial, Okayama, Japan),a miniature gas cylinder (74 g, Nippon Tansan Gas,
Tokyo, Japan), a Velcro strap and an elastic band (Figure
1B). A profile view of the splint (Figure 2) shows thecharacteristics of this splint that pulls the articularsurface and corrects the flexural direction by applying
a PAM to the dynamic splint; the splint permits thetreatment of two or more fingers, simultaneously. The
PAM used in this study is made of curved rubber (Figure
3A and 3B) and comprises a rubber tube covered witha bellows sleeve that only extends or contracts axially.
By inhibiting the extension of one side, with the fiber
reinforcement, the bending motion in the desired direction occurs by supplying compressed air to the rubber
tube. As shown in Figure 3A, the curved tube is covered(a) The dynamic flexion splint (DFS splint)

Fig. 2. The PAM used in this study is the curved type pneumatic rubber artificial muscle.

by an inner, non-contracting cloth and an outer, rubbercloth. The curved, rubber PAM bends when the rubber
tube expands as result in the difference of the lengths of
the rubber and cloth (outer and inner) covers. The bending motion was used to flex the joint, and the extension
movement was used for joint traction (Figure 3B). The
subject finger was wrapped to avoid any possibility of
local ischemia.
Statistical methods
Statistical analyses were performed using the
Kruskal-Wallis and Bonferroni methods for making
within-group comparisons, and the Mann-Whitney(b) Pneumatic-Type Dynamic Traction and flexion splint (DTF splint)

Fig. 1. The dynamic splint used in this study.
A) Dynamic flexion splint; Couk-up splint fixed at the wrist joint and metacarpal bones. The flexion-type equip gloves
on the subject’s finger, pulls the tip of the finger directly in and causes flexion at the MP joint due to the rubber.
B) Pneumatic-Type Dynamic Traction and flexion splint: A characteristic motion of the artificial muscle is madepossible such that extension and bending of the fingers takes place. The bending motion was used for flexion of thejoint, and the movement of the extension was used for traction of the joint.

88

Clinical response of dynamic splint

Fig. 3. Structure of the curved type pneumatic rubber artificial muscle.
A) Non pressurized rubber tube.
B) Pressurized curved rubber tube.

U-test was used to perform between-group comparisons.
The significance of the differences between mean values
was calculated. All statistical analyses were performed
using the SPSS Base 11.0J statistics software (SPSS
Japan, Tokyo, Japan); P-values < 0.05 were considered
statistically significant.

Table 2. Evaluation results in relation to the use of dynamic flexion
splint (DFS) and pneumatic-type dynamic traction and flexion (DTF).
Evaluation

DFS

DTF

P value

Joint flexion (°)

pretreatment
final
gain

27.3±10.860.1±9.832.823.3±8.965.1±12.3
41.8

0.65
*0.04
†
0.01

Results

TAM

Table 2 shows the details of the effects of wearing
both splint types over the 8-week treatment period.

pretreatment
final
gain

175.3±19.8
207.9±10.932.6

171.5±27.2
218.7±12.3
47.2

0.72
*0.02
†
0.01

Grasp (kg)pretreatment
final
gain

5.8±6.1
25.3±9.8
19.5

5.2±3.922.6±10.7
17.4

0.89
0.61
0.08

VAS-score

pretreatment
final
gain

2.2±1.0
1.2±0.61

2.5±0.5
1.1±0.7
1.4

0.54
0.43
0.71

MCP joint flexion angle
The pretreatment MCP joint flexion angles were27.3 ± 10.8° and 23.3 ± 8.9° in the DFS and DTF-splintgroups, respectively. In the DTF-splint group, the MCP
joint flexion angles improved significantly more, overthe 8-week treatment, than those in the DFS-splint group(P < 0.05, Table 2). Furthermore, the range of motion
improvement was significantly improved in the grouptreated with the DTF-splint for 8 weeks, compared tothose treated with the DFS-splint (P < 0.01, Table 2).
TAM scores
The pretreatment TAM scores for the DFS- andDTF-splint groups were 175.3 ± 19.8° and 171.5 ± 27.2°,
respectively. Over the 8-week treatment period, theDTF-splint group showed significantly improved flexion
angles compared with the DFS-splint group (P < 0.05).
Furthermore, the TAM improvement was significantly
greater for those wearing the DTF-splint than for thosewearing the DFS-splint (P < 0.01).

* P values < 0.05 were considered statistically significant.
†P values < 0.01 were considered statistically significant.

Grasp strength
The mean grasp strength of the patients wearing
the DTF-splint was not significantly different from thatfor the patients wearing the DFS-splint, at the end of thetreatment period. Hence, the improvements in the twogroups were similar.
VAS-score
Similarly, there were no significant differences in
VAS pain scores between the groups wearing the DFS
and DTF-splints.
The 2-week rates of improvement for the patientswearing both types of splints

Asian J Occup Ther 12: 85−91, 2016(a) MP joint flexion angle

Nakayama J et al.

89(b) Total Active Motion-score

Fig. 4. The 2-week improvement rates in patients wearing DFS and DTF splint.
We dissected 21 patients 52 fingers. (A) was the MP joint flexion angle, (B) was the total Active Motion-score.
The significance level was set at *p < 0.05 †p < 0.01.

MCP joint flexion angle improvement angle (Figure 4A)
As shown in Figure 4A, for the first 4 weeks, there
was no significant difference between the DTF and
DFS-splint groups. However, patients wearing the DTFsplint improved significantly faster by weeks 6 and 8
than did the patients in the DFS-splint group (P < 0.01).
TAM score improvement angle (Figure 4B)
The TAM scores, over the first 6 weeks of treatment, were not significantly different between the twogroups However; the DTF-splint group improved significantly more during the last two weeks of treatment
than did the DFS-splint group (P < 0.01, Figure 4B).

Discussion
Generally, extension contractures are the mostcommon contractures of the MCP joint. Maintaining
maximum finger range of motion during the early
treatment of these contractures is important to achieve
optimal outcomes. Contracture of the MCP joint is acommon clinical condition [17], but treatment is difficult and requires more time when the contracture is fully
formed. This is the reason that the contractures shouldbe treated as early as possible. There are several possible causes of joint contractures, including adhesionsof the extensor tendons over the dorsum of the hand orof the extensor hood mechanism over the MCP joint;
thickening of the dorsal MCP joint capsule; contractureof the collateral ligament; insufficient skin coverage or
scarring of the skin over the dorsum of the hand, as in aburn; or a bony block within the joint [21, 22]. Of these,

the most common cause of extension contractures of the
MCP joint is shortening of the collateral ligament [11].
The dynamic splint is a well-accepted modality
used for restoring joint motion to an injured hand. However, in extension contractures that involve a bent MCP
joint, such treatment may not only be ineffective, but
may also injure the articular cartilage causing greater
damage. Therefore, thermotherapy is an effective treatment adjunct, prior to the use of a joint traction method[11]. This study assessed whether the DTF-splint isan effective device for treating MCP joint extension
contractures. We used both the novel DTF-splint and theconventional DFS-splint to treat patients with extension
contractures of the MCP joint. The results indicatedthat the DTF-splint yielded early recovery of both joint
flexion angle and finger function. However, the changes
in grasp strength and VAS scores were not significantly
different between the DTF and DFS-splint treatments.
Specifically, the improvement angle in the range of
motion of the joint flexion angle was significantly improved at both 6 and 8 weeks of treatment, compared tojoints treated using a DFS-splint. As a result, the TAM
scores in joints treated using the DTF-splint were alsosignificantly improved by week 8, compared to joints
treated using the DFS-splint.
Generally, a PAM enables effective treatment to bedelivered under conditions of relatively low pressure
and reduced tension; PAM provided powered torque tothe splint in the DTF-splint. Additionally, the utilizationof PAM enables the use of a splint that is flexible, lightweight, easily maintained, and inexpensive. Recent
studies have quantified the force-length, force-velocity,

90

Clinical response of dynamic splint

force-activation, and bandwidth properties of artificial
pneumatic muscles in detail [23−26]. The low compliance and high of the PAM is well suited for mimicking
natural gait movements [24, 25] and, in the current
orthosis, for providing a power-assisted glove [18].
According to our preliminary research, the joint
space in the most palmar part of the MCP joint was increased by approximately 1.7 mm, using the DTF-splint
compared to the joint, without orthotic treatment [18].
The DFS-splint works by adding tension to the joint, inthe flexional direction, using elastic power to the fingertip. On the other hand, the DTF-splint allows extension
and bending of the fingers. The bending motion wasused to flex the joint, and extension was enabled using
joint traction. Thus, the DTF-splint allows extension of
the extensor tendon as well as the application of traction.
The improved flexion angle of the whole finger, into theinterphalangeal joint, was accomplished using the PAM
along the full length of a finger. As a result, there was
improvement in both the extension and flexion of thewhole finger, including the interphalangeal joint.
The traction force of the DTF-splint extended thecollateral ligaments of the MCP joints. This may indicate an improvement in the overall function of the finger
as well as an improvement in the flexural angle, compared to fingers treated with a DFS-splint. However, as
for the splints, a grip and a pain did not have a change.
Furthermore, the effect in DTF-splint is not immediate,
and it is actualized several weeks later. We regulated
power of traction while being careful about sharp pain.
Therefore, we think that stretch of tissue might taketime. That is why there is not the DTF-splint immediate
effect. However, it is the DTF-splint may be an effective
tool for improving a patient’s digital range of motion incomparison with DFS-splint several weeks later.
Study limitations
This study has a few limitations. First, each patientused the splint for only 8 weeks, rather than over a long
period. Hence, we were unable to determine the periodof treatment. Second, only patients who had been diagnosed with MCP joint contractures within 6 months ofthe start of the study were enrolled. Third, we did notevaluate the impact of the treatment on the activities
of daily living. Finally, the study involved a limited
number of patients. In future studies, we plan to increase
number of patients and test the long-term effects of the
splint and the usefulness of the splint for treating contractures diagnosed more than 6 months prior to the startof therapy.

Conclusion
Our results show that use of the novel DTF splint
allows early improvements in the overall flexion of afinger and in the MCP joints flexural angle in patientswith MCP joint extension contractures. Additionally, inthis limited study, the DTF-splint appeared to be more
effective than DFS-splints for treating patients withextension contractures of the MCP joint.
Acknowledgment: This study has received a grant fromthe Okayama Prefecture Industrial Promotion Foundation in 2011.

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■ORIGINAL ARTICLE

Effects of tasks involving different numbersof processes on working memory:
Assessment by conducting cognitive function tests
and using NIRS oxygen monitoring equipment
Katsumi Sugihara1, 3, Mizuho Fujiwara2, Hiroshi Furukawa2
1

Faculty of Rehabilitation, Shijonawate Gakuen University
Faculty of Rehabilitation, Kobe Gakuin University
3
Graduate Student, Kobe Gakuin University Graduate School
2

Abstract: The present study examined the effects of tasks involving different numbers of processes on working memory (WM) by conducting cognitive function tests and using NIRS (near-infrared spectroscopy). The subjects were asked
to perform two types of task involving varying numbers of processes. After the subjects performed both tasks involving
one and multiple processes: drawing and the creation of a box, respectively, the oxygen hemoglobin concentration in
the DLPFC was higher. However, there was no significant difference between the two tasks. The results of cognitive
function tests following the production of boxes were also compared, and the PASAT 2 sec and SDMT scores weresignificantly higher. These results suggested that the efficient implementation of the task involving multiple processes
generated an appropriate level of cognitive load required to promote the active functioning of WM and, as a result, thesubjects achieved higher cognitive function test scores after completing the tasks.
Keywords: working memory, occupational therapy intervention, work-related practices, cognitive function(Asian J Occup Ther 12: 93−102, 2016)

Introduction
Baddeley and Hitch [1] define working memory(WM) as a system designed to maintain temporarily
information required for sets of complex cognitive
processes, such as language understanding, learning,
and inference, and to manipulate it. The function of
WM is required to facilitate smooth actions by a person,
and it principally operates in the dorsolateral prefrontal
cortex (DLPFC). The prefrontal region not only serves
as a basis for high-level cognitive functions, including
thinking and cognition, but is also responsible forgoal-oriented actions, such as performing behaviors andmemorizing plans [2].
In recent years, an increasing number of studies
have suggested that exercise activates the DLPFC. AcReceived: 6 October 2014, Accepted: 3 June 2015
Corresponding to: Katsumi Sugihara, Faculty of Rehabilitation, Shijo­
nawate Gakuen University, 5-11-10, Hojo Daitou-city Osaka 5740011, Japane-mail: sugihara@reha.shijonawate-gakuen.ac.jp©2016 Japanese Association of Occupational Therapists

cording to Soya et al. [3], moderate or intense exercise
for ten minutes activated the left DLPFC, and Taniguchi
et al. [4] suggested that arm-reaching exercise activated
the right DLPFC.
Other previous studies suggested that performing
cognitive tasks improved cognitive functions and activated the prefrontal area. Komai et al. [5] asked patientswith Alzheimer-type dementia to undergo training
including visual and auditory tasks, and they received
higher scores in cognitive function tests related to attentional function and WM following the training. Taniguchi et al. [4] conducted a test involving verbal WM
tasks, and the prefrontal area of the subjects undergoing
the tasks was activated, which suggested that WM functions are associated with the prefrontal area. According
to the results of other previous studies, the implementation of meaningful tasks with respect to the valuesof individual participants [6] and antagonistic exercise
performed by the elderly as a cognitive task effectively
activated the prefrontal area [7]. Another previous study
suggests that different tasks performed by examinees
have varying influences on their cognitive functions. A
study conducted by Nebes et al. [8] suggests that, al-94

Effects of tasks involving different numbers of processes on working memory

though dysfunction cannot be noted when patients withmild Alzheimer-type dementia undergo simple attention
tasks, patients tend to develop dysfunction while performing WM tasks and those that require the distribution
and conversion of attention. These findings provided
by previous studies suggest that performing exercise or
cognitive tasks activates the cerebral blood flow in theprefrontal area and influences WM functions.
On the other hand, no previous studies focused on
the number of processes involved in each task to examine the effects of its differences on WM. The system of
WM actively processes information required to perform
highly goal-oriented tasks while maintaining it [9].
Therefore, when a task involving multiple processes isperformed, WM has a larger number of opportunities tomaintain and operate information included in the processes actively. In other words, when a task involving asingle process is performed, WM maintains and operates
information fewer times. This led to the hypothesis thatdifferences in the number of processes involved in eachtask may affect the activation of the DLPFC, which
controls WM. The present study examined the effects of
those differences on WM, using cognitive function tests
and NIRS oxygen monitoring equipment (NIRO200NX,
Hamamatsu Photonics). The subjects were asked toperform two tasks involving different numbers of processes.

while referring to a process chart including development
views and a completed box, without receiving advice.
The box, the length, width, and depth of which were 4,4, and 3 cm, respectively, was created using craft paper.
The tools used included pencils, rulers, scissors, and staplers. Four processes, or the following instructions, anddevelopment views were written on the process chart:(1) Draw a development view on craft paper, (2) Cut out
the view with scissors, (3) Fold the paper into the shapeof a box while ensuring that the margins of the paper for
paste are facing in the proper direction, and (4) Overlap
the margins and staple them.
In the drawing session, reflection drawing equipment (Takei Scientific Instruments Co., Ltd.), designed
to assess the dexterity of the hands and learning skills,
was used. There was only one process: the subjects drewa line between two star-shaped lines, using only a pencil.
Although the numbers of processes and tools used were
smaller, other conditions, including the provision ofan explanation of the work procedure, presentation of
the process chart, designation of tools, and responses
to questions, were similar to those for the creation ofboxes. Since the drawing task involved only one process:“Drawing a line with a pencil between two lines - anoutline of a figure, reflected on a mirror”, the subjects
were required to refer to the process chart fewer times
than for the task of creating a box.

Subjects and methods

3. Cognitive function tests
As cognitive function tests to assess WM, the Paced
Auditory Serial Addition (PASAT) 1 and 2 second,
Symbol Digit Modalities (SDMT), and Digit Span Tests(recital of numbers) were adopted. In the PASAT [10],participants listen to a CD and continue adding onedigit numbers that they have just been informed of in
their head. The numbers are read out at an interval of
one or two seconds. In the SDMT [10], participants
write a number that corresponds to each of nine symbols
according to a rule. The recital of numbers [10] assesses
the auditory memory span, and there are two types: participants recite the numbers that have been read out by
an examiner in the normal or reverse order (normal- andreverse-order recitals).

1. Subjects
The subjects were ten college students, including
four males and six females (mean age: 20.3 ± 0.5 yearsold). The subjects were asked to undergo the Edinburgh
Handedness Inventory to confirm that their right arms
are dominant.
2. Tasks and methods
In the present study, the following tasks were performed: “the creation of a box” involving four processes
and “drawing using a mirror” consisting of one process.
The task of creating boxes using A4 craft paper has
been introduced to many clinical settings in Japan since
occupational therapists adopted it to assess problemsolving skills. The task can be easily introduced for theassessment of task implementation skills and cognitive
functions as well as treatment in occupational therapy
because tools and materials for the creation of boxes arereadily available. The task also has meaning as treatment
since the created boxes can be used in daily life.
In the experiment, the examiner presented a completed box to the subjects and explained the work procedure to them. The subjects were asked to create boxes

4. Measuring equipment
NIRS (near-infrared spectroscopy) is a non-invasive
brain-function diagnostic imaging technique used tomeasure cerebral activities. In rehabilitation and otherfields, oxygen hemoglobin (Oxy-Hb) concentrations andtheir changes, which depend on neural activity, havebeen measured [11]. The prefrontal area is considered to
be a representative cortex in charge of performing WMtasks. In recent years, an increasing number of studies

Asian J Occup Ther 12: 93−102, 2016

Sugihara K et al.

95

ment and postures of the subjects appropriately andimplement baseline correction based on measurements
at rest in order to prevent artifacts from interfering withNIRS measurements [14]. Therefore, prior to attaching
the probes to the bodies of the subjects, they were asked
to assume a specific sitting position so that their body
movements could be controlled and their hands could
be observed while performing the tasks. They were also
instructed not to close or open their eyes too widely
during measurement. After receiving these instructions,the subjects underwent measurement and performed thetasks when the waveform had become stable.

Fig. 1. Dipping of probes.

have been conducted to assess the functions of the frontal lobe using NIRS [2]. NIRS was adopted to analyze
the activation of the DLPFC - the targeted measurementsite. A pair of one-channel probes (for left and right)
were attached 5 cm from the C3 and C4 points in thesagittal direction according to the international 10−20
method, based on the method developed by George et al.
[12]. Time-series NIRS data within a specific period oftime are related to each other, and cannot be regarded as
independent. Therefore, a block design was adopted, inwhich the same task followed by a rest was repeated, toanalyze statistically changes in the Oxy-Hb concentration during the tasks [13].
Furthermore, there were also spontaneous periodic
variations in NIRS measurements other than those attributed to the activation of the brain while performing
the tasks. In addition, the blood also flows in the tissuesof the surface layer of the head other than the brain
parenchyma, so NIRS measurements are also influenced
by the dynamics of the blood flow. The above-mentioned
results suggest that it is necessary to control the move-

Fig. 2. Experiment procedures.

5. Experimental procedures
The experimental procedures are presented in
Figs. 2 and 3. The experiment was conducted for eachindividual subject in an experimental room that lacked
external stimuli. The following research procedure was
implemented: (1) Cognitive functional tests (PASAT
1 sec and 2 sec, SDMT, and recitals in the normal andreverse orders) had been conducted before the subjects
performed the tasks. (2) NIRS probes were attached tothe subjects and, after confirming that the waveforms
were consistent, measurement was conducted while
the subjects performed the tasks. (3) The subjects performed a 180-second task four times at rest intervals of
30 seconds. While resting, the subjects were asked toassume the same posture as that when they performed
the task, and gaze at the “+” mark on the screen of aPC. (4) When the subjects had completed the task, theprobes were detached from them. (5) Cognitive function
tests (PASAT 1 sec and 2 sec, SDMT, and recitals in
the normal and reverse orders) were conducted for the
subjects who had completed the task.
The processes and tools were prescribed so that the
subjects would not become confused when performing
the task. The process of the task and tools were designated to help the subjects perform it efficiently andfacilitate the active maintenance and manipulation of

96

Effects of tasks involving different numbers of processes on working memory

Fig. 3. Instruction procedures.

information - functions of WM. The examiner did notprovide the subjects with advice on the method for performing the task efficiently. The subjects could improvethe efficiency of performing the task - creation of fourboxes, by implementing the following methods: omit
drawing folding lines when “drawing a development
view on craft paper”, and reducing the frequenciesof referring to the development view to confirm thedimensions and the process chart. Although the subjects
were supposed to follow the order of the processes when
performing the task, they were allowed to improve thework efficiency by modifying the procedure, which was
expected to affect WM.
The subjects performed the task of drawing according to the same procedure more than six months after
they had created boxes. This was because participationin cognitive function tests often enhances learning
effects, and the experiments involving college students
as the subjects were conducted during the periods oftheir summer and winter vacations. The subjects were in
the same school year in the same college and involved
in similar activities in their school lives. There wasno significant difference in their mean age when they
performed the tasks (20.3 ± 0.5 and 21.1 ± 0.3 years
old at the time of the production of boxes and drawing,
respectively). The present study was conducted withthe approval of the ethics committee of Kobe Gakuin
University. The subjects received written and verbal
explanations of the purpose of the study and its method,and consented to participate in it (Approval number:
HEB120706-1).

Analysis methods
1. Analysis of the activation of the DLPFCIn NIRS data analysis, conducting averaging canisolate stimulus-dependent responses. Specifically,adding and averaging are performed to correspond to
the intervals of similar stimuli applied multiple times toeliminate the waveforms of background activities, which

fluctuate independently of the timing of the stimuli
applied, and identify only stimulus-dependent responses[11]. In the present study, the body movements andpostures were appropriately controlled to exclude data
mixed with artifacts. The means of Oxy-Hb concentrations during 170 of the 180 seconds required to perform
each task, excluding the first 10 seconds, were calculated as the Oxy-Hb activation values, and their baseline
correction was conducted. The mean of Oxy-Hb concentrations measured during the first to third resting periods
was calculated as the resting-state (baseline) value. The
procedure for measurement was as follows: Immediately
prior to the start of measurement, the subjects were
instructed to look at a picture on a wall in front ofthem, and performed the tasks when the waveform had
become stable.
The Wilcoxon signed-rank test was conducted tocompare the Oxy-Hb activation and resting-state values
between the two tasks. The resting-state value wassubtracted from the Oxy-Hb activation value for comparison, and the relative activation values and baseline
levels were compared between the tasks, using theMann-Whitney U test. The significance level was set toless than 5%.
2. Analysis of cognitive function test scores
The subjects performed the task of drawing morethan six months after they had created boxes because
participation in cognitive function tests often enhances
their learning effects. The cognitive function test scores
before the tasks were performed were defined as thebaseline values. The paired t-test was conducted tocompare the scores received prior to and following the
cognitive function tests between the two tasks. The
baselines were compared between the two tasks, anddifferences between the cognitive function test scores
received before and after the tasks had been performed
were calculated and compared between the tasks, using
Welch’s test. The significance level was less than 5%.

Sugihara K et al.

Asian J Occup Ther 12: 93−102, 2016

Results

97

Table 2. Oxy-Hb concentrations (resting-state and activation values)
measured during the creation of boxes and drawing.

1. Oxy-Hb concentrations and baseline levels as theresults of cognitive function tests
Table 1 shows that there were no significant differences in the Oxy-Hb concentration in the DLPFC andcognitive function test baselines for the tasks of creatingboxes and drawing between the two tasks.
2. Oxy-Hb concentrations(1) Resting-state and activation values (Oxy-Hb concentrations)
Table 2 shows Oxy-Hb concentrations (resting-state
and activation values) measured during the creation ofboxes and drawing.
1) Creation of boxes
Significant activation was noted in the right DLPFC(resting-state value in the right DLPFC: 1.0 ± 1.0μmol/L, activation value in the right DLPFC: 1.7 ± 1.5μmol/L, p < 0.05). There was no significant differencein the value in the left DLPFC (resting-state value in theleft DLPFC: 0.7 ± 1.0 μmol/L, activation value in theright DLPFC: 1.3 ± 1.7 μmol/L).
2) Drawing
Significant activation was noted in both areas of the
DLPFC (resting-state value in the left DLPFC: 0.2 ± 1.4μmol/L, activation value in the left DLPFC: 0.9 ± 1.5μmol/L, p<0.01) (resting-state value in the right DLPFC:
1.5 ± 0.9 μmol/L, activation value in the right DLPFC:
2.6 ± 1.1 μmol/L, p < 0.01).

DLPFC

Restingstate value(mmol/L)

Activation
value(mmol/L)

Mean

SD

Mean

SD

Box
Box

Left
Right

Oxy-Hb
Oxy-Hb

0.7
1.0

1.0
1.0

1.3
1.7

1.7
1.5

0.2
0.04*

MirrorMirrorLeft
Right

Oxy-Hb
Oxy-Hb

0.2
1.5

1.4
0.9

0.9
2.6

1.5
1.1

0.0093**0.0051****p < 0.01 *p < 0.05
n = 10• The subjects performed the task of drawing more than six months
after they had created boxes.

3) Comparison of relative Oxy-Hb activation values
between the tasks
Relative Oxy-Hb activation values were compared
between the tasks. There were no significant differences in the values for both sides between the two tasks(creation of a box in the left DLPFC: 0.6 ± 1.1 μmol/L,drawing in the left DLPFC: 0.6 ± 0.6 μmol/L) (creationof a box in the right DLPFC: 0.7 ± 0.9 μmol/L, drawing
in the right DLPFC: 1.1 ± 0.8 μmol/L). Figs. 4 (creationof boxes) and 5 (drawing) show the mean waveforms
for the two tasks.

Table 1. Oxy-Hb concentrations and baseline levels as the results of cognitive function tests.
DLPFC
Left
Right

Oxy-Hb
Oxy-Hb(mmol/L)(mmol/L)

Cognitive function tests
PASAT1 second
PASAT2 second
SDMT
ForwardBackward(points)(points)(points)(figure)(figure)P value

The creation ofa box

Drawing using
a mirror

Mean

SD

Mean

SD

0.3
0.1

0.7
0.7

0.6
0.1

1.4
0.4

The creation ofa box

Drawing using
a mirror

Mean

SD

Mean

SD

62.4
87.8
67.8
7.1
5.2

18.3
9.6
9.1
0.9
0.6

67.1
94.9
65.2
7.0
4.6

11.7
5.2
16.1
1.1
0.8

U value

P value

0.2
0.1

0.9
0.9
P value
0.5
0.1
0.7
0.8
0.2

n = 10• The subjects performed the task of drawing more than six months after they had created boxes.
• Oxy-Hb: oxygen hemoglobin concentrations• In the PASAT, participants listen to a CD and continue adding one-digit numbers that they have justbeen informed of in their head. The numbers are read out at an interval of one or two seconds.
• In the SDMT, participants write a number that corresponds to each of nine symbols according to a rule.
• The recital of numbers assesses the auditory memory span, and there are two types: participants recite
the numbers that have been read out by an examiner in the normal or reverse order.

98

Effects of tasks involving different numbers of processes on working memory

Fig. 4. Wave form of the creation of a box.
• Average waveform of relative value in the creation of a box.
• Bold line is the right side, and a thin line is a left side.

Fig. 5. Wave form of droawing using a mirror.
• Average waveform of relative value in droawing using a mirror.
• Bold line is the right side, and a thin line is a left side.

3. Results of cognitive function tests(1) Comparison of cognitive function test scores before
and after the tasks were performed
Table 3 shows the results of the comparison of cognitive function test scores before and after the creationof boxes and drawing were performed.
1) Creation of boxes
There were significant increases in the mean scoresfor the PASAT 2 sec (prior to the task: 87.8 ± 9.6 points,
following the task: 93.9 ± 4.9 points, p < 0.05) andSDMT (prior to the task: 67.8 ± 9.1 points, following
the task: 77.2 ± 11.9 points, p < 0.01). There were no
significant differences in the scores for the PASAT 1
sec (prior to the task: 62.4 ± 18.3 points, following thetask: 67.9 ± 13.8 points), normal-order citation (prior to
the task: 7.1 ± 0.9 points, following the task: 7.4 ± 1.1
points), and reverse-order citation (prior to the task: 5.2± 0.6 points, following the task: 5.3 ± 1.1 points).
2) Drawing
There was a significant increase in the PASAT 1 sec(prior to the task: 67.1 ± 11.7 points, following the task:
74.6 ± 10.9 points, p < 0.01). There were no significant
differences in the scores for the PASAT 2 sec (prior to
the task: 94.9 ± 5.2 points, following the task: 94.9 ±7.6 points), SDMT (prior to the task: 65.2 ± 16.1 points,
following the task: 69.3 ± 16.8 points), normal-ordercitation (prior to the task: 7.0 ± 1.1 points, following thetask: 7.2 ± 1.0 points), and reverse-order citation (priorSugihara K et al.

Asian J Occup Ther 12: 93−102, 2016

99

Table 3. The results of the comparison of cognitive function test scores before and after
the creation of boxes and drawing were performed.
The creation of a box
PASAT1 second
PASAT2 second
SDMT
ForwardBackward(points)(points)(points)(figure)(figure)Drawing using a mirror
PASAT1 second
PASAT2 second
SDMT
ForwardBackward(points)(points)(points)(figure)(figure)Prior to the task

Following the task

Mean

SD

Mean

SD

62.4
87.8
67.8
7.1
5.2

18.3
9.6
9.1
0.9
0.6

67.9
93.9
77.2
7.4
5.3

13.8
4.9
11.9
1.1
1.1

Prior to the task

Following the task

Mean

SD

Mean

SD

67.1
94.9
65.2
7.0
4.6

11.7
5.2
16.1
1.1
0.8

74.6
94.9
69.3
7.2
4.9

10.9
7.6
16.8
1.0
0.5

P value
0.17
0.02*
0.003**
0.08
0.59
P value
0.004**
0.99
0.13
0.34
0.27

**p < 0.01 *p < 0.05
n = 10• The subjects performed the task of drawing more than six months after they had createdboxes.

to the task: 4.6 ± 0.8 points, following the task: 4.9 ± 0.5
points).
(2) Comparison of differences in cognitive function testscores prior to and following the tasks
Differences in test scores before and after the tasksof creating boxes and drawing had been performed (value
following the task - value prior to it) were compared.
There was a significant increase in the PASAT sec 2
score following the creation of boxes (creation of a box:
6.2 ± 6.9 points, drawing: −0.01 ± −4.7 points, p < 0.05).
There were no significant differences in scores for cognitive function tests other than the PASAT 1 sec (creationof a box: 5.4 ± 11.3 points, drawing: 7.5 ± 6.1 points),
SDMT (creation of a box: 9.3 ± 7.4 points, drawing:
4.1 ± 7.8 points), normal-order citation (creation of abox: 0.3 ± 0.4 points, drawing: 0.2 ± 0.6 points), andreverse-order citation (creation of a box: 0.1 ± 0.6
points, drawing: 0.3 ± 0.8 points).

Discussion
In the present study, the subjects performed twotasks involving different numbers of processes, and theeffects of their differences on WM were assessed byconducting cognitive function tests and NIRS, and basedon the cerebral blood flow in the DLPFC and other test
results. Prior to conducting analyses, the following point
was confirmed: there were no significant differences in
the Oxy-Hb concentrations in the DLPFC and baseline
levels determined by the cognitive function tests between the two tasks.
The study results were as follows: there were no

significant differences in the Oxy-Hb concentrationin the DLPFC and baseline levels determined by the
cognitive function tests after both tasks were performed.
Although the Oxy-Hb concentration in the DLPFC wassignificantly higher after both tasks were performed, no
significant difference was noted between the two tasks.
Cognitive function test scores were significantly higher
following the creation of a box, which involved multiple
processes. There were significant increases in the meanscores for two cognitive function tests after the subjects
performed the task of creating a box. In the comparisonof cognitive function test scores between the two tasks,
the mean score for the PASAT 2 sec following the creation of a box was significantly higher.
Oxy-Hb concentrations were significantly higher
in the right area of the DLPFC after the subjects createda box, and in both left and right areas after they performed the task of drawing. An increase in the Oxy-Hb
concentration in the right prefrontal area is related tothe positional relationship between a person and an
object. On the other hand, an increase in the Oxy-Hb
concentration in the left prefrontal area is related to theeye movement to gaze at an object and the function of
WM to process spatial information [15, 16]. There wasa significant increase in the Oxy-Hb concentration in
the right prefrontal area following the creation of a box,
presumably because WM continues using visual images
when a subject creates a box. The task of drawing was
performed using a mirror. Complex motor learning
including the skillful use of a pencil by the subjects
presumably involved the processing of information
obtained from the eye movement and other visual infor-

100

Effects of tasks involving different numbers of processes on working memory

mation. These results suggest that the task of drawing
significantly increased the Oxy-Hb concentrations inboth left and right prefrontal areas. However, there wasno significant difference in the relative Oxy-Hb activation value between the two tasks. This suggests that theeffects of tasks involving different numbers of processes
on WM cannot be explained solely by an increase in the
Oxy-Hb concentration in the DLPFC.
Regarding the cognitive function tests following
the completion of the tasks, the mean correct answer
rates in the PASAT 2 sec and SDMT were significantly
higher after the subjects had created boxes. On the other
hand, only the correct answer rate in the PASAT 1 sec
was significantly higher after the task of drawing was
performed. In the comparison of the two tasks, the mean
correct answer rate in the PASAT 2 sec was significantly
higher after the task of creating a box involving multiple
processes had been performed, compared with the taskof drawing. According to Callicott et al. [17], WM in theprefrontal area is less activated when the cognitive load
is excessively large or small, and more activated when
the appropriate amount of cognitive load is applied. The
processes of the tasks and tools were prescribed to help
the subjects concentrate on the tasks and to facilitate theactive maintenance and manipulation of information functions of WM.
The number of processes involved in the creationof a box is larger than for the task of drawing, whichmeans that there are more opportunities for improving
the work efficiency. When the work efficiency was high,the appropriate amount of cognitive load was applied
and WM was activated - there were significant changes
in the cognitive function test scores following the completion of the tasks.
Levine et al. [18] conducted research on the effectsof goal management training (GMT), and suggested that
GMT, in which trainees learn about planning and goal
accomplishment, is a method for improving frontal lobe
dysfunction. In this method, the planning of a final goal
involves the setting of multiple sub-goals, and the final
goal is accomplished by conducting goal management,or the accomplishments of all sub-goals. Since WM
functions the most effectively when people are goaloriented, undergoing GMT is expected to improve thefunctions of WM. When a box is created, or to reach thefinal goal, four processes as sub-goals are accomplished
one by one and, as a result, WM is rewritten more frequently than when the task of drawing is performed. The
goal of the task of drawing is to draw a line between
two lines, which serve as an outline of a figure. When aline is drawn - a task involving only one process, subgoals are accomplished fewer times than when a box iscreated, and WM is also rewritten fewer times. WM isused less frequently during drawing than when a box iscreated, presumably due to a smaller number of processes required for the task of drawing. Kingberg et al. [19]suggest that, when patients undergo WM tasks as partof training, changing the difficulty level for each patient
will improve the effect. The results of the present study
suggest that, as the capacity of WM varies from person
to person, WM can be effectively activated by changing
the number of processes involved in tasks according to
the WM capacity.
Although the present study focused on the numberof processes involved in each task to examine the effects
of its differences on WM, it is also necessary to discusslearning methods for performing tasks. When the subjects draw a line between two star-shaped lines reflected
on a mirror, they make mistakes until they learn to use
the pencil with dexterity. In other words, they makemany mistakes to master complex motor learning andbecome able to draw properly. Since it is difficult tocorrect false responses caused by mistakes as one of thecharacteristics of the task, Watamori et al. [20] suggestthat a learning method that prevents mistakes (errorlesslearning) effectively helps people memorize new things.
In principle, the task of creating boxes is based on errorless learning because the process chart is referred to and
it is not difficult to imagine a completed box. Both error­
less learning and GMT are considered to be effective inthe creation of a box involving four processes.
In the present study, the oxygen hemoglobin (OxyHb) concentration in the DLPFC following the completion of the task was significantly higher, and cognitive
function test scores were influenced by the creation ofa box - a task involving multiple processes. However,there was no significant difference in the relative
Oxy-Hb activation value in the DLPFC between the
two tasks. This suggests that, although the scores in the
cognitive function test (designed to assess the functionsof WM) following the production of boxes were higher
than the test scores after the completion of the task ofdrawing, the effects of a difference in the number of processes on the functions of WM could not be adequately
explained.
As a future task, it is necessary to measure thecapacity of the WM of subjects, and calculate the appropriate amount of cognitive load applied when performing a task. The spatial resolution of NIRS is low and it
can only determine values relative to Oxy-Hb baseline
values and their changes, so it will be necessary tointerpret values by combining actual measurements withbaseline values obtained using PET and other methods,
as a future challenge.

Asian J Occup Ther 12: 93−102, 2016

Conclusion
The present study examined the effects of two
tasks involving different numbers of processes on WM
by assessing the cerebral blood flow in the DLPFC andconducting cognitive function tests to assess the functions of working memory (WM). Although the oxygen
hemoglobin (Oxy-Hb) concentration in the DLPFC wassignificantly higher after the subjects had performed
both tasks, there was no significant difference between
the two tasks. The results of cognitive function tests
following the production of boxes were also compared,
and the mean PASAT 2 sec and SDMT scores were significantly higher. Cognitive function test scores after thetwo different tasks had been performed were compared,
and the PASAT 2 sec score following the task of creating a box was significantly higher than the score afterdrawing. The processes of the tasks and tools were prescribed to help the subjects perform the tasks efficiently
and facilitate the active maintenance and manipulationof information - functions of WM. The task of creating abox, which involves a larger number of processes, provided the subjects with an opportunity for performing it
more freely and efficiently than the task of drawing. The
results suggested that the efficient implementation of
the task involving multiple processes generated an appropriate level of cognitive load required to promote theactive functioning of WM and, as a result, the subjects
achieved higher cognitive function test scores after completing the tasks. The scores in the cognitive function
test (designed to assess the functions of WM) following
the production of boxes were higher than the test scores
after the completion of the task of drawing, presumably
because the production of a box involved multiple steps,
in which the subjects were able to improve their work
efficiency. However, since there was no significant difference in the relative Oxy-Hb activation value between
the two tasks, the effects of a difference in the numberof processes have not yet been completely clarified.
Acknowledgement: I would like to express my sincere
appreciation to the ten people who participated in the
study.

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Rapid Communications, Case Reports, Miscellaneous,which are important to the occupational therapy profession for their originality, timeliness, effectiveness andreadability.
Original Articles
Original Article contains the original clinical or laboratory research. The body of original articles needs to bein the general format consisting of: Abstract, Keywords,
Introduction, Materials/Subjects, Methods, Results andDiscussion. Authors need to make articles clear andconcise and avoid non-standard abbreviations. Pleaseprovide abstract in 200−250 words and 3−5 keywords
before the body. The total length should be approximately 5,000 words in general including main body,references, tables, figures, and illustrations. One figure(or table and illustration) is calculated as 200 words.
Reviews
Reviews can deal with scientific topics either clinicalor laboratory. Relatively brief reviews between 2,500 to
3,000 words are particularly welcomed. Longer reviews
can be accepted when they were justified by topic andcomprehensiveness. It needs to have sufficient discussion supported by more than 30 references.
Rapid Communications
They should deal with scientific material which
deserves a rapid publication as the top priority. They
should be 2,000 words or less with a total of no morethan 4 tables and figures and up to 15 references.
Case Reports
A case report need to describe a new disease, confirmation of a rare or new disease, a new insight into pathogenesis, etiology, diagnosis, or treatment, a new finding
associated with a currently known disease. A report on
special scientific investigation will be regarded as an
original article even with a single case. The length should
be 1,000 words or less in general with 3 tables andfigures in total with up to 10 references. They can be exceeded only when justified by extensive special studies.
Miscellaneous
It includes the article which the editing committee
judged as useful including; a committee report, news
from international conference, an introduction of theassociation and a research institute, an introduction of
new technology and new products.
Manuscript format
The manuscript needs to be set to start a new page
with the beginning of each section as the followings:(i) Title page(ii) Structured abstract and key words(iii) Main body(iv) References(v) Figure with caption(vi) Table with caption
1. Title page: The title of the paper should reflect thecontent accurately and need to indicate the name(s) ofauthor(s), degrees and affiliation(s), job titles, contact
address including e-mail addresses, telephone and fax
numbers, and type of article such as Original Articles,
Reviews, Rapid Communications, Case Reports, andMiscellaneous.
2. Structured abstract and key words: Please attach
an abstract of your paper in 200−250 words whichenables the readers to grasp the essence of the paper
immediately. The paper must give the reader quick
recap on the statement of the problem or issues, methodology, results and conclusions. Please include three
to five key words after the abstract.

3. Main body: The main body should be divided into
sections which includes sub-headings. The main text
should include the followings: an introduction, material and subject, method, results, discussion, summaryand conclusions. Acknowledgements must be brief
and listed before the reference page. The main bodymust be numbered consecutively starting with the introduction. The manuscript must be written in Times
New Roman with the font size of 12-points.
4. References: Reference literature must be indicatedconsecutively in Arabic numerals in square brackets
through the paper. In case that the same referenceis cited more than once in the main body, the same
number should be used for each time. Reference styleshould follow the “Vancouver” style. If the cited paper
is written in a language other than English, pleasetranslate it into English and identify the original language in parenthesis in the end (e.g. in Japanese).
Exceptions:(1) List all authors or editors. Please list six people
from the top if there are more than six authorsand editors and put the word “et al” in the end.
(2) The page number on the first page must be
listed in full letters, but the page number on thelast page can be listed in abbreviated form (e.g.
51−9). Unpublished data and personal communications should be given in round brackets in the
text but not in references.
The title of Japanese journals should be listed
in Japanese in Roman letters. For example, if you
want to write “occupational therapy” in Japanese,
please write “sagyouryouhou”. To quote a paper
from a book or journal written in Japanese, thephrase ‘‘(in Japanese)’’ should be added after thetitle of the book or journal.
Examples of items listed:
Author. Title. Journal. Year; Volume(Issue): Pages.
[1] Radford KA, Lincoln NB. Concurrent validityof the stroke drivers screening assessment.
Arch Phys Med Rehabil. 2004; 85(2): 324-8.
[2] Akinwuntan AE, De Weerdt W, Feys H,
Pauwels J, Baten G, Arno P, et al. Effect ofsimulator training on driving after stroke: arandomized controlled trial. Neurology. 2005;
65(6): 843-50.
Electronic publication ahead of print[3] Ohyanagi T, Sengoku Y. A solution for measuring accurate reaction time to visual stimuli
realized with a programmable microcontroller.
Behav Res Methods. 2010, in press.
Journal article in Japanese[4] Sengoku Y, Nakajima S, Nakamura Y. Effectsof occupational therapy on identical twin chil-dren with hydrocephalus based on variations
in static and dynamic equilibrium reaction (inJapanese). The Japanese Occupational Therapy
research (sagyouryouhou). 2009; 28(5): 55564.
Examples of books and other monographs:
Personal author(s), Editor(s), compiler(s)Author. Title, Edition ed. Place Published: Publisher;Year.
[5] Kane RL, Ouslander JG, Abrass IB, Resnick B.
Essentials of Clinical Geriatrics. 7th ed. New
York: McGraw-Hill; 2013.
Author, editors. Book Title, Edition ed. Place
Published: Publisher; Year
[6] Cicchetti D, Cohen DJ, editors. Developmental
psychopathology. New York: John Wiley &Sons Inc; 1995.
Chapter in a book
Author. Title. In: Editor, editors. Book Title, Edition
ed. Place Published: Publisher; Year; Pages.
[7] Tangarorang GL, Kerins GJ, Besdine RW.
Clinical Approach to the Older Patient: An
Overview. In: Cassel CK, Leipzig RM, Cohen
HJ, Larson EB, Meier DE, editors. GeriatricMedicine: An Evidence-based Approach, 4thed. New York: Springer Science+BusinessMedia; 2006; 149-62.
Japanese book[8] Nakamura R, Saito H, Nagasaki H. Fundamental Kinesiology, 6th ed (in Japanese). Tokyo:
Ishiyaku Publishers Inc; 2013.
[9] Shimomura T. Stroke. In: Eto F, Takeda K,
Hara H, Bando M, Watanabe S, editors. Rehabilitation of higher cortical dysfunction Ver.2(in Japanese). Tokyo: Ishiyaku Publishers Inc;
2011; 95-101.
Web (literature)
Author. HP name [online]. Place [cited Access Date].
Available from: URL.
[10] Hooper JF. Psychiatry & the Law: Forensic
Psychiatric Resource Page [online]. University of Alabama, Department of Psychiatry and
Neurology [cited 2015 June 30]. Available
from: http://bama.ua.edu/~jhooper/.
Web (web page, etc.)
HP name [online]. Place: Web site name [cited AccessDate]. Available from: URL.
[11] The American Occupational Therapy
Association, Inc [online]. Montgomery:
Health & Wellness [cited 2015 June 30].
Available from: http://www.aota.org/Practice/
Health-Wellness.aspx

5. Figures and Photographs: Figures and photographsof good quality should be submitted online as a separate file. Please use a lettering to make them clear
and readable even after reducing the size to about
66%. An explanatory note must be provided for every
figure or photograph. All the authors who wish touse illustrations which were already published mustobtain the permission of the first author, publisher
and/or copyright holders to give precise reference tothe original work. This permission must include theright to publish in electronic media.
Photographs of identifiable subjects must be attached with permission with the signature of patientor legal representative who gives permission to publish.
Photographs which the faces or eyes of the subjects
can be identified should cover their faces or eyes withblack bars if necessary.
6. Tables: Tables should be numbered in order in Arabic
numerals and must be listed in the order corresponding to the reference cited in the text. Each table mustbe attached with an appropriate brief explanatory note
which is comprehensible enough without referringto the text. They should begin with a separate pageand uploaded online. They should be kept as simple
as possible and as a graphical representation. Table
titles should be brief and complete. Information otherthan the definition of the data should be presented as
footnotes.
Copyright
The copyright of the paper published (including themoral rights and property rights of the author) belong toan author. The author shall assign Japanese Associationof Occupational Therapists (hereinafter referred to as“JAOT”) the right to copy, reproduce, translate, adapt
and summarize the published article and/or the right togive permission for the third party to reprint the article
to make use of them for JAOT’s public services.
Linking to the J-STAGE’s website (https://www.jstage.
jst.go.jp/browse/asiajot) is advisable in the case of
publishing your own paper to an individual website of
the author or the website of the corporate or association
which the author belongs, the website of the granting
agency funding research fund, an archive of noncommercial electronic thesis, and the repository of
association. Please contact JAOT if you want to post the
PDF file itself.
Stipulating the sources (including the journal title,
the number of the volume and the page which the article
was posted) is necessary for publication.