■ORIGINAL ARTICLE

Time Use for Occupation and the Expectationsof People with Schizophrenia and Their Relatives
from the Perspective of Themselves
and Their Relatives
Maethisa Pongsaksri
Department of Occupational Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand

Abstract: The objectives of this research were to compare time use for occupation: self care, work and leisure, fromthe perspective of people with schizophrenia and their relatives, and investigate the expectations of people with schizophrenia and of their relatives towards their time use, and the congruence of these. The time use checklists were used tointerview seven people with schizophrenia and their relatives. The results demonstrated that there were significant differences among the time use of three types of occupation from both perspectives ( p < 0.05). The most expectation of
the participants was being able to earn a living.
Keywords: People with schizophrenia, Relatives of people with schizophrenia, Time use, Expectation(Asian J Occup Ther 14: 1−7, 2018)

Introduction
Schizophrenia is a chronic mental illness. Even if
treatment is received, around two out of three schizophrenic patients have relapses. Additionally, the chronic
conditions of most of these patients have affected theirliving functions [1] especially occupations in areas ofdaily living activities, work and leisure [2]. Routine
occupations are important to maintain and promotemental health [3]. If occupational performance is lostor disturbed; well-being and satisfaction with life may
decrease [4]. Therefore, the management of time usefor occupations can be used to promote health and wellbeing. Alternatively, the study of time use for occupation
is another method to understand the importance of each
occupation: activities of daily living, work and leisure;which promote good health and well-being [3].
There are many studies focusing on time use foroccupations of schizophrenic patients. For example, theReceived: 3 December 2016, Accepted: 20 September 2017
Corresponding to: Maethisa Pongsaksri, Department of Occupational
Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailande-mail: maethisap@gmail.com©2018 Japanese Association of Occupational Therapists

study of Hays & Halford [5] showed that schizophrenic
patients in a community participated less in occupations
and spent most of their time on passive leisure andsleep. In 2003, the work of Shimitras, Fossey & Harvey[6] survey time use of people with schizophrenia andfound that their time consuming occupations were
sleeping, personal care and passive leisure. Moreover,the study of Minato & Zemke [7] demonstrated thatschizophrenic patients in a community used their time
for three occupations differently and used most of theirtime in self care including sleep as well. Apart from
this, Bejerholm & Eklund [8] found that schizophrenic
patients were lethargic in participating in occupationsin terms of the patterns and time uses. Many people
with schizophrenia have no structured occupation andperform occupations, which have little meaning to them[9]. People with schizophrenia often fail to accomplish
occupational areas: work, self-care, and play, suitable totheir ages [10].
Most studies in Thailand focused on time uses ofschizophrenic patients who were admitted in hospitals;
there is no study for those who live at home. Nevertheless, the survey of community need for rehabilitating
psychiatric patients showed that the patients needed
positive attitude from others, having jobs or careers,
receiving medication consistently and conveniently,

2

TIME USE IN SCHIZOPHRENIA

knowledge about their psychiatric diseases and how tolook after themselves; the needs of their relatives, neighbours and leaders were the same as the patients apartfrom how to help and look after the patients appropriately. They also expected their relatives to take care of thepatients on a more intimate level [11]. This study did notsurvey occupations that the psychiatric patients really
performed in their communities or how they spent theirtime, which collected data from the patients themselvesor their relatives.
Another study of the relationship between time usefor occupation and volition of 60 schizophrenic patients
aged 20−40 years, admitted at psychiatric hospital foundthat time use for work positively related to personalcausation, however, time use for activity of daily living
negatively related to personal causation, and time use
for activity of daily living negatively related to value
and interest [12]. This result implies that personal
factors may affect the time use for occupation of schizophrenic patients when staying in hospitals. In addition,needs of people with schizophrenia to perform occupations, their living conditions [13], their accessibility tosocial contact [13, 14] and structured daily occupations[15] have been related to occupational performance ofschizophrenic people.
From the previous review, the expectations of thepatients themselves and their relatives may influence thetypes of occupation they perform or how they performthese occupations especially when living in the community. These factors may have impacts on how people
with schizophrenia spend their time to perform occupations in their communities. Therefore, it is interesting
to study time use for occupation and the expectationsof those with schizophrenia who live in communities
and their relatives from their own perspectives and theirrelatives. The sources of information from both people
with schizophrenia and their relatives may be practicalbenefits for taking care of this vulnerable group in thecommunity. The benefits of this study are useful forthe patients and their relatives in order to manage time
appropriately in daily life and also to meet their expectations.
The objectives of this research were to
1. compare time use from the perspectives of people
with schizophrenia for occupation: self care, workand leisure,
2. compare time use from the perspectives of theirrelatives for occupation: self care, work and leisure,
3. investigate the expectations of people with schizophrenia and their relatives towards their time use,
and the congruence of these.

Methods
Prior to the commencement of the study, human
ethics approval was sought and given by Faculty of
Associated Medical Sciences, Chiang Mai University
Participants
Seven people with schizophrenia and their relatives
in Muang District, Chiang Mai participated in this study
according to the following inclusion criteria:
1. people with schizophrenia who were diagnosed
with schizophrenia by psychiatrists of Suanprung
Psychiatric hospital
2. Discharged to live at their homes for at least 1month
3. Homes were located in 1.5 kilometer from Facultyof Associated Medical Sciences which made it
convenient to collect data, and were connected with
telephones.
4. Were able to respond to the points, discuss theirtime use, and be willing to participate in this study.
5. Relatives of the above schizophrenic participants
who were caregivers, able to provide information
regarding time use of their schizophrenic relatives,
and were willing to participate in this study.
Instruments
The instruments included as follows:
1. Record of demographic data and a record of daily
time use, designed by the researchers
2. Time use survey checklist of Christiansen [16],which were translated and modified to Thai language and context by the researcher. This checklist
was verified for Thai translation and modification toThai context by an occupational therapy academic
who graduated Doctor of Philosophy in occupational therapy from USA. This checklist includes
2 parts: part 1 consisted of demographic data andexpectation; part 2 consisted of two sections asfollows: Section 1 was a daily time use record for 7days, which included what they had done and how
much time they spend in each activity for each day;
Section 2 was a record form of types of occupationand how much time they spent on each type ofoccupation for each day as well as time average ofeach type of occupation. The types of occupation
comprised self-care, work and leisure as following
details:
1. Self-care referred to routine activities performing
for personal cares such as eating, grooming,bathing and dressing, rest and sleeping
2. Work referred to obligatory for pay, duties orvolunteer activities such as paid work, volunteer

Asian J Occup Ther 14: 1−7, 2018

work, housework, caring the others, studying,training, or travel
3. Leisure referred to discretionary activities which
did not disturb self-care and work such as exercise, recreation, shopping, social activities, watch­
ing television or movies or plays or exhibitions,reading, listening to music, surfing internet.

Process of collecting data
1. The researcher cooperated with the group of relatives of schizophrenic patients of Suanprung Hospital to recruit the participants.
2. Made appointments with 2 schizophrenic patients
who lived at home to pre-test the ease of using adaily time use record, then revised this record forunderstanding and data collection.
3. Made appointments with the participants who wereschizophrenic patients and their relatives to collectdata.
4. Requested the participants to sign the consent forms
and interviewed then regarding their demographic
data and their expectations as shown in part 1 of thetime use survey checklist, then asked them to fill arecord of daily time use for 7 days in a section 1 ofa part 2 after the explanations from the researchers.
The researcher would telephone to remind them
about recording the forms every day at 9 am for 7
days.
5. The researcher made appointments again to collect
the record of daily time use after 7 days, then interviewed them to categorize types of occupations
according to the definitions and components of eachtype of occupation as shown in a section 2 of a part2 and calculated averages of time use for each typeof occupation, and filled it in.
6. Checked the completion of the records and thechecklists, and then analyzed the data.

Statistical analysis
SPSS (Statistical Package for Social Sciences V 17
for Windows) was used for the statistical analysis. In
order to examine the comparison of time uses for occupation: self care, work and leisure from the perspectivesof people with schizophrenia; and from the perspectivesof their relatives, Friedman Two-way Analysis of
Variance by Rank were conducted because the data distribution was not a normality. Afterwards, the multiple
comparison tests using Wilcoxon Signed Ranks test
were administrated to further examine the differences ofpairs of time uses for each occupation.

Pongsaksri M

3

Results
Demographic characteristics of people with schizophrenia and their relatives
Table 1 shows Demographic characteristics ofpeople with schizophrenia and their relatives. Most
people with schizophrenia were males, between 20−30
years, high school graduates, unemployed, and single.
Most of their relatives were males of 60 years or more.
Two relatives did paid work, three out of seven have hadbusinesses, one was a housewife and the other one wasa civil Servant. Five relatives received education levels
below bachelors degree, and two of them were uneducated. Nevertheless, information regarding the marital
status of their relatives was not applicable. In addition,
most of their relatives (5) were parents and 2 others
were a brother and a sister.
Time uses of people with schizophrenia and their relatives
Table 2 shows the amount of time used in 24 hours
for self-care, work, and leisure. People with schizophrenia spent most of their time (69.17%) for self-care(median = 17.30, Q.D. = 14.0), then leisure (24.33%)
Table 1. Demographic characteristics of people with schizophrenia
and their relatives
Schizophrenics(n = 7)

GenderMale
FemaleAge (in year)
20−30
31−40
41−50
51−60
≥ 60
Education
Primary school
High school
Certification
Bachelor
UneducatedVocation
Salaried
Paid work
Housewife
Unemployed
Civil Servant
Business
Marital status
SingleDivorce
Note: N/A = Not applicable

Relatives(n = 7)

N

%

N

%

6
1

85.71
14.29

4
3

57.14
42.86

3
2
1
1
−

42.85
28.57
14.29
14.29
−

−
1
1
1
4

−
14.28
14.28
14.28
57.16

1
3
2
1
−

14.29
42.85
28.57
14.29
−

2
1
2
−
2

28.57
14.29
28.57
−
28.57

1
−
−
6
−
−

14.29
−
85.71
−
−

−
2
1
−
1
3

−
28.57
14.29
−
14.29
42.85

6
1

85.71
14.29

N/A
N/A

N/A
N/A

4

TIME USE IN SCHIZOPHRENIA

Table 2. The comparison of the amount of time uses for self-care, work, and leisure of people withschizophrenia and of their relatives
GroupsOccupation

Mdn

Q.D.

%

Mean Rank

df

λ2

p

Schizophrenics (n = 7)

Self-careWork
Leisure

17.30
0.42
4.42

14.00
0.25
4.09

69.17
6.50
24.33

3.00
1.14
1.86

2

12.29

.002*

Relatives (n = 7)

Self-careWork
Leisure

17.76
1.98
4.80

12.68
0.43
4.26

67.24
11.14
21.62

3.00
1.14
1.86

2

12.29

.002*

Mdn = Median, Q.D. = Quartile, *P < 0.05

Table 3. The comparison of the amount of time uses for self-care, work, and leisure of people
with schizophrenia and of their relatives in pairs
Rank−

Rank+

N

Mean

N

Mean

Work-Self-care
Leisure-Self-care
Leisure- Work

7
7
1

4.00
4.00
1.00

0
0
6

Work-Self-care
Leisure-Self-care
Leisure- Work

7
7
1

4.00
4.00
4.00

0
0
6

GroupsOccupation

Schizophrenics (n = 7)

Relatives (n = 7)

Z

p

0.00
0.00
4.50

−2.37
−2.37
−2.20

.018*
.018*
.028*

0.00
0.00
4.00

−2.37
−2.37
−1.69

.018*
.018*
.091

*P < 0.05
Table 4. The expectation for use of time

(median = 4.09, Q.D. = 4.42) and the least amount oftime for work (6.50%) (median = 0.42, Q.D. = 0.25).
Relatives viewed that schizophrenics spent most of
their time (67.24%) for self-care (median = 17.76, Q.D.
= 12.68), secondarily for leisure (21.62%) (median =4.80, Q.D. = 4.26) and the least time for work (11.14%)(median = 1.98, Q.D. = 0.43). Moreover, this tableshows the comparison of time uses for self-care, work,and leisure of people with schizophrenia using a Friedman test, which demonstrates significant difference (λ2= 12.29, P < 0.05). Additionally, there was a significant
difference of time uses for self-care, work, and leisure ofpeople with schizophrenia from the perspectives of theirrelatives, using a Friedman test (λ2 = 12.29, P < 0.05).
After this test, Table 3 shows the comparison of selfcare, work, and leisure of people with schizophrenia inpairs using Wilcoxon Signed Ranks test, which demonstrates significant difference of the amount of timeuses between work and self-care (Z = −2.37, P < 0.05),
leisure and self-care (Z = −2.37, P < 0.05), and leisureand work (Z = −2.2, P < 0.05). In addition, this tableshows the comparison of the amount of time uses for
self-care, work, and leisure of people with schizophrenia
from their relatives’ perspectives in pairs, using Wilcoxon Signed Ranks test, which demonstrates significant
difference in the amount of time uses between work andself-care (Z = −2.37, P < 0.05), and leisure and self-care

Schizophrenics(n = 7)

Earning a living
Doing a little housework
Looking after himself in
his medication routine andseeing the doctors according
to an appointment
Going out to interact withfriends

Relatives(n = 7)

Numbers%

Numbers

%

4
3

57.14
42.86

3
2
1

42.85
28.57
14.29

1

14.29

(Z = −2.37, P = 0.05), but not between leisure and work
(Z = −1.69, P > 0.05).
The expectation for use of time
Table 4 shows the numbers and percents of expectations of people with schizophrenia toward their timeuses and their relatives. The expectations of people withschizophrenia and their relatives were that the subjects
would be earning a living and doing a little housework
respectively. One relative expected the patient in looking
after himself in his medication routine and seeing his
doctors according to his appointments. Another relative
expected a schizophrenia person to go out to interact
with friends.

Asian J Occup Ther 14: 1−7, 2018

Discussion
The schizophrenic patients spent time for self-care,leisure and work respectively; there were significant differences of time use for self-care, work and leisure fromboth sources of information as shown in Table 2. Nevertheless, from the perspectives of their relatives, the differences of time use of the patients with schizophrenia
for leisure and work was not significantly different asdemonstrated in Table 3. The patients spent most time inself-care, which included sleep. This result is compatible with the survey of time use for adults in the UnitedState which found that they spent 30% of 24-hour day
on sleeping and 10% on self-care activities including
eating because this occupation is obligatory activity
influenced by biological rhythms [3]. Most participantsin this study were male adults of working age but mostof them were unemployed so that they spent more timeon self-care and leisure than for work. This result iscompatible with the study of Weeder [17] which showedpeople with schizophrenia spent more time on sleep andpassive leisure and less time in work. In addition, it isalso congruent with the study of Minato and Zemke [7],which found that non-working schizophrenic patients
spent more time on sleep and rest, and play.
The differences of time uses for self-care, work andleisure may have resulted from psychiatric symptoms,
lethargy, lack of motivation and regression, which affectoccupational performances of the schizophrenic participants [2]. The perspectives of people with schizophrenia
and their relatives is congruent except time use forwork as presented in Table 2. Their relatives provided
information that the schizophrenic members spent moretime for work than the patients themselves did (seeTable 2) and spent time for work and leisure with thedifference that was not significant (see Table 3). Most
schizophrenic participants were between 20−40 years,
which are adult ages, and their relatives felt that they
were supposed to use more time for work such as earning a living and doing a little housework as presented inTable 3. This is compatible with the statement of Christiansen [3] that work is classified as obligatory activity
for adults and 25% of their daily time is spent on work.
Moreover, schizophrenia may affect attention, executivefunction, verbal & visual memory, and working memoryof the patients [18, 19], which have an impact on theirwork. In addition, work performance limitation may
result from the deficit of concept formation ability ofthe schizophrenic patients which is a part of executivefunction [20]. In Thai context, if the patients can do orhelp in housework, their relatives will perceive that they
can work [21], however, most patients (85.71%) weremale and he should take a role of earning a living for his

Pongsaksri M

5family [22]. For these reasons, it is possible that theirwork performance may not be as effective as their own
perception so that they viewed that their time use forwork was less than the perspectives of their relatives ontime use of schizophrenic patients for work.
The expectations of the schizophrenics and relative
participants were congruent in items of earning a living
and doing a little housework because 85.71% of schizophrenic participants were unemployed and most of themwere working ages. Due to the chronic condition ofschizophrenia [23], which usually has the recurrence ofsymptoms when the patients encounter some pressure
conditions [25], their function may be lost, especiallywork. Nevertheless, most relatives expected them towork to support themselves. Most relatives were aged
60 years or more, and it is possible that these patientswere a burden to the senior relatives; hence they expected the schizophrenic members to earn a living to pay
off loans of the families. In addition, 42.85 percent of
their relatives conducted business or self-employments,
they may need helping for these from the schizophrenic
patients because gaining income for the family improves
their relatives’ quality of life [26] and being employedby other organizations is difficult for the patients [21].
Furthermore, one relative expected the schizophrenic members to look after themselves in medication andseeing the doctors because they need continuous treatment [23]. In addition, due to schizoid personality [25],another relative would like the schizophrenic members
to interact with others. Since social and community
functioning deficits of schizophrenic patients are stressful for them, they contribute to relapse [27, 28], and on
the other hand, social skills develop social network forthe patients and support their effective coping with dailystresses [27, 29]. Social interaction in the community
should be useful for schizophrenic people to prevent
their stress and recurrence. In addition, Tsang [30] andTsang & Pearson [31] reported from their research thatsocial skills training was effective at helping people
with schizophrenia to engage in work. For these reasons,the relative would like them to develop social skills via
going out to interact with friends.

Conclusion and Recommendation
People with schizophrenia used their time for selfcare, leisure and work respectively. Most expectations ofthem were earning living and doing a little housework,and so did their relatives. This study recommended thecooperation between people with schizophrenia andtheir relatives in time management in order to prevent
recurrence.

6

TIME USE IN SCHIZOPHRENIA

Acknowledges
I would like to sincerely thank to all participants inthis study.

Conflicts of interest
None

References[1] Bonder BR. Schizphrenia and other psychotic disorders.
In: Bonder BR, editor. Psychopathology and function.
Thorofare: SLACK; 2010; 125−144.
[2] Russel YT. Schizophrenia. In Hansor RA, Atchison B,
editors. Conditions in occupational therapy: Effect on occupational performance. Baltimore, MD: Lippicolt; 2000;
68−69.
[3] Christiansen CH. Three perspectives on balance inoccupation. In Zemke R, Clark F, editors. Occupational
science: The evolving discipline. Philadelphia, PA: F.A.
Davis; 1996; 431−451.
[4] Kielhofner G. Occupational therapy-Base in occupation.
In Hopkins HL, Smith HD, editors. Willard and Spackman’s occupational therapy. 7th ed. Philadelphia, PA: J.B.
Lippincott. 1988; 84−92.
[5] Hays RL, and Halford WK. Time use of unemployed andemployed single males schizophrenia subjects. Schizophrenia Bulletin. 2000; 22: 659−669.
[6] Shimitras L, Fosse E, and Harvey C. Time Use of People
Living with Schizophrenia in a North London Catchment
Area. The British Journal of Occupational Therapy. 2003;
66: 46−54.
[7] Minato M, and Zemke R. Time use of people withschizophrenia living in community. Occupational Therapy
International. 2004; 11: 177−191.
[8] Bejerholm U, and Eklund M. Time Use and Occupational
Performance Among Persons with Schizophrenia. Occupational Therapy in Mental Health. 2004; 20: 27−47.
[9] Socialstyrelsen. Community achievement for people withmental disability [cited 2016 August 10]. Available fromhttps://www.folkhalsomyndigheten.se/publicerat-material/publikationer/Folkhalsorapport-2005 (in Swedish).
[10] APA. Diagnostic and Statistical Manual of Mental Disorders, DSM-TR. Washington, DC: American Psychiatric
Association; 2000.
[11] Maethisa Pongsaksri, Khwanruthai Thanaruk, Ankana
Samathtiya, Onuma Phoosopa. The study of the development of a rehabilitation program related to occupational
therapy for psychiatric patients in community: survey ofcommunity need for rehabilitating psychiatric patients.
Department of Mental Health, Ministry of Public Health;2005 (in Thai with English abstract).
[12] Atcharaporn Sittitkad. The relationship between time usefor occupation and volition of schizophrenic patients at
Suanprung Psychiatric hospital. [Term paper of Bachelorof Science (Occupational Therapy)]. Chiang Mai: Chiang
Mai University; 2000 (in Thai with English abstract).
[13] Bengtsson-Tops A. Mastery in patients with schizophrenia living in the community: relationship to sociodemographic and clinical characteristics, needs for care andsupport, and social network. Journal of Psychiatric and
Mental Health Nursing. 2004; 11: 298−304.
[14] Pearlin L, Menaghan, E, Lieberman, M, and Mullan, J.
The stress process. Journal of Health and Social Behavior. 1981; 22: 337−356.
[15] Rosenfield S. Factors contributing to the subjective quality of life of the chronically mentally ill. Journal of Healthand Social Behaviour. 1992; 33: 299−315.
[16] Christiansen CH. Time use and patterns of occupation.
In Christiansen CH, Baum CM, Bass-Haugen J, editors.
Occupational therapy: Performance, Participation, andWell- being. 3rd ed. Thorofare, NJ: SLACK; 2005; 70−93.
[17] Weeder T. Comparison of temporal patterns and meaningfulness of the daily activities of schizophrenia and normal
adults. Occupational Therapy in Mental Health. 1986; 6:
27−45.
[18] Sharna T, and Antonova L. Cognitive function in schizophrenia: Deficit, functional consequences, and future
treatment. The Psychiatric Clinics of North America
Journal. 2003; 26: 25−40.
[19] Keri S, Szekeres Q, Szendi I, Antal A, Kovdcs Z, JankaZ, and Benedek Q. Category Learning and Perceptual
Categorization in Schizophrenia. Schizophrenia Bulletin.
1999; 25: 593−600.
[20] Josman N, and Katz N. Relationships of categorization on
tests and daily tasks in patients with schizophrenia, poststroke patients and healthy control. Psychiatry research.
2006; 4: 15−28.
[21] Soontareeporn Thongsai. Sustainable caring of psychiatric patients in Thai context. Journal of Nursing Division.
2015; 42: 159−167 (in Thai with English abstract).
[22] Thidarat Kanungpiarn. Experience of Care Gs in Caring
for People with Schizophrenia in Community. Journal of
Nursing Division. 2013; 40: 57−66 (in Thai with English
abstract).
[23] MacRae A. Schizophrenia. In Care E, MacRae A, editors.
A Psychosocial occupational therapy: A Clinical practice.
2nd ed. New York, NY: Thomson Delmar Learning; 2005;
140−161.
[25] Bebbington PE, and Kuipers E. Schizophrenia and psychosocial stresses. In Hirsch SR, Weinberger D, editors.
Schizophrenia. 2nd ed. Malden, MA: Blackwell; 2003;
613−635.
[26] Norrawee Phoomchan. The study of schizophrenic patients’ and their relatives’ quality of life: a case – studyof Day Hospital’s patients, Somdetchaopraya Institute of
Psychiatry. Journal of Mental Health of Thailand. 2005;
13: 147−156 (in Thai with English abstract).
[27] Anthony WA, and Liberman RP. The practice of psychiatric rehabilitation: Historical, conceptual, and researchbase. Schizophrenia Bulletin. 1986; 12: 542−559.
[28] Falloon JRH, Boyd JL, and McGill RW. BehaviouralAsian J Occup Ther 14: 1−7, 2018

family management of mental illness: enhancing family
coping in community care. New Your, NY: Guilford
Press; 1984.
[29] Liberman R, DeRisi WJ, and Mueser KT. Social Skills
Training With Psychiatric Patients. New York, NY: Pergamon Press; 1989.

Pongsaksri M7[30] Tsang HW. Applying social skills training in the context
of vocational rehabilitation for people with schizophrenia. Journal of Nervous and Mental Disease. 2001; 189:
90−98.
[31] Tsang HW, and Pearson V. Work-related social skills
training for people with schizophrenia in Hong Kong.
Schizophrenia Bulletin. 2001; 27: 139−148.

■ORIGINAL ARTICLE

Risk Factors for Impaired Instrumental Activities
of Daily Living in Alzheimer’s Disease
Takashi Fujita, Masako Notoya, Nobuyuki Sunahara, Ken Nakatani,
Daisuke Kimura
Division of Occupational Therapy, Faculty of Rehabilitation and Care, Seijoh University

Abstract: Objective: Despite the considerable importance of maintaining support for instrumental activities of dailyliving (IADLs) for patients with dementia living at home, there have been no formal investigations of what factors influence IADLs.
Method: We administered various neuropsychological tests, the Timed Up and Go [TUG] test, and the GeriatricDepression Screening Scale-15 to 54 individuals in Japan who had visited a day care center or a preventative careclass and who had either 23 mild Alzheimer’s disease (mild AD) or 31 no dementia. IADLs were measured using the
Self-Report Frenchay Activities Index.
Results: The factors related to the domestic chores subscale of the Frenchay Activities Index were gender, backward
digit recall performance (Wechsler Memory Scale-Revised [WMS-R]), and TUG test performance (R2 = 0.53). Factors
related to the leisure/work subscale were backward digit recall and logical memory II performance on the WMS-R,
scores on the Behavioral Assessment of the Dysexecutive Syndrome, and TUG test performance (R2 = 0.66). Finally,factors related to the outdoor subscale were backward digit recall, logical memory II, and the TUG test performance (R2= 0.62).
Conclusions: The factors affecting IADLs among elderly individuals with mild AD or no dementia vary depending on
the type of IADL. Notably, TUG test performance has a direct influence on all IADL types, and might relate to cognitive function. When providing preventative care or IADL support, it may be beneficial to evaluate and intervene with afocus on the cognitive and physical functions highlighted in this study.
Keywords: Alzheimer’s disease, cognitive function, environmental factors, neuropsychological tests(Asian J Occup Ther 14: 9−16, 2018)

Introduction
There were an estimated 5.2 million people with
Alzheimer’s disease (AD) in the United States in 2013[1]; therefore, policies to combat AD constitute anurgent international priority. The Japanese population
has aged at an accelerated rate in recent years. In
addition, in 2012, the Ministry of Health, Labour andWelfare reported that the population of individuals withdementia had reached 3 million [2]. AD and cerebrovascular disorders with comorbid AD account for approxiReceived: 18 February 2017, Accepted: 16 January 2018
Corresponding to: Takashi Fujita, Division of Occupational Therapy,
Faculty of Rehabilitation and Care, Seijoh University, 2-172 Fukinodai, Tokai, Aichi 476-8588, Japane-mail: fujita@seijoh-u.ac.jp©2018 Japanese Association of Occupational Therapists

mately 70−80% of dementia cases [2].
In response to the rapid increase in dementia cases,
the Ministry of Health, Labour and Welfare establishedthe 5-year “Orange Plan” to promote policy measuresagainst dementia. One of the concrete features of theplan is the improvement of at-home, early-term, intensive support for cognitive function for individuals withearly-stage dementia. More specifically, it aims to create
additional opportunities for provision of support for activities of daily living (ADLs) for people with very mildor mild AD. Although it is possible for these individuals
to perform certain home-based ADLs, such as feedingthemselves and using the toilet, they are known toexperience difficulty performing “instrumental” ADLs
(IADLs), such as shopping and household budgeting/money management [3]. Indeed, according to Ueda,
Takayama, Koyama, and Osaka’s independent IADL
survey [4], Laurent et al.’s 8-item IADL scale [5], and10

IADL DISORDER FACTOR OF ALZHEIMER’S DISEASE

the Alzheimer’s Disease Cooperative Study IADL scale
developed by Galasko et al. [6], individuals with mild
AD showed impaired IADL performance. All of thesereports mentioned similar impairment in performanceof IADLs, including meal preparation (e.g., cooking),
traveling to a particular location for the first time, keeping one’s home and oneself neat and tidy, and managing
finances, in patients with mild AD. Previous researchshowed that individuals with mild AD experienced disability in specific types of IADL; therefore, it is logicalto assume that different types of IADL are affected bydifferent factors.
According to the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision [7] and a report created by the
National Institute of Neurological and Communicative
Disorders and Stroke, in collaboration with the Alzheimer’s Disease and Related Disorders Association[8], cognitive disorders associated with memory loss
have been implicated in IADL impairment in mild AD.
Indeed, amnesia-like memory impairment is a confirmed
characteristic of individuals with AD and one of the coreclinical criteria for diagnosis of the disorder [9]; furthermore, memory impairment is listed as a prominent
symptom that begins during the early stages of probabledementia of the Alzheimer’s type, while anterograde
amnesia is particularly apparent in early-phase AD[10]. According to Perry and Hodges [11], impairment
of attention and visuospatial cognition, in addition tomemory impairment, occur in AD. Kramer et al. [12]reported that the amnesic type of mild cognitive impairment, which has a high rate of progression to dementia,
was accompanied by impaired attention and executivefunction disorders. We performed a desk study, which
involved scoring IADLs and examining factors affecting
them, and found that constructional ability, working
memory, executive function, and memory all influenced
IADLs [13]. In accordance with these findings, wehypothesized that the cognitive impairment (including
impairment of visuospatial cognition, attention, working
memory, executive function, and memory) describedin previous studies would exert a direct influence on
IADLs in AD.
In addition, depression is common in people with
AD and has been found to affect IADL. In Japan inparticular, mild AD is frequently accompanied by depression [14], which leads to motivational (volitional)
decline; therefore, it is reasonable to speculate that it
affects IADL performance.
There are several methods, including the Alzheimer’s Disease Cooperative Study IADL scale [6], Frenchay Activities Index (FAI) [15, 16], and Tokyo Metropolitan Institute of Gerontology Index of Competence[17], available for use in evaluating IADLs in elderly
individuals and people with AD. Moreover, the FAI
has been used to evaluate IADLs in elderly individuals
and people with various diseases [18−21]. These IADL
scales include all “housework” and “outdoor activities.”
Therefore, both cognitive function and bodily function
are likely to influence IADL in people with AD.
There are currently three main types of support
available for Japanese people with mild AD: (a) drug
therapy; (b) treatment of secondary symptoms to maintain psychological security; and (c) use of social services
including those provided via long-term care insurance.
However, few studies have been conducted to examine
the adequacy of these types of ADL support for people
with mild AD, who usually live at home, or the factors
responsible for specific IADL difficulties. Because there
are few reports that describe the relationship between
functional impairment and IADL disability of AD patients. This information would be invaluable for those
who provide IADL support and could help in the selection of useful assessment methods. Therefore, we sought
to identify factors related to cognitive, psychological,
and physical functioning affecting IADLs in elderly
people with mild AD and individuals without dementia(i.e., non-dementia [ND] group).

MethodSubjects
The study included 54 subjects: 23 with mild AD
and 31 no dementia (Table 1). The mild AD group included patients who were diagnosed with AD by psychiatrists or neurologists during an outpatient examination
and undergoing ambulatory rehabilitation at one of threehealth centers for the elderly. Rehabilitation staff determined whether the mild AD group had very mild or mild
dementia, using the Clinical Dementia Rating scale (i.e.,scores of 0.5 or 1 respectively). Subjects with a historyof other central nervous system diseases were excluded
from the study. The 23 subjects in the mild AD groupwere all local community residents.
The ND group included 31 elderly people enrolledin aged-care prevention classes (i.e., classes that teachTable 1. Characteristics of the subjects
People (man:woman)

ND group
31 (7:24)

mild-AD group23 (3:20)

t-testp-valueAge (year)
MMSE
CDR

76.7 ± 6.0
28.32 ± 1.68
079.9 ± 7.1
20.65 ± 3.58
0.5 or 1

n.s.
< 0.001−

ND; Non-Dementia Elderly persons AD; Alzheimer’s disease
CDR; Clinical Dementia Rating

Fujita T et al.

Asian J Occup Ther 14: 9−16, 2018

older adults to prevent the onset of problems necessitating home-based care). We excluded individuals
with Mini-Mental State Examination scores of < 24 ora history of other central nervous system diseases. ND
group members who met the selection criteria were
volunteers at one of two health centers for the elderlyor participants in aged-care prevention classes at one ofthree sites. All subjects in both groups were able to walk
independently or with the assistance of a T-cane.
All subjects received written descriptions of thestudy and provided written informed consent. People
with AD had previously listened to oral descriptions of
the study, provided by a family member or caregiver.
The study was approved by the research ethics committee at the university with which the first author wasaffiliated (Approval No. 2010C0018).
IADL Evaluation Methods
IADLs were evaluated using the Japanese versionof the FAI, or Self-Rating FAI (SR-FAI) [22]. We used
the SR-FAI because it provides a number of IADL

11

categories and is therefore a sensitive measure of
IADLs and better suited to examination of specific influential factors. Holbrook and Skilbeck [16] describeda three-factor structure for the original FAI: domestic
chores, leisure/work, and outdoor activities (Table 2).
The SR-FAI includes 15 items pertaining to IADLs,
such as walking and employment activities, divided
between three subscales. Although the items are scoredusing a scale ranging from 1 to 4 in the original FAI,
the scale in the SR-FAI ranges from 0 to 3; therefore,
total scores differ between the two versions [16, 22]. It
should be noted that the factor structure for the Japaneseversion has not been validated. In addition, the SR-FAI
was amended, resulting in differences in scale ranges(either from 1 to 4 or from 0 to 3) according to item [22].
The original SR-FAI (prior to amendment) was used
to identify predictors in the original FAI’s three-factor
structure, as it was closer to the original scoring method;in addition, we recalculated scores to reflect a scale
range of 1 to 4 rather than 0 to 3. The score stage is notdifferent from an original FAI in between an SR-FAI.

Table 2. Comparison of the Original Frenchay Activities Index (FAI) and The Self-Rating Frenchay Activities Index
Original FAI

Factor 1:
Domestic
chores

Factor 2:
Leisure/work

Factor 3:
Outdoors

Total points

SR-FAI

Activities

Score

Activities

Score

Preparing main meals (Preparing meals)
Washing-up (Washing dishes)
Washing clothes
Light housework (Dusting/Vacuum cleaning)
Heavy housework (Cleaning)

1−4 a*
1−4 a*
1−4 b*
1−4 b*
1−4 b*

Preparing meals
Washing dishes
Washing clothes
Dusting/ Vacuum cleaning/Clear up
Heavy housework (hanging up futon bedding for airing
and taking it down, cleaning floors)

0−3
0−3
0−3
0−3
0−3

Domestic chores total points

5−20

Social outings
Pursuing active interest in hobby (Hobby/sport)
Outings/car rides
Household and /or car maintenanceGainful work (Employment)

1−4 b*
1−4 b*
1−4 c*
1−4 d*
1−4 f*

Social outings
Pursuing active interest in hobby (Hobby/sport)
The use of public transport (bicycle, car, bus, airplane)
Household and/or car maintenanceGainful work (Employment)

0−3
0−3
0−3
0−3
0−3

Leisure/work total points

5−20

Walking outdoors > 15 min.
Driving a car/travel on bus
Gardening
Reading books
Local shopping

1−4 b*
1−4 b*
1−4 d*
1−4 e*
1−4 b*Walking outdoors > 15 min.
Driving a car/travel on bus, airplane etc.
Gardening
Reading books
Shopping

0−3
0−3
0−3
0−3
0−3

Outdoor total points

5−20
15−60

FAI code
a* 1 = Never, 2 = Under once weekly, 3 = 1−2 time a week, 4 = Most daysb* 1 = Never, 2 = 1−2 times in 3 months, 3 = 3−12 times in 3 months, 4 = At least weekly
c* 1 = Never, 2 = 1−2 times in 6 months, 3 = 3−12 times in 6 months, 4 = At least weekly
d* 1 = None, 2 = Light, 3 = Moderate, 4 = All necessary
e* 1 = None, 2 = 1 in 6 months, 3 = Less than 1 a fortnight, 4 = Over 1 a fortnightf* 1 = None. 2 = Up to 10 h/week, 3 = 10−30 h/week, 4 = Over 30 h/week
The codes of Original FAI and SR-FAI are the same

0−45

12

IADL DISORDER FACTOR OF ALZHEIMER’S DISEASE

Therefore, as 0−3 points were awarded, the method used
to recalculate scores added a point. The SR-FAI was administered to subjects in the ND group via face-to-faceinterviews with the first author, and AD group of family
members were asked to complete SR-FAI forms.
Neuropsychological, Depression, and Physical Function
Tests
We used the following tests to identify predictorsof IADLs. The neuropsychological evaluation included
measurement of attentional functioning, memory, visuospatial cognitive function/constructional function, andexecutive function. Attentional functioning was measured using the backward digit span and mental control
tasks, which were Wechsler Memory Scale-Revised(WMS-R) subtests. Memory was assessed using logicalmemory II, which is also a WMS-R subtest. Visuospatial cognitive/constructional function was measured
using the clock-drawing test. Executive function wasmeasured using the Behavioural Assessment of the
Dysexecutive Syndrome (BADS).
The WMS-R logical memory II subtest was selected because it is a delayed-recall memory test and therefore appropriate for detecting anterograde amnesia, amajor AD symptom. The scoring criteria established byRouleau, Salmon, Butters, Kennedy, and McGuire [23],which involve an 11-step evaluation with scores ranging
from 0 to 10, were used to score the clock-drawing test.
Concerning the BADS, a floor effect was confirmed for
the Zoo Map Test. Specifically, the entire mild AD groupexhibited low scores; therefore, the test was excluded.
Total scores for the remaining tests (rule shift cards,
action program, key search, temporal judgment, andmodified six element tests) were included in the analysis, with a highest possible score of 20 for each test.
The Geriatric Depression Scale-15 (GDS-15) wasused to screen for depression. This is a simple test, forwhich responses of “yes” or “no” are provided. Total
scores range from 0 to 15, with scores of 0−5 and ≥ 6
indicative of no depression and depression, respectively.
As some SR-FAI items assess outside walking ability or repeated changes in direction and movement withina narrow area while cleaning, we used the Timed Up and
Go (TUG) test to measure physical function, because it
is a balance test and evaluates walking and changes in
direction. Specifically, the TUG test measures the timerequired to rise from a seated position, walk for 3 m,
return to the seat, and sit down. A stopwatch was used torecord TUG test times, in seconds.
Data Analysis
We performed between-group comparisons usingt tests or the Mann-Whitney U test ( p < 0.05) to deter-mine differences in WMS-R, the clock-drawing test,
BADS, GDS-15, TUG test, and SR-FAI scores between
the mild AD and ND groups. We also used the Shapiro-Wilk test as the normal distribution test. In addition,
we examined factors influencing SR-FAI scores (WMSR, clock drawing test, BADS, GDS-15, TUG test),
using multiple regression analysis with the three SR-FAI
subscale scores as dependent variables after cancellation
the two groups. Age, sex (male = 1, female = 2), neuropsychological test and GDS-15 scores, and TUG test
performance (in seconds) were included as independent
variables.
We then performed multiple regression analysis
using the stepwise method, with independent variables( p < 0.05).
All statistical analyses were performed using IBM
SPSS Statistics Ver. 21 (IBM Corp., Armonk, NY).

Results
Result of the normality test
As a result of the Shapiro-Wilk test, no normal
distribution was found in the results of WMS-R mindcontrol tasks, WMS-R digit span backward, WMS-R
logical memory II, the clock drawing test, and GDS15. However, for BADS, the TUG test, and SR-FAI,
normality was recognized.
Between-Groups Comparison
Table 3 shows the results of the between-groups
comparison of SR-FAI scores and other variables.
GDS-15 scores did not differ significantly between
groups. However, SR-FAI, neuropsychological test, andTUG test scores in the mild AD group were significantly
lower relative to those of the ND group ( p < 0.05).
Multiple Regression Analysis
To ensure that we avoided multicollinearity between independent variables, we calculated the varianceinflation factor, which was < 3.0; therefore, multicollinearity was assumed to be under control (Table 4).
Risk factors for the domestic chores subscale included
backward digit span (β = 0.42, p < 0.001) and TUG test
(β = −0.42, p < 0.001) performance and sex (β = −0.26,
p < 0.001). The weight determination coefficient by
these factors was R2 = 0.56; root mean square error was
4.40. Risk factors for the leisure/work subscale included backward digit span (β = 0.22, p = 0.029), logicalmemory II (β = 0.29, p = 0.01), and TUG test (β = −0.23,
p = 0.017) performance and total BADS score (β = 0.31,
p = 0.008). The weight determination coefficient by thesefactors was R2 = 0.66; root mean square error was 2.69.
Risk factors for the outdoor activities subscale includ-Fujita T et al.

Asian J Occup Ther 14: 9−16, 201813

Table 3. Results of each evaluation and SR-FAI

Executive function test
Balance test
SR-FAI
Attentional function test
Memory test
Visuospatial cognitive function/
Constructional function test
Depression screening

ND groupn = 31
Mean ± SD

mild-AD groupn = 23
Mean ± SD

p-value

BADS
Timed Up and Go test
Domestic chores
Ieisure/work
Outdoors
WMS-R mind-control tasks
WMS-R digit span backward
WMS-R Logical Memory II
Clock Drawing Test

13.5 ± 2.6
11.2 ± 12.7
13.1 ± 4.7
14.5 ± 2.9
15.3 ± 3.4
5.13 ± 0.16
6.5 ± 1.9
13.4 ± 9.0
9.4 ± 1.5

7.2 ± 2.5
17.2 ± 5.6
7.5 ± 4.6
7.4 ± 2.3
8.2 ± 3.7
3.3 ± 2.3
4.2 ± 1.5
0.3 ± 0.8
6.7 ± 2.4

*** a
*a
*** a
*** a
*** a
*** b
*** b
*** b
** b

GDS-153.0 ± 2.6

3.0 ± 2.3

n.s b***p < 0.001 **p < 0.01 *p < 0.05
a = t-test, b = Mann-Whitney U test
ND; Non-Dementia Elderly persons AD; Alzheimer’s disease WMS-R; Wechsler Memory Scale-Revised
BADS; The Behavioural Assessment of the Dysexecutive Syndrome
GDS-15; Geriatric Depression Screening Scale-item 15 SR-FAI; The Self-Rating Frenchay Activities Index

Table 4. Impact factor of FAI; Result of multiple regression analysis
Dependent variable

Independent variable

Standard βtp-value

VIF

Domestic chores

GenderWMS-R digit span backward
Timed Up and Go test

0.25
0.42
−0.42

2.68
3.91
−4.02

0.001
< 0.001< 0.001

1.01
1.10
1.11

Ieisure/work

WMS-R digit span backward
WMS-R Logical Memory II
BADSTimed Up and Go test

0.22
0.29
0.31
−0.23

2.24
2.47
2.78
−2.48

0.029
0.017
0.008
0.017

1.42
2.03
1.78
1.22

Outdoors

WMS-R digit span backward
WMS-R Logical Memory II
Timed Up and Go test

0.35
0.28
−0.38

3.42
2.70
−3.99

0.001
0.009
< 0.001

1.40
1.50
1.19

VIF; Variance Inflation Factor WMS-R; Wechsler Memory Scale-Revised
BADS; The Behavioural Assessment of the Dysexecutive Syndrome

ed backward digit span (β = 0.35, p = 0.001), logicalmemory II (β = 0.28, p = 0.009), and TUG test (β = 0.38,
p < 0.001) performance. Further, the weight determination coefficient by these factors was R2 = 0.62; root
mean square error was 3.15.

Discussion
The study identified factors (i.e., sex and cognitive,
neuropsychological, and physical functioning) thatpredicted IADL performance (as measured via the three
SR-FAI subscales) in people with mild AD or no dementia. Notably, the contributions made by the variables
to the variance in the three SR-FAI subscale scores wereas follows: domestic chores: R2 = 0.53, leisure/work: R2= 0.66, and outdoor activities: R2 = 0.62. Therefore, they
explained a substantial proportion of the variance.

Factors predicting domestic chore scores included
backward digit span and TUG test performance andsex. The domestic chores subscale represents habitualhousehold tasks performed regularly by subjects formany years. Therefore, working memory (i.e., backward
digit span performance) and balance (i.e., TUG test performance) naturally contributed to performance of thesetasks. The inclusion of meal preparation and cleaning as
domestic chores could explain why sex was identified asa risk factor, as women perform approximately 80% of
these domestic chores in Japan [24]. Here, we noticed
that cultural differences existed in the original FAI and
SR-FAI’s heavy housework, which includes “hanging
up futon bedding for airing and taking it down, cleaning
floors” (Table 2). In Japan, such housework is often
done by old women. Therefore, there is a possibility
that the heavy housework chores in Japan have further

14

IADL DISORDER FACTOR OF ALZHEIMER’S DISEASE

extracted gender as a risk factor.
The leisure/work subscale showed slightly different
risk factors, including BADS scores and logical memory
II, backward digit span, and TUG test performance. Leisure/work IADLs involve social outings, hobby-related
activities, and gainful employment. Relative to domestic
chores, leisure/work IADLs are less habitual and require
planning and predictive skills (i.e., the ability to foresee
results). Therefore, delayed recall memory (i.e., logicalmemory II performance) and executive function (i.e.,
BADS score) are likely to be required for these activities.
Furthermore, outdoor activities subscale scores
were predicted by logical memory II, backward digit
span, and TUG test performance; these results suggestthat attention, working memory, and delayed recall
memory all exerted a strong influence on outdoor activities. Notably, BADS scores did not predict outdoor
activities, which include driving, riding on a bus, andshopping, even though executive function is likely to berequired for such tasks.
This result shows that leisure/work requires more
performing executive function than outdoor activities.
Also, logical memory II (delayed recall memory) andbackward sounding (attention and working memory)
are the basic elements of the execution function. Fromthese facts, in the case of the outdoor activities, there isa possibility that attention, working memory, and recall
memory, which is the foundation element of outdoor
activities, has a stronger influence than the executionfunction.
Piquard et al. reported that there was no correlation
between IADL scores of AD patients and BADS score[25]. Monaci et al. reported that AD patients initiallyrecognized an association between the executive functions scale and the IADL scale but that there was no
association after 18−24 months [26].
From these facts, when investigating factors affecting IADL of AD patients, it may be better to use
the fundamental elements of executive functions (suchas attention and working memory) rather than BADS.
Furthermore, the influence of the relationship between
IADL and executive functions may be lowered depending on the degree of progression of AD symptoms. The
current result also showed that the outdoor activities in
IADL may indicate that it is an activity that causes theexecutive functions function to disappear from early on.
TUG test performance was identified as a common
risk factor for all three SR-FAI subscales. It is likely that
TUG test performance influenced domestic chores because they involve mainly indoor household tasks, suchas meal preparation and doing laundry, and performanceof these chores within the narrow spaces in Japanese

homes necessitates numerous changes in direction andposture (from squatting to standing), requiring good balance. Leisure/work and outdoor activities both include
movements over a broad area; therefore, good walking
ability and directional changes (both assessed via the
TUG test) would be required for these activities.
Another possible reason for identification of TUG
test performance as a risk factor for all three types of
IADL is that cognitive functioning could influence physical functioning, as suggested by the finding that themild AD group’s TUG test performance was significantly worse relative to that of the ND group (Table 3). In a
study involving people with mild cognitive impairment,
McGough et al. [27] found that TUG test performance
was associated with cognitive function, and Voelcker-Renhage, Godde, and Staudinger [28] reported strong
relationships between fitness in exercises requiring
speed, balance, and fine motor coordination, and executive function and perception speed, which are related toactivity in the frontoparietal network. Moreover, lower
levels of activity in the temporal lobe’s inner surface,posterior cingulate gyrus, and parietal cortex have beenreported in individuals with mild AD [29,30], but motor
activity impairment has not been observed during theearly stages.
However, it is possible that deterioration of parietal
function in mild AD influenced TUG test performance
via mediation of the frontoparietal network. In otherwords, cognitive decline could have affected IADL indirectly via physical function (i.e., TUG test performance).
Age was not significantly associated with any of
the FAI factors. Although aging is associated with both
physical and cognitive decline, the results indicated thatit did not exert an independent effect on IADLs beyond
an indirect influence exerted via cognitive and physicalfunction.
Because motivational (volitional) decline could
also affect IADLs, the GDS-15 was used to screen for
depression; however, the results showed that depression
did not affect IADLs. This could have been because
people with severe depression were not included in thesample (Table 3).
Overall, the results indicate that the factors influencing IADLs in the ND and mild AD groups differedaccording to IADL category. The results regarding
neuropsychological tests (i.e., working memory, delayedrecall memory, and executive function) are consistent
with those of Albert, Moss, Tanzi, and Jones [31], whoreported that verbal and auditory memory tasks, thePart B of the Trail Making Test for executive function,and the backward digit span test were all indices of progression from health to mild AD. The study was novelin that it demonstrated the ways in which the effects ofFujita T et al.

Asian J Occup Ther 14: 9−16, 2018

cognitive function on IADLs differed according to IADL
category, suggesting that certain cognitive functions
could be prioritized during IADL-related rehabilitation.
Furthermore, the finding that TUG test performance influenced all three SR-FAI subscales indicates that walking balance was important in IADLs (or that cognitive
function influenced walking balance) in both groups.
Therefore, it is worthwhile to evaluate both cognitive
function and walking/balance in elderly individuals participating in dementia-prevention activities or receiving
home-based care for AD. The neuropsychological tests
and TUG should be used to evaluate daily support services, and the results could assist doctors and therapists
in determining necessary services for patients.
Study Limitations and Future Recommendations
One of the limitations of this study was that the
subjects were ambulatory rehabilitation patients or participated in aged-care prevention classes, at three healthcenters for the elderly. Therefore, the results might not
be generalizable to ambulatory patients at other institutions or elderly residents in other areas.
Rapcsak, Croswell, and Rubens [32] and Okazaki,
Kasai, Meguro, Yamaguchi, and Ishii [33] reported that
IADL performance in individuals with AD was affectedby executive function and apraxia. Moreover, Grossi,
Becker, Smith, and Trojano [34] found that attentionallocation disorders arose in individuals with AD because of a reduction in their ability to perceive stimuli
simultaneously. Therefore, another limitation of thestudy was that apraxia and attention-allocation disorders were not considered, even though there appears
to be sufficient evidence to warrant examination of
cognitive disorders affecting IADL performance. In
addition, we did not consider apathy, which could leadto reductions in motivation and interest in performing
IADLs. Furthermore, the study was biased in terms ofsex, as the sample included 44 women and only 10 men,which could have affected the results. Future researchis required to clarify the effects of apraxia, attentionallocation functions, depression, apathy, and sex differences in IADL.
Conclusion
Overall, the results indicated that the effects ofthe cognitive and physical function variables differedaccording to IADL type. The finding that TUG test
performance was related to all IADL types could haveoccurred because it is sensitive to cognitive impairment
or exerted a strong direct effect on IADLs in a general
sense. Evaluations and interventions that involve thecognitive and physical functions identified in this study
could be beneficial in activity planning for the provision

15

of IADL support to individuals with mild AD or no dementia in aged-care prevention classes and ambulatory
rehabilitation.

Conflicts of Interest
The authors have no conflicts of interest to declare.

Acknowledgements
We would like to thank the participants, theirfamilies, and the staff at each institution for their cooperation. The study was supported by a Grant-in-Aid for
Research from Seijoh University (grant number 2011.
No.07).

References[1] Alzheimer’s Association: 2013 Alzheimer’s disease facts
and figures. Alzheimers Dement. 2013; 9: 208−45.
[2] Ministry of Health, Labour and Welfare [online]. Location: For Investigation of Dementia Prevalence (inJapanese). [cited 2016 February 20]. Available from:http://www.mhlw.go.jp/stf/shingi/2r98520000035rce-att/
2r98520000035rfx.pdf[3] Perneczky R, Pohl C, Sorg C, Hartmann J, Tosic N,
Grimmer T, et al. Impairment of activities of daily living
requiring memory or complex reasoning as part of the
MCI syndrome. Int J Geriatr Psychiatry. 2006; 21: 158−
62.
[4] Ueda M, Takayama Y, Koyama Y, Osaka H. Characteristics of memory disorders and deteriorations of IADL invery mild Alzheimer’s disease and MCI. A survey of amemory clinic questionnaire. Jpn J Gerontol. 2008; 29:506−15.
[5] Lechowski L, de Stampa MD, Denis B, Tortrat D,
Chassagne P, Robert P, et al. Patterns of loss of abilities
in instrumental activities of daily of daily living in Alzheimer’s disease: the REAL cohort study. Dement Geriatr
Cogn Disord. 2008; 25: 46−53.
[6] Galasko D, Bennett D, Sano M, Emesto C, Thomas R,
Grundman M, et al. An inventory to assess activities ofdaily living for clinical trials in Alzheimer’s disease. The
Alzheimer’s Disease Cooperative Study. Alzheimers Dis
Assoc Disor. 1997; 11: 33−9.
[7] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington,
DC: American Psychiatric Association Press; 2000.
[8] McKhann GM, Drachman D, Folstein M, Katzman R,
Price D, Stadlan EM. Clinical diagnosis of Alzheimer’s
disease: report of the NINCDS-ADRDA Work Group
under the auspices of Department of Health and Human
Services Task Force on Alzheimer’s Disease Neurology.
1984; 34: 939−44.
[9] McKhann GM, Knopman DS, Chertkow H, Hyman BT,

16

IADL DISORDER FACTOR OF ALZHEIMER’S DISEASE

Jack CR Jr., Kawas CH, et al. The diagnosis of dementia
due to Alzheimer’s disease: recommendations from the
National Institute on Aging-Alzheimer’s Association
workgroups on diagnostic guidelines for Alzheimer’s
disease. Alzheimers Dement. 2011; 7: 263−9.
[10] Giovagnoli AR, Erbetta A, Reati F, Bugiani O. Differential neuropsychological patterns of frontal variant frontotemporal dementia and Alzheimer’s disease in a studyof diagnostic concordance. Neuropsychologia. 2008; 46:
1495−504.
[11] Perry RJ, Hodges JR. Attention and executive deficits in
Alzheimer’s disease. A critical review. Brain. 1999; 122:
383−404.
[12] Kramer JH, Nelson A, Johnson JK, Yaffe K, Glenn S,
Rosen HJ, et al. Multiple cognitive deficits in amnestic
mild cognitive impairment. Dement. Geriatr Cogn Disord.
2006; 22: 306−11.
[13] Fujita T, Notoya M, Sunahara N, Kato K, Nagai T, Inoue
K. Development and review of the validity of an “instrumental activities of daily living test” (IADL test) performed as a desk evaluation of patients with Alzheimer’s
type of dementia. J Tsuruma Health Sci Soc. 2010; 34:
1−14.
[14] Kawakatsu S, Sagawa K, Shinohara M, Morinobu S,
Higashitani Y, Koyama H, et al. Frequency of depressive
state in Alzheimer’s disease: early symptoms and differential diagnosis of depression. Jpn J Psychiatr Treat inJapanese. 1990; 5: 883−9.
[15] Bond MJ, Harris RD, Smith DS, Clark MS. An examination of the factor structure of the Frenchay Activities
Index. Disabil Rehabil. 1992; 14: 27−9.
[16] Holbrook M, Skilbeck CE. An activities index for use
with stroke patients. Age Ageing. 1983; 12: 166−70.
[17] Koyano W, Shibata H, Nakazato K, Haga H, Suyama Y.
Measurement of competence: reliability and validity of
the TMIG Index of Competence. Arch Gerontol Geriatr.
1991; 13: 103−16.
[18] Atkinson HH, Rapp SR, Williamson JD, Lovato J, Absher
JR, Gass M, et al. The rehabilitation between cognitive
function and physical performance in older woman:
results from the women’s health initiative memory study.
J Gerontol A Biol Sci Med Sci. 2010; 65A: 300−6.
[19] Haren MT, Malmstrom TK, Banks WA, Patrick P, Miller
DK, Morley JB. Lower serum DHEAS levels are associated with a higher degree of physical disability anddepressive symptoms in middle-aged to older African
American women. Maturitas. 2007; 57: 347−60.
[20] Hsieh CL, Jang Y, Yu TY, Wang WC, Sheu CF, Wang
YH. A Rasch analysis of the Frenchay Activities Index inpatients with spinal cord injury. Spine. 2007; 32: 437−42.
[21] Visschedijk JHM, Caljouw MAA, Bakkers E, van Balen
R, Achterberg WP. Longitudinal follow-up study on fearof falling during and after rehabilitation in skilled nursing
facilities. BMC Geriatr. 2015; 15: 161.
[22] Hachisuka K, Tsutsui Y, Furusawa K, Ogata H. Genderdifferences in disability and lifestyle among community-dwelling elderly stroke patients in Kitakyushu, Japan.
Arch Phys Med Rehabil. 1998; 79: 998−1002.
[23] Rouleau I, Salmon DP, Butters N, Kennedy C, McGuire K.
Quantitative and qualitative analyses of lock drawings in
Alzheimer’s and Huntington’s disease. Brain Cogn. 1992;
18: 70−87.
[24] Ohno S, Taya Y, Kashiwagi K. Factors relevant to men’s
involvement in household labor. Hum Dev Res. 2003; 17:
53−68.
[25] Piquard A, Derouesné C, Meininger V, Lacomblez L.
DEX and executive dysfunction in activities of dailyliving in Alzheimer’s disease and frontotemporal dementia. Psychol Neuropsychiatr Vieil. 2010; 8: 215−24.
[26] Monaci L, Morris RG. Neuropsychological screening
performance and the association with activities of dailyliving and instrumental activities of daily living indementia: baseline and 18- to 24-month follow-up. Int J
Geriatr Psychiatry. 2012; 27: 197−204.
[27] McGough EL, Kelly VE, Logsdon RG, McCurry SM,
Cochrane BB, Engel JM, et al. Associations between
physical performance and executive function in older
adults with mild cognitive impairment: gait speed and thetimed “up & go” test. Phys Ther. 2011; 91: 1198−207.
[28] Voelcker-Rehage C, Godde B, Staudinger UM. Physicaland motor fitness are both related to cognition in old age.
Eur J Neurosci. 2010; 31: 167−76.
[29] Frisoni GB, Pievani M, Testa C, Sabattoli F, Bresciani L,
Bonetti M, et al. The topography of grey matter involvement in early and late onset Alzheimer’s disease. Brain.
2007; 130(Pt 3): 720−30.
[30] Kemp PM, Holmes C, Hoffmann SMA, Bolt L, Holmes
R, Rowden J, et al. Alzheimer’s disease: differences intechnetium-99m HMPAO SPECT scan findings between
early onset and late onset dementia. J Neurol Neurosurg
Psychiatry. 2003; 74: 715−9.
[31] Albert MS, Moss MB, Tanzi R, Jones K. Preclinicalprediction of AD using neuropsychological tests. J Int
Neuropsycho Soc. 2001; 7: 631−9.
[32] Rapcsak SZ, Croswell SC, Rubens AB. Apraxia in Alzheimer’s disease. Neurology. 1989; 39: 664−8.
[33] Okazaki M, Kasai M, Meguro K, Yamaguchi S, Ishii H.
Disturbances in everyday life activities and sequence
disabilities in tool use for Alzheimer disease and vasculardementia. Cogn Behav Neurol. 2009; 22: 215−21.
[34] Grossi D, Becker JT, Smith C, Trojano L. Memory for visuospatial patterns in Alzheimer’s disease. Psychol Med.
1993; 23: 65−70.

■RAPID COMMUNICATIONS

Relationship of Unaffected Grip Strengthand Trunk Function with Toileting Performancein Stroke Patients
Yuta Kisara1, Takaaki Fujita2, Takuro Ohashi1, Kazuhiro Yamane1, Atsushi Sato3
1

Department of Rehabilitation, Kita-Fukushima Medical Center
Department of Rehabilitation, Faculty of Health Sciences, Tohoku Fukushi University
3
The Database Center of the National University Hospitals, University of Tokyo Hospital2

Abstract: Purpose: Toileting independence is important for patients to maintain self-esteem and to return home. Unaffected grip strength and trunk functions have been noted in earlier studies to be associated with toileting independence
in stroke patients. The objective of this study was to explore appropriate indices and calculate cut-off values with regard
to unaffected grip strength and trunk functions that could be completed in a short time for estimating toileting independence in stroke patients.
Methods: The subjects were 37 stroke patients, each of whom scored at least 21 points in the Revised Hasegawa’s
Dementia Scale. The patients were divided into independent and non-independent toileting groups by FIM® scores related to toiling items (“Toileting” and “Toilet transfer”). Logistic regression and receiver operating characteristic curve
were used to elucidate items that showed an association with the presence or absence of toileting independence, and to
calculate cut-off values of grip strength and trunk function from the Stroke Impairment Assessment Set as variables.
Results: Grip strength was significantly associated with toileting independence. The cut-off value was 3 points (sensitivity, 74%; specificity, 71%; receiver operating characteristic area under the curve, 0.730).
Discussion: Because grip strength can be quickly measured, calculated grip strength cut-off values can estimate a patient’s ability for toileting independence. However, the cut-off value shown in the present study may be applicable to
only patients with good trunk function.
Keywords: toileting independence, grip strength, stroke(Asian J Occup Ther 14: 17−21, 2018)

Introduction
Toileting independence requires independence in
activities such as manipulating lower garments and transferring to a toilet. However, these activities are some of
the most challenging tasks for stroke patients [1]. Toileting independence is important for patients to maintainself-esteem and requires proper evaluation in rehabilitation settings because it is associated with patients’ likelihood of returning home [2].
In an earlier study on toileting independence in
Received: 29 August 2017, Accepted: 24 April 2018
Corresponding to: Takaaki Fujita, Department of Rehabilitation, Faculty of Health Sciences, Tohoku Fukushi University, 1-8-1, Kunimi,
Aoba-ku, Sendai-shi, Miyagi, 981-8522, Japane-mail: t-fujita@tfu-mail.tfu.ac.jp©2018 Japanese Association of Occupational Therapists

stroke patients, Sato et al. [3] reported that balance function is important for toileting independence, and is integral for acts like transferring to the toilet seat. A balance
function score of approximately 42 in the Berg Balance
Scale (BBS), a typical balance index, is required. The
BBS cut-off value that Sato et al. calculated in the same
report can serve as a target value during balance exercises directed toward toileting independence, and as anindex for estimating toileting independence. If occupational therapists, physical therapists, nurses, and othermedical professionals have information on BBS scoresin addition to functional state of cognitive and physicalactivity in the early stages of post-stroke recovery, theywould be better able to understand patients’ toileting assistance and other support needs beforehand, and would
be able to make various preparations such as environmental adjustments. However, it takes approximately
20 min to complete the BBS, which means that the BBS

18

RELATIONSHIP OF GRIP STRENGTH WITH TOILETING IN STROKE

is not easy to use as an index for determining toileting
independence. Therefore, an assessment that could becompleted in a short time was needed.
Other factors associated with toileting independence include grip strength [4], and trunk function [5−7].
We believe that these factors can provide useful cut-off
values that are capable of distinguishing patients withtoileting independence from those with non-independence in a similar manner to the aforementioned BBS.
The objective of this study was to explore indices thatmight easily and quickly estimate toileting independence in stroke patients. We hypothesized that we could
achieve this by calculating cut-off values and verifying
their accuracy, using unaffected grip strength and trunk
functions as indices, both of which are associated withtoileting independence [5−7]. Rehabilitation therapists
can use this in combination of information of functional
status from other assessments and observations to makemore informed decisions about toileting independence.

Materials and Methods
This was a retrospective observational study inwhich data collected from the medical records of previously-discharged patients were analyzed. This study
carried out at North-Fukushima Medical Center. The
institutional Ethical Review Board of North-Fukushima
Medical Center reviewed and approved the content of
this study (No.56).
The subjects were stroke patients who were hospitalized in the hospital’s convalescent rehabilitation
ward between October 2012 and December 2014. The
inclusion criteria were having no significant cognitive
dysfunction (a score of at least 21 points in the Revised
Hasegawa’s Dementia Scale), and no missing records
of interest variables mentioned below. We categorized
the patients who scored at least 6 points for the items
of “Toileting” and “Toilet transfer” in the FIM® instrument [8] as members of the independent toileting group;
patients in the non-independent toileting group scored5 points or lower for at least one of these two items.
Then, the patients in these two groups were comparedfor background factors (age, gender, type of stroke, andaffected side), unaffected grip strength, and trunk function. Unaffected grip strength and trunk function (verticality and abdominal muscle strength) were evaluatedusing items from the Stroke Impairment Assessment Set(SIAS) [9] as indices. In unaffected grip strength test, if
the grip strength is above 25 kg in two trials, a score of
3 is given. A score of 2 means a strength of 10−25 kg,
and a score of 1 is given if the unaffected grip strengthis 3−10 kg [9]. SIAS was adopted because it is widelyused in the rehabilitation clinical setting and can be

Fig. 1. Receiver operating characteristic curve for unaffected
grip strength on the Stroke Impairment Assessment
Set.

completed in a short time. Intergroup comparisons weredone using the Student’s t-test, Chi-square test, andMann-Whitney U test. To identify factors strongly associated with the level of toileting independence, logistic
regression analysis (forced-entry) was performed using
the items that showed a significant difference between
the two groups as independent variables, and the groups
as dependent variables. In addition, logistic regression
analysis (forced-entry) was also performed by adding
age, gender, and affected side as independent variables
to remove the confounding influence. Taking the small
sample size in this study into consideration, age, gender,
and affected side were entered one by one. To finish,receiver operating characteristic (ROC) analysis [10]of items that were significant in the logistic regression
analysis was performed to calculate cut-off values using
the Youden index [11].

Results
The subjects included 37 stroke patients (21 men
and 16 women, mean age: 65.7 ± 14.5 years, mean period since the onset of stroke at the time of evaluation:
92.8 ± 38.3 days). The independent toileting group
included 23 patients, and the non-independent group included 14 patients. Table 1 presents the results obtained
from patients in each group. Intergroup comparisons revealed that significantly higher scores for unaffected grip
strength on the SIAS in the independent group, compared to the non-independent group. However, no significant differences were found for trunk function fromthe SIAS (verticality and abdominal muscle strength).
Logistic regression analysis identified unaffected grip

Kisara Y et al.

Asian J Occup Ther 14: 17−21, 201819

Table 1. Comparison of parameters of the independent and non-independent groups
Independence(N = 23)

Non-independence(N = 14)Significant

62.6 ± 16.0
65.2
47.8

70.9 ± 10.1
42.9
42.9

nsa
nsb
nsb

73.9
26.1
86.7 ± 37.5

64.3
35.7
100.1 ± 39.5

nsb

3 (0)
3 (0)
3 (1)

3 (0)
3 (1)
2 (1)

nsc
nsc
p < 0.05c

Age, years
Men, %
Right-side hemiplegia, %Type of stroke
Cerebral infarction, %Cerebral hemorrhage, %Time poststroke, days
SIAS Verticality (0−3)
SIAS Abdominal Muscle Strength (0−3)
SIAS Unaffected Grip Strength (0−3)

nsaMean ± SD or Median (IQR) or %Abbreviations: SIAS, Stroke Impairment Assessment Set
aStudent’s t test; b Chi-square test; c Mann-Whitney test

Table 2. Logistic regression analysis to estimate the independence of toileting
Model 1a

SIAS Unaffected Grip Strength
Age
Gender (0, women; 1, men)
Affected side (0, right; 1, left)

Model 2bModel 3c

Model 4dOdds ratio

P value

Odds ratio

P value

Odds ratio

P value

Odds ratio

P value

7.08< 0.01

5.56
0.98< 0.05
0.496

12.83

< 0.057.06< 0.05

0.438

0.487

0.851

0.832

Abbreviations: SIAS, Stroke Impairment Assessment Set.
Model 1 into which only SIAS unaffected grip strengthbModel 2 into which SIAS unaffected grip strength along with agecModel 3 into which SIAS unaffected grip strength along with genderdModel 4 into which SIAS unaffected grip strength along with affected sideastrength from the SIAS as significantly associated withtoileting independence (Table 2). This significant association was also maintained after the influences of age,gender, and affected side were removed. The ROC analysis of unaffected grip strength from the SIAS provided
a cut-off value of 3 points (sensitivity, 74%; specificity,
71%; ROC area under the curve, 0.730), at which independence was differentiated from non-independence.

Discussion
The results of this study suggest that toileting independence is associated with unaffected grip strength
scored using the SIAS criteria. It has already been reported that unaffected grip strength is associated with
the independence level of various ADL items including
toileting and ADL prognosis in stroke patients [4, 12],and the originality of this study was to calculate thecut-off value associated with the presence or absenceof toileting independence. It is assumed that the association between these two variables is attributed to theneed for a certain degree of unaffected grip strength formanipulating lower garments. In addition, unaffected
grip strength correlates with quadriceps muscle strength,skeletal muscle mass, one-leg standing time, and otherfactors in the elderly [13], and grip strength on the unaffected side has been found to correlate with the strengthof other ipsilateral muscles in stroke patients [14, 15].
Therefore, there is a possibility that unaffected grip
strength reflects whole body performance, and wholebody performance influences toileting independence.
However, these theories remain a matter of speculation.
Our results agree with those of a previous study by Bae
et al. [4] that describe the relationship between unaffected grip strength and toileting independence in subacutestroke patients; however, there seems to be a slight difference regarding the relationship with the affected side.
Bae et al. [4] reported that this relationship is observed
only in right hemiplegic patients, whereas our results
suggest that the relationship is maintained even after the
influences of the affected side (i.e., right and left hemiplegia) are removed. It is thought that the reason for thisdifference is the influence of the analysis method thatthe previous study [4] used bivariate analysis whereas

20

RELATIONSHIP OF GRIP STRENGTH WITH TOILETING IN STROKE

our study performed multivariate analysis. Because
bivariate analysis cannot generally adjust the influenceof confounding factors, the results of bivariate and multivariate analysis may be different. Further studies areneeded to reveal whether the affected side influences therelationship between unaffected grip strength and toileting independence.
No association was seen between toileting independence and trunk function in the present study. Earlier
studies have reported that trunk function is associatedwith toileting abilities [5−7]. The difference between the
results of the present study and those of earlier studies
can be explained by the patients in the present study
who scored nearly full points for the verticality and abdominal muscle strength items in the SIAS. This could
have produced a ceiling effect that prevented detecting
an association with toileting independence. Therefore,
the results of the present study do not rule out an association between toileting independence and trunk function. This means the relationship between unaffected
grip strength and toileting independence and cut-off
value indicated by this study cannot deny the possibility of being complicated by functional state of trunk.
Therefore, it is necessary to keep in mind that the cutoff value shown in the present study may be applicable
to only patients with good trunk function.
In the present study, the calculated SIAS cut-off
value of 3 points for unaffected grip strength may be
useful for easily estimating toileting independence. Grip
strength can be quickly measured regardless of healthcare provider experience (in our experience, it is possible within 3 minutes.). Regarding the accuracy of the
cut-off value, a previous study has calculated the cutoff value for toileting independence using BBS [3] andhas reported that if 42/41 points for BBS were adapted,
ROC area under the curve, sensitivity, and specificity
were 0.832, 78%, and 83%, respectively. In contrast,
ROC area under the curve, sensitivity, and specificity of
our cut-off value were 0.730, 74%, and 71%, respectively. Therefore, the accuracy of the cut-off value calculated in this study may seem to be at a slight disadvantage
compared with that of the value calculated using BBS;
however, we believe that it is within a practical range
and using grip strength saves valuable time over using
BBS.
A limitation of this study was that we unintentionally recruited patients who did not have any marked
deterioration of trunk function. Further investigations
are needed to determine if the cut-off value shown in
the present study is applicable to patients with reduced
trunk function. Other limitations included the small
sample size and limited examination of unaffected grip
strength, using only the SIAS. In addition, the subjects

were inpatients of a rehabilitation hospital ward. Therefore, generalization of this study’s results may be limited. Furthermore, higher brain dysfunction variables (e.g.,aphasia, unilateral spatial neglect, apraxia, and attention
deficit) and motor and sensory functions of the upperand lower limbs on the affected side were not addressed.
Further studies are needed to expand upon these results.

Summary and Conclusions
We examined assessments that could be completed
in a short time for measuring toileting independence
using the grip strength of the unaffected side and trunk
functions in stroke patients. In distinguishing independent and non-independent toileting groups, the cutoff
value for the grip strength from the SIAS was 3 points(sensitivity, 74%; specificity, 71%; ROC area under the
curve, 0.730). Grip strength can be quickly measured regardless of healthcare provider experience, and the calculated cut-off value may be useful for easily estimating
toileting independence.

Conflict of interest
There are no conflicts of interest to declare.

Acknowledgments
This work was supported by a grant from the Japanese Society for the Promotion of Science Grants-inAid for Scientific Research (grant no. 16K20768).
The use of the FIM® instrument to collect data for thisresearch study was authorized and conducted in accordance with the term of a special purpose license granted
to the licensee by the Uniform Data System for Medical Rehabilitation (UDSMR). Licensee has not been
trained by UDSMR in the use of the FIM® instrument,
and the patient data collected during the course of thisresearch study has not been submitted to or processedby UDSMR. No implication is intended that such data
has been or will be subjected to UDSMR’s standard dataprocessing procedures or that it is otherwise comparable
to data processed by UDSMR. FIM® is a trademark of
Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.

References[1] Takami M, and Chida T. Analysis of time course of ADL
recovery in stroke patients: with reference to development of clinical pathways in convalescent stroke rehabilitation (in Japanese). Sogo Rihabiriteshon. 2008; 36(8):775−81.

Asian J Occup Ther 14: 17−21, 2018[2] Mauthe RW, Haaf DC, Hayn P, and Krall JM. Predicting
discharge destination of stroke patients using a mathematical model based on six items from the Functional
Independence Measure. Arch Phys Med Rehabil. 1996;
77(1): 10−3.
[3] Sato A, Ohashi Y, Kawasaki E, Yamamoto Y, Onobe J,
and Fujita T. Evaluation criteria of excretion motion independence for stroke patients (in Japanese). Annual Reportof the Tohoku Section of Japanese Physical Therapy Association (Tohoku-rigakuryohogaku). 2013; 25: 104−9.
[4] Bae JH, Kang SH, Seo KM, Kim DK, Shin HI, and Shin
HE. Relationship between grip and pinch strength andactivities of daily living in stroke patients. Ann RehabilMed. 2015; 39(5): 752−62.
[5] Fujita T, Sato A, Togashi Y, Kasahara R, Ohashi T, andYamamoto Y. Contribution of abdominal muscle strengthfor various activities of daily living in stroke patientswith mild paralysis. J Phys Ther Sci. 2015; 27(3): 815−8.
[6] Koike Y, Sumigawa K, Koeda S, Shiina M, Fukushi H,
Tsuji T, Hara C, and Tsushima H. Approaches for improving the toileting problems of hemiplegic stroke patientswith poor standing balance. J Phys Ther Sci. 2015; 27(3):877−81.
[7] Sato A, Okuda Y, Fujita T, Kimura N, Hoshina N, Kato
S, and Tanaka S. Cognitive and physical function related
to the level of supervision and dependence in toileting on
stroke patients. Phys Ther Res. 2016; 19(1): 32−8.
[8] Data Management Service of the Uniform Data System
for Medical Rehabilitation and the Center for functional

Kisara Y et al.

21

Assessment Research: Guide for the Uniform Data Set
for Medical Rehabilitation, Version 3.0. New York: State
University of New York at Buffalo, 1990.
[9] Chino N, Sonoda S, Domen K, Saitoh E, and Kimura A.
Stroke impairment assessment set (SIAS). In: Chino N,
Melvin JL, editors. Functional evaluation of stroke patients. Tokyo: Springer-Verlag; 1996; 19−31.
[10] Akoberg AK. Understanding diagnostic tests: Receiver
operating characteristic curves. Acta Paediatr. 2007;
96(5): 644−7.
[11] Fluss R, Faraggi D, and Reiser B. Estimation of theYouden Index and its associated cutoff point. Biom J.
2005; 47(4): 458−72.
[12] Yi Y, Shim JS, Oh BM, and Seo HG. Grip strength on theunaffected side as an independent predictor of functional improvement. Am J Phys Med Rehabil. 2017; 96(9):616−20.
[13] Ikeda N, Murata S, Otao H, Kai Y, Murata J, Tominaga
K, and Mizota K. Relationship between grip and physicalfunction in the elderly (in Japanese). West Kyushu Journal of Rehabilitation Sciences. 2010; 3: 23−6.
[14] Takahashi J, Nishiyama T, and Matsushima Y. Does grip
strength on the unaffected side of patients with hemiparetic stroke reflrect the strength of other ipsilateral muscles. J Phys Ther Sci. 2017; 29(1): 64−6.
[15] Ekstrand E, Lexell J, and Brogårdh C. Grip strength is a
representative measure of muscle weakness in the upper
extremity after stroke. Top Stroke Rehabil. 2016; 23(6):400−5.

■MISCELLANEOUS

Sky Mirror Model: A Fusion Model of Therapeutic Useof Self for Occupational Therapy Practice
Chris Kang
Health and Social Sciences, Singapore Institute of Technology

Abstract: This paper articulates for the first time an Asian-Western fusion model of therapeutic use of self for occupational therapy practice. The Sky Mirror Model synthesizes concepts, metaphors, and praxes from Asian and Westerncultures. Metaphors of sky and mirror form the epistemic receptacle for a set of twelve therapeutic factors. A case study
illustrates the interplay of key factors as the therapist embodies and enacts the ‘sky mirror’ in the fluid dance of a therapeutic relationship with the client. Sky Mirror Model’s paradigm of unconditioned being and therapeutic presence iscounter-hegemonic, radically different, and intimately linked to the psychospiritual integration frame of reference.
Keywords: Metaphor, therapeutic presence, unconditioned being, counter-hegemonic, psychospiritual integration(Asian J Occup Ther 14: 23−31, 2018)

Introduction
Therapeutic use of self is a concept that has received little attention in occupational therapy literatureand low prominence in occupational therapy education
curriculum [1, 2]. This is despite the finding that occupational therapists surveyed regarded therapeutic use of
self as central and important to the occupational therapy
process [3]. In the same survey, occupational therapists
indicated that while they highly valued therapeutic useof self as a core skill, their formal occupational therapy
education did not provide them sufficient training in thiskey area. Theoretical and published information wassparse and practical training in therapeutic use of self
was more incidental than intentional. As a result, mostoccupational therapists surveyed did not feel adequately
prepared in the skills on therapeutic use of self.
Various occupational therapy scholars have attempted to define therapeutic use of self. Punwar and
Peloquin [4] proposed that therapeutic use of self on
the part of the therapist is the “… planned use of his or
her personality, insights, perceptions, and judgments
as part of the therapeutic process”. Taylor [2] in her
Received: 8 November 2017, Accepted: 24 April 2018
Corresponding to: Chris Kang, Health and Social Sciences, Singapore
Institute of Technology, 10 Dover Drive, Singapore 138683.
e-mail: chriskang.phd@gmail.com©2018 Japanese Association of Occupational Therapists

Intentional Relationship Model envisioned therapeutic
use of self as the ability to flexibly apply six modes ofpractice or interpersonal skills comprising advocating,collaborating, empathizing, encouraging, instructing, or
problem solving with the client at the appropriate timeand depending on need. Kielhofner and Forsyth [5] inthe Model of Human Occupation detailed a set of therapeutic strategies that can be construed as elements oftherapeutic use of self in facilitating client occupational
performance – validating, identifying, giving feedback,advising, negotiating, structuring, coaching, encouraging, and providing physical support. In the CanadianModel of Client-Centred Enablement, Townsend et al.
[6] highlighted a set of ten key enablement skills –adapt, advocate, coach, collaborate, consult, coordinate,
design/build, educate, engage, specialize – which are
relevant to therapeutic use of self. There is a certain
degree of overlap among the three models articulated
thus far, even as they attempt to provide a map of facilitating or enabling occupational performance in thecontext of a therapeutic relationship.
A common thread or ethos that runs through thesemodels is that of intentional, strategically-directed, therapist-initiated activity or skill. All the modes, strategies,
and enablement skills of the Intentional Relationship
Model, Model of Human Occupation or Canadian Modelof Client Engagement respectively can be seen to pertain to the occupational therapist’s doing and becoming.
That is, these models seem to be talking about what the24

SKY MIRROR MODEL

occupational therapist actively does (e.g. advocating,advising, and coordinate) in the interaction between
therapist and client, and thus what he/she becomes in
the process of doing (e.g. role of advocate, advisor, andcoordinator).
The Sky Mirror Model of therapeutic use of self isa fusion of Asian and Western cultural metaphors, concepts, and praxes (theory-informed practice). It draws
on cultural images of mirror and sky ubiquitous in Asia.
Metaphors of mirror and sky have profound connotations of inner clarity, stillness, openness, presence, andinsight. As such, they fit well with the overarchingemphasis of Sky Mirror Model on the being of an occupational therapist. This model articulates therapeutic
use of self in terms of the occupational therapist’s being,both its inner dynamics and its mutuality with the beingof another.

Sky mirror as core metaphor
The work of Iwama [7] underscores the centralityof cultural assumptions and metaphors in constructionof occupational therapy theory and practice. Occupation-centred models of practice and current articulationsof therapeutic use of self in occupational therapy arethemselves culturally bound and historically located.
Globalization of goods, services, and knowledge hascreated an impression of universalized knowledge categories and metaphors stemming from Anglo-American
culture. Hammell [8, 9] pointed out that such universalized knowledge is naturalized to the extent that it is seen
not as cultural artefact but as unproblematic universal
truth. For example, occupational science claims toespouse a set of universal ‘truths’ about human occupational nature, essentiality of occupation, the incontrovertible link between autonomy, occupation, and health,and other related ideas. Research evidence is summarily
gathered to render support to such ideas, through various
qualitative or quantitative methodologies. Yet, implicit
assumptions and ideological commitments that serve tounderpin and construct notions of evidence and methodologies remain assumed rather than questioned. Tacit
but powerful metaphors hidden beneath our constructionof knowledge remain unexposed.
In this regard, the Sky Mirror Model is constructedfrom a fusion of both Asian and Western metaphors,concepts and praxes. This is seen in the model’s core
metaphors of “sky” and “mirror” as well as the set oftherapeutic factors within its four domains. As core metaphor, “sky” is a meaningful cultural image within Asian
cultures – particularly Indian, Chinese, Vietnamese,
Japanese, and particularly Himalayan cultures like Tibet
and Nepal [10−15]. The salience and prominence of thesky metaphor in Himalayan cultures may be linked togeographical and climatic factors distinctive to these
territories.
Across these cultures, the sky is a powerful symbol
for the vast, open, luminous nature of the mind that perceives and cognizes all sensory and psychological data
in a free-flowing, non-fixated, non-concretizing way [16,17]. In particular, the sky is seen as an immaculate expanse akin to awareness as a centerless clearing throughwhich one’s unique life history flows, just as clouds
might flow through the vast open sky without centre or
circumference. Ontologically, awareness or consciousness or mind is open because it is free of concretized
identity [18]; luminous because myriad appearances
manifest in awareness; and knowing because it is able
to cognize or know whatever appears in consciousness[19]. Phenomenologically, realizing this sky-like natureof awareness is a state of peace and joy with absenceof inner affliction and conflict. This lack of reactivity
also means presence of dynamic responsiveness to theanguish of others. Thus, the sky metaphor is a metaphor
rich in meaning in Asian contexts [20, 21].
The core metaphor of mirror is another cultural
image in Chinese, Japanese, Indian, and Himalayan
cultures. In these Asian contexts, the mirror’s ability
to reflect things as they are unbiasedly symbolizes theability of awareness to cognize all phenomena without
reactivity. The mirror’s reflective capacity is based on it
being still, simple and clear, free of dust and dirt. Evenas the mirror reflects, it remains unstained in any real or
permanent way. Similarly, mirror-like awareness reflects
things as they are, without embellishment or detraction,
and without being permanently stained in any way [22].
Hence, as cultural metaphor, the mirror is highly relevant to how a therapist is present in his/her therapeutic
relationship – still, simple, clear, non-reactive, non-judgmental, and reflecting client issues, needs, and values
without bias.
Taken together, the metaphor of ‘sky mirror’ can beunderstood as sky reflected in mirror as well as mirror
reflecting in the sky – both of which convey the implications of therapeutic presence focused less on doing
and more on being. This focus on being a wise therapist
skilled in healing bears resonance with a pervasive
ancient meme of Asia – that of a sage, awakened being,
and realized soul [23, 24]. From Sky Mirror Model’s
perspective, a therapist’s use of self is not so much adeliberate concocting of a ‘therapeutic personality’
replete with a collection of ‘highly desirable skills’ thatwhen enacted conduces to positive therapy outcomes.
Rather, Sky Mirror Model advocates an approach totherapeutic use of self that has as its core the powerof therapeutic presence – uncontrived and unmerited,Asian J Occup Ther 14: 23−31, 2018

Kang C

neither performance-driven nor outcome-focused, butspontaneously manifest and focused on the presentmoment. The qualities represented by the sky and mirror
as previously discussed, when taken together, coalesce
into a picture of spontaneous, present-moment, uncontrived therapeutic presence that is powerfully healing in
non-self-conscious ways.
Congruent with its part-Asian roots, Sky Mirror
Model focuses on the priority of being over doing andbecoming, where the latter two are regarded as outflowsof the former. The priority of being can be seen in multiple discourses and praxes of Asia that at various points
in history have intermingled and co-constituted the spiritof the Asian worldview. These discourses and praxes include those of Buddhist, Confucianist, Taoist, and Hindu
origins, and their diverse inter-fusions and combinations(e,g, confluence of Buddhist and Taoist ideas in Chan/
Zen).
Being is not the exclusive domain of Asia, as evidenced in the philosophies of Heidegger and Gadamerof the existentialist-hermeneutic tradition, and the influential theology of Torrance in the biblical tradition [25−27]. Heidegger’s notion of the primordiality of dasein
in human experience [25] and Torrance’s pivot on theoutflow of doing from the fullness of being [26] areimportant ideas salient to Sky Mirror Model. Sky Mirror
Model is one that vocalizes and reclaims a practicalconcept marginalized in modernity’s and occupational
therapy’s accentuation of activity over restedness,becoming over being, extroversion over introversion,
speed over slowness, profit over people, and productivity over fruitfulness.
A fusion model?
Sly Mirror Model’s therapeutic factors illustrate thefusion of Asian and Western concepts and praxes. The
organization of these factors into four domains is a theoretical move embedded in Western conceptual differentiation and structuralism. The structure of a model interms of its component parts and how they are organizedis a case in point. Sky Mirror Model’s four domains of
the cognitive, affective, attentional, and conative arederived from Western psychological science. Amongthe factors identified and included under these domains,
about half derives from Western intellectual traditions
while the other half derives from Asian wisdom cultures(see Table 1).
In particular, factors of flexibility of consciousness,three-tracked mind of clinical reasoning, knowledge ofmodels in context, presence, genuineness, and humour
derive from Western clinical and therapeutic traditions.
Factors such as mindfulness, acceptance, attentional balance, presencing, compassion, and empathic attunement
derive from Asian wisdom traditions such as Buddhism,
Taoism, and Yoga [16, 23, 28−32]. Without overstating
the different cultural origins of the two sets of factors, it
is evident that cultural difference and fusion are implicitin their conceptualization. For instance, without thefertile encounter between Western psychology [33] andbehavioural medicine [34] with Buddhism, concepts
and practices of mindfulness (Pali: sati; Sanskrit: smrti)
would not have been promulgated in Western scientific
literature and assumed prominence in academic andprofessional discourse.

Domains and factors of sky mirror
Sky Mirror Model privileges therapeutic presence
as the essence of therapeutic use of self, where becoming
does not create one’s being but is rather a natural outflow of the fullness of being. Torrance as cited in Molnar[35] spoke of becoming expressing the dynamic natureof being. In other words, a Sky Mirror Model-inspired
therapist ceases striving to become the pre-conceived
therapist he/she wants to be by doing more of this orthat. Rather, the therapist stops all ego-driven striving,
doing, and becoming to rest profoundly in the plenitude
of being where these four domains of twelve factors canbe spontaneously actualized. Without actualizing a fullness of being that overflows, all attempts at doing are at
risk of being either contrived or ego-driven, prone to therisk of fatigue and burn-out on the part of the therapist.
Four domains
Sky Mirror Model’s cognitive, affective, attentional, and conative domains follow the model of mental

Table 1. Domains and factors of the Sky Mirror Model.
Cognitive

25

Affective

Attentional

Conative

Flexibility of consciousness

Presence

Mindfulness

HumourThree-tracked mind of clinicalreasoning (+ narrative reasoning)

GenuinenessAcceptancePresencing

Knowledge of models in context

Compassion

Attentional balance

Empathic attunement

26

SKY MIRROR MODEL

balance articulated by Wallace and Shapiro [36]. The
cognitive domain pertains to the processes of thinking
and cognizing – how we think, analyse, problem solve,
construct, synthesize, recall and so forth. The affective
domain pertains to emotional processes – what and how
we feel, react, respond to things. The attentional domain
pertains to the capacity of the mind for focusing, sharpening, clarifying, broadening, and deepening attention.
The conative domain is the realm of intention and will,
the exercise of volition and choice.
Twelve factors
Sky Mirror Model’s therapeutic factors synergize
and synchronize to elicit therapeutic use of self thatis skilful and efficacious. The organic and harmonicorchestration of these factors is not subject to volitional
control or manipulation of the therapist. They are notviewed as concrete skills to be gained but creative abilities that emerge out of deep ‘self-forgetful’ restedness inbeing [37, 38].
Cognitive domain
The cognitive domain is the discursive and inferential aspect of mental functioning that contributes
to therapeutic use of self. The first cognitive factor of
flexibility of consciousness is the ability to shift flexibly
from one frame of reference to another, traversing multiple paradigms in an open, fluid and creative way [39,40]. Such flexibility of consciousness confers upon thetherapist the freedom to adopt non-dominant and alternative perspectives to familiar or intractable problems.
Instead of being fixed on one point of view or fixated on
one ideological agenda, the therapist has the freedom toseamlessly enter the lifeworlds of their clients.
The second cognitive factor is three-tracked mindof clinical reasoning [41]. The first track is procedural
reasoning, which is solution-focused thinking that targets specific problems. The second track is interactive
reasoning, which seeks to build positive therapist-client relationships and promote collaborative problem
identification and problem solving. The third track is
conditional reasoning, which integrates procedural andinteractive reasoning to respond to changing situations
and predict possible client futures. To these three tracks
of reasoning can be added narrative reasoning, the formof thinking that “… make[s] sense of people’s particular
circumstances of the client; prospectively imagine[s] theeffect of illness, disability or occupational performance
problems on their daily lives; and create[s] a collaborative story that is enacted with clients and families
through intervention” [42]. Taken together, these formsof clinical reasoning allow the therapist to assess theclient’s occupational performance and participation inorder to best enable it.
The third cognitive factor is knowledge of models
in context [7]. This is the ability of the therapist to contextualize and personalize various conceptual practicemodels of occupational therapy to the unique life situation, needs, cultural background, values, and history of
the person seeking therapy. In particular, culturally safe
and competent practice involving reflexivity, awareness(both self and cultural), and cultural sensitivity on thetherapist’s part is crucial to efficacious therapeutic use of
self. Such culturally competent practice has the potential
to help the client “… reach a higher plane that is meaningful to the client’s particular worldview and sphere ofmeanings” [7].
Affective domain
The affective domain is the locus of our emotions
and feelings as we react or respond to events of our life
situation. The affective factors of presence and genuineness are salient to how and the extent to which therapists
are emotionally available to the clients they serve. Presence means being fully there for another human being,
not emotionally withdrawing or isolating from a person
without any justifiable reason [43, 44]. Genuineness isthe ability to be real and transparent, not hiding one’s
flaws or holding hidden agendas, to the extent of being
willing to appear vulnerable [43, 45]. Thus, genuinenessis the courage to be human with all its failings, weaknesses, and vulnerabilities.
Compassion is the sense of active caring for another
who is suffering and the desire to alleviate that suffering[31]. Compassion can extend to others who are sufferingand also to oneself. Self-compassion is the caring of
oneself and attentiveness to one’s own suffering without
self-condemnation or judgment [32].
Empathic attunement is the availability and capacity to track the emotional ups and downs of anotherperson, staying close to them in their deeply personaland often difficult emotional journey [43, 45]. Empathic
attunement requires an emotional maturity and stability
that creates an interpersonal space of attunement that isitself a healing experience.
Attentional domain
The attentional domain comprises factors of mind­
fulness, acceptance, and attentional balance. Mindfulness is defined as moment-by-moment attention to present experience that is intentional, non-judgmental, andpurposeful [34]. As such, mindfulness confers a metaperspective to experience, allowing for a less reactive
and more constructive relationship to persons, things,
and events [47]. As present-moment attention, mindfulness counteracts cognitive fusion – the identification

Asian J Occup Ther 14: 23−31, 2018of awareness with its content (i.e. concepts, thoughts,
and verbalizations) such that the immediacy of present
moment experience is lost. Mindfulness enables cognitive defusion and recapturing of experiential immediacy[46, 47].
Acceptance is corollary to mindfulness, following
the approach of Acceptance and Commitment Therapy[46]. Acceptance is openness to experience in all degreesof pleasantness or unpleasantness. It is the antithesis ofexperiential avoidance – the pathological resistance toand avoidance of difficult unpleasant emotional experiences [46]. By opening to challenging emotions throughacceptance, one can fully acknowledge one’s humanityand dedicate oneself to valued life goals without paralysis of fear or avoidance.
Attentional balance is a rare and exquisite state ofmental stillness, clarity, pliancy, and joy brought about
by skilled relaxed focusing of attention for prolonged
periods [16, 17, 23]. There exists various depths ofattentional balance ranging from initial unified attention for four hours at a stretch to profound cognitive
unification beyond sensation of time, place, and person
for as long as one wishes. Attentional balance is a contemplative skill that can be mastered by any dedicatedpractitioner [48]. Once established, attentional balance
confers upon the practitioner an exceptional degree ofpsychological wellbeing, with benign effects on physicalwellbeing [23].
Conative domain
The conative domain comprises two factors,
humour and presencing, that relate to intentionality andchoice. Conscious surrendering of will and choice in the
spontaneous bursting forth of humour, though not an
act of wilful choice per se, is a dynamic expression ofconation. In humour, it can be said that the controlling
will is released into a field of open spontaneity where
playfulness can arise [49, 50]. Vergeer and MacRae
proposed that humour has multiple facets that include
the balancing and transforming of negative emotions,
grounded in spontaneity, and conveying empathy andhonesty as part of therapeutic use of self [51].
Presencing is the intentional quietening of heart,
mind, and will so to be fully present to the moment andto sense acutely the dynamics, possibilities, and potentials of the emerging future. Presencing as a concept
comes from leadership theory and is a way of leadingfrom the future as it emerges [30]. It aims to address theblind spot of leadership found within the inner state of
the leader himself/herself. As such, presencing involves
a profoundly quiet heart, mind, and will sensitized tostirrings in the field of present and future possibilities.
Presencing resonates with the concept of wisdom as

Kang C27

higher order metaperspectives and transperspectival“pure awareness” where multiple angles of viewing theworld are celebrated [52].
Applied to the process of occupational therapy,
presencing takes the form of co-entering the shared
therapeutic space of conative silence with the client, so
as to birth a vision for future occupational fulfilment.
A ‘prototype’ of this occupationally fulfilled future
can be designed and built collaboratively by client andtherapist, inviting further iterations as new facts come tolight. Presencing as a therapeutic factor thus serves as a
powerful force for recrafting an occupational life after
illness, disability, displacement, or disruption.

Case example: Dancing the sky mirror inpractice
A case example will illustrate the dance-like interplay of all therapeutic factors across the four domainsof Sky Mirror Model. Here, the therapeutic process isundergirded by the uncontrived being of the therapist – acentreless clearing through which the unique life historyof the therapist flows and where all thoughts, emotions,sensations, colours and sounds are seen as displays ofawareness much like paintings in the sky. Fenner andWallace, speaking from within an Asian cultural worldview, advocate just such a state of uncontrived being [17,24, 38]. From this perspective, the therapeutic factors
spontaneously actualize out of the unbounded centrelessclearing of awareness as wisdom that responds organically to the needs of the client.
Introducing James
James (not his real identity) was an entrepreneur in
his late forties who had experienced a recent depressive
episode, had overweight issues linked to diabetes, andhad undergone a divorce and business liquidation. At thetime of first consultation, James had just started a second
business as a solo entrepreneur, which was a huge stepdown from his previous company of about 150 staff.
He was having communication challenges with his exwife around child custody matters and struggled withfinances due to minimal income from his business. He
had referred himself to occupational therapy through an
information brochure he picked up.
Dancing the Sky Mirror
Occupational therapy began with James and theoccupational therapist collaboratively identifying andprioritizing James’s occupational performance issues.
This was a challenging process at first as James was
experiencing strong resistance to contacting the painful
memories and thoughts of his current life situation at

28

SKY MIRROR MODEL

that point in therapy. He had an ambivalence of desiring therapy on one hand and resisting the therapeutic
process on the other. Therapeutic use of self at thispoint was focused on being an effortless openness andcentreless clearing for the unique life world of Jamesto flow and intersect with the unique life world of thetherapist. In the up-close and personal encounter of twolife worlds, cradled in the centreless clearing presenced
by the therapist, dense knots of thought and emotion
were laid bare and released in the dialogical space that
opened up [14, 21].
Presence and genuineness as described by Elliot,
Watson, Goldman, and Greenberg [43] on the therapist’s
part reassured James that the therapeutic space was freeof judgment and false pretences – that the therapist was
truly and honestly available to him by being willing,
vulnerable, and fully there. Mindfulness – the capacity toabide clearly and sharply in present-moment experience
without reactivity [33, 34] – coupled with acceptance ofthe many surging waves of emotions in the therapist allowed for a non-defensive, warm and sincere emotional
availability to James [43, 46]. Synergy of mindfulness
and acceptance was essential for the therapist in embracing emotional reactions triggered by James’s defensive
and at times aggressive remarks.
The therapist’s natural compassion for James as
he journeyed through his painful life situation enriched
and infused the moment with a supportive, safe, andhealing ambience. The therapist’s self-compassion andcompassion for James concatenate to enable such ambience [31, 32]. In the synchronous co-synergy of these
therapeutic factors within the expanse of the therapist’s‘sky mirror’ awareness, a gradual and profound shift
began to occur in James. He began to relax into themoment, became less fixated on and defensive aroundhis emotional issues, and became more willing to contact his present-moment experience of past hurts anddisappointments.
Cognitively, the therapist’s three-tracked mind ofclinical reasoning was central to the occupational enablement process [41]. For the initial phase of therapy,
interactive reasoning took centre-stage in the foregroundwith procedural reasoning and conditional reasoning in
the background. As James became more emotionally,
cognitively, and attentionally engaged in the therapy
process over time, procedural reasoning in collaboration with James to identify and prioritise occupational
performance issues became prominent. Conditional andnarrative reasoning were employed as therapy focusedmore deeply on the changing circumstances of hislife [42]. Collaboratively, we engaged in occupational
storying of his life and occupational reconstruction ofa preferred future. Threads of his past and present were

woven together with threads of his passions, interests,
values, previous knowledge and expertise, emerging
worldview, sense of the sacred, and recent spiritualexperiences into a compelling vision of his future occupational self and world.
Flexibility of consciousness played a key role in
the process of occupational storying and reconstruction. Flexibly adopting various perceptual positions
on the part of the therapist enables a more complete
appreciation of the client’s life world [39, 40]. Taking asecond-person perspective required meta-awareness on
the part of the therapist – to not be fixated on and lostin the content of the therapist’s own consciousness. By
entering the client’s world through a dynamic flow ofawareness away from self to the other, the therapist wasable touch a place of mutuality where James’s life world
mattered and came alive for the therapist. In adopting athird-person perspective, the therapist simply observed
the dynamics and flow of dialogue as an impartial
witness. Taken together, the therapist’s ability to enact
shifts in perspectives fostered a healthy therapist-client
rapport.
After identifying James’ occupational performanceissues, the therapist selected a suitable frame of reference for working with him. This was done collaboratively with James, taking into account his cultural context,
personal inclinations, and choices, and with recognitionof cultural boundedness of both therapist and client. This
thus exemplifies the therapist’s knowledge of models
in context [7]. In so doing, the therapist consideredJames’s cultural metaphors, worldview, and preferencesin conjunction with various frames of reference, whichthemselves were cultural constructs. For James, issuesof spirituality pertaining to life direction, purpose, andspiritual practice were of profound significance to him.
He had a cosmopolitan outlook open to the diversity ofhuman cultures, having lived in the city for all his life.
He was particularly drawn to Asian philosophies andworldviews. Thus, the Psychospiritual Integration (PSI)
frame of reference [53], based on a multi-civilizational
perspective, was selected as the occupational therapy
approach that best fitted James.
Attentional balance is a state of consciousness
with varying degrees of intensity and depth. At its mostfundamental level, attentional balance is characterized
by mental stillness, simplicity, non-conceptuality, andbliss of physical and mental pliancy [23]. This conditionof attentional balance occurs only in the context ofdeep meditation. Effortlessly focused, alert yet relaxed,
the therapist with attentional balance can imbue his/her consciousness with a similitude of that stillness,
non-conceptuality, and blissful pliancy in the midstof a therapeutic relationship. In the case of James, theAsian J Occup Ther 14: 23−31, 2018

qualities of attentional balance suffusing therapist consciousness during therapy sessions facilitated unhurried,
non-controlling, non-outcome fixated tempo and textureof therapist-client communication.
Attentional balance stabilized and supported theabiding of the therapist in the open transparency of ‘sky
mirror’ awareness. As a result, James was able relax
sufficiently to unlearn old habit patterns of cognitionand emotion that blocked his life flow. He was amenable
to being artfully coached by the therapist to relearn his
enthusiasm for life. More than that, he was sufficiently
inspired by the therapist’s quality of attention to seek
meticulous mentoring in the intricacies of meditative
practice, which was at the heart of his spiritual journey
and practice.
Humour interspersed the therapeutic process andrelationship from beginning to the end [49, 50]. WhenJames first attended therapy, he was having difficulties
opening up and relaxing into the moment. Adopting
a genuine, light-hearted, and playful attitude to each
moment on the therapist’s part was conducive to placing
James at ease. At the same time, it was necessary to be
mindful of the appropriate times for humour and forseriousness. There would be times when the therapy
session would naturally burst forth in bouts of laughteras both therapist and James shared spontaneous playful
humour in the form of stories, anecdotes, jokes, andcaricatures.
These moments of therapeutic humour added atouch of grace and lightness to a sometimes emotionallyintense therapy process. On one particular therapy session, both therapist and James spontaneously decided
to have lunch together instead, enjoying a pleasant ridein James’s new sports car. This unplanned event created the opportunity for debriefing of therapy sessions
thus far and invited a sense of celebration of James’sachievements in spite of various odds. Thus, what began
as spontaneous humour became a therapeutic milestone.
Empathic attunement was frequently enacted by thetherapist during therapy [43, 45]. This was particularly
evident during the initial phase of therapy when many
past wounds and present conflicts surfaced for James. In
synergy with mindfulness, acceptance, self-compassion,presence, and echoes of attentional balance, the therapist
was able to mindfully and empathetically track James’
emotional ups and downs. This enabled the therapist to
adjust the speed, intensity, rhythm and energy levels oftherapy sessions so as pace James’s emotions. Connect­
ing with James on a basic emotional level was instru­
mental to helping James begin the process of innerheal­ing through emotional coaching.
Presencing was a therapeutic factor that became
more prominent and salient as therapy progressed [30].

Kang C29

As James grew in self-confidence and spiritual wholeness, he was increasingly focused on specific detailsof actualizing his occupational vision. There came atime when quietening of hearts, minds, and wills in the
ground of silence was beneficial to allow for emergenceof creative possibilities. James’ growing presence, mindfulness, and attentional balance afforded a conducivedialogical space for presencing to occur.

Conclusion
Sky Mirror Model grew out of a paradigm thatprivileges, accentuates, and valorizes being over doing
in its ontology and epistemology [10−12, 15, 27]. This
paradigm is especially salient in Asian conceptions oftruth and knowledge, especially in Buddhist and Taoist
philosophies [17, 29]. It is also present in Continental
strands of existential and humanist philosophy represented by Heidegger [25]. Biblical theologies of Barthand Torrance as cited in Molnar [35] articulates a paradigm of being as well. Nevertheless, these discourses
are marginalized relative to empirical positivist modesof thinking that currently dominate academic space.
Sky Mirror Model offers a perspective and space of
mutuality, where both therapist and client co-participate
in a profound process of healing, restoration, transformation, and growth. From Sky Mirror Model’s point ofview, analysis of client occupational performance issues,collaborative goal-setting, treatment planning andimplementation, and outcome evaluation are incidental
activities that flow from the dynamic and responsive
ground of sky-like, mirror-like being. As a therapeuticground of wise presence, compassion, and skill, such
depth and plenitude of being serves as a treasury of therapeutic benefit for all clients and a worthwhile vision of
professional growth and consciousness evolution for theoccupational therapist.
In line with Sky Mirror Model’s paradigm of unconditioned being, therapeutic presence is not so mucha skill or technique to be acquired but a breakthroughawareness to be discovered. In connection with this,the PSI frame of reference provides cogent suggestions
on how such breakthrough into sky-like, mirror-likeawareness can occur: through the enabling process oftransmission, instruction, coaching, co-presencing,and immersion in the realms of meta-occupation, nonoccupation, and trans-occupation [54]. These processes
are not achievements but facets of a seamless organic
process of spontaneous actualization of being beyond
contrived effort and self-occupied performance [55].

30

SKY MIRROR MODEL

References[1] Holmqvist K, Holmefur M, and Ivarsson AB. Therapeutic
use of self as defined by Swedish occupational therapists
working with clients with cognitive impairments following acquired brain injury: A Delphi study. Aust Occup
Ther J. 2013; 60: 48−55.
[2] Taylor R. The Intentional Relationship: Occupational
Therapy and the Use of Self. Philadelphia, PA: F. A.
Davis; 2008.
[3] Taylor RR, Lee SW, Kielhofner G, and Ketkar M. Therapeutic use of self: A nationwide survey of practitioners’
attitudes and experiences. Am J Occup Ther. 2009; 63(2):198−207.
[4] Punwar AJ, and Peloquin SM. Occupational Therapy
Principles and Practice. 3rd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 2000. 285 p.
[5] Kielhofner G, and Forsyth K. Therapeutic strategies forenabling change. In: Kielhofner G, editor. A Model of
Human Occupation: Theory and Application, 4th ed.
Baltimore, MD: Williams and Wilkins; 2008. p.110−125.
[6] Townsend EA, Beagan B, Kumas-Tan Z, Versnel J,
Iwama M, Landry J et al. (2013). Enabling: Occupational
therapy’s core competency. In: Townsend EA and Polatajko HJ, editors. Enabling Occupation II: Advancing an
Occupational Therapy Vision for Health, Well-being, andJustice through Occupation. Ottawa, ON: CAOT Publications ACE; 2013. p.109−133.
[7] Iwama MK. The Kawa model: Culturally relevant occupational therapy. Philadelphia, PA: Elsevier; 2006. 228 p.
[8] Hammell KW. Sacred texts: A skeptical exploration of theassumptions underpinning theories of occupation. Can J
Occup Ther. 2009; 76(1): 6−13.
[9] Hammell KW. Resisting theoretical imperialism in thedisciplines of occupational science and occupational
therapy. Br J Occup Ther. 2011; 74(1): 27−33.
[10] Analayo. Satipatthana: The Direct Path to Realization.
Cambridge: Windhorse Publications; 2003.
[11] Chagme K. A Spacious Path to Freedom: Practical
Instructions on the Union of Mahamudra and Atiyoga.
Commentary by Gyatrul Rinpoche. Wallace BA, trans.
Ithaca, NY: Snow Lion Publications; 1998.
[12] Dogen E. Beyond Thinking: A Guide to Zen Meditation.
K. Tanahashi, editors. Boulder, CO: Shambhala Publications; 2004.
[13] Hanh TN. Anger: Wisdom for Cooling the Flames. New
York, NY: Riverhead Books; 2001.
[14] Rabjam L. The Precious Treasury of the Basic Spaceof Phenomena. Barron R, translator. Junction City, KS:
Padma Publishing; 2001.
[15] Shengyen. Song of Mind: Wisdom from the Zen Classic
Xin Ming. Boulder, CO: Shambhala Publications; 2004.
[16] Wallace BA. Contemplative Science: Where Buddhism
and Neuroscience Converge. New York, NY: Columbia
University Press; 2007.
[17] Wallace, BA. Mind in the Balance: Meditation in Science,
Buddhism and Christianity. New York, NY: Columbia

University Press; 2009.
[18] Tsering GT. Relative Truth, Ultimate Truth. The Foundation of Buddhist Thought. Volume 2. Somerville, MA:
Wisdom Publications; 2008.
[19] Rabten G. The Mind and its Functions. Batchelor S,
translator and editor. Le-Mont Pelerin: Editions Rabten
Choeling; 1992.
[20] Yeshe LT. Becoming Your Own Therapist. Boston, MA:
Lama Yeshe Wisdom Archive; 2003.
[21] Rabjam L. The Practice of Dzogchen. 2nd ed. Talbot H,
editor. Thondup T, translator. Ithaca, NY: Snow Lion
Publications; 1996.
[22] Samararatne G. Watching thoughts and emotions. In
Bucknell R and Kang C, editors. The Meditative Mind:
Readings in the Theory and Practice of Buddhist Meditation. Richmond Surrey: Curzon Press; 1997. p.136−145.
[23] Wallace BA. The Attention Revolution: Unlocking thePower of the Focused Mind. Somerville, MA: Wisdom
Publications; 2006.
[24] Wallace BA. Minding Closely: The Four Applications of
Mindfulness. Ithaca, NY: Snow Lion Publications; 2011.
[25] Heidegger M. Being and Time. J, Macquarie and E. Robinson, Trans. London: SCM Press; 1962.
[26] Gadamer HG. Truth and Method. 2nd ed. London: Sheed
and Ward; 1989.
[27] Torrance TF. The Christian Doctrine of God: One Being
Three Persons. Edinburg: T & T Clark; 1996.
[28] Feuerstein G. The Yoga Tradition: Its History, Literature,
Philosophy and Practice.3rd ed. Chino Valley, AZ: Hohm
Press; 2001.
[29] Wong E. Being Taoist: Wisdom for Living a Balanced
Life. Boulder, CO: Shambhala Publications; 2015.
[30] Scharmer O. Theory U: Leading from the Future as It
Emerges. 2nd ed. Oakland, CA: Berrett-Koehler Publishers; 2016.
[31] Gilbert P. Compassion Focused Therapy: Distinctive
Features. London and New York, NY: Routledge Taylor
and Francis; 2010.
[32] Neff KD. Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and
Identity. 2003; 2: 85−102.
[33] Segal ZV, Williams JMG, and Teasdale JD. Mindfulnessbased Cognitive Therapy for Depression: A New Approach to Preventing Relapse. New York, NY and London:
The Guilford Press; 2002.
[34] Kabat-Zinn J. Full Catastrophe Living: How to Cope with
Stress, Pain, and Illness using Mindfulness Meditation.
New York, NY: Dell Publishing; 1990.
[35] Molnar PD. Faith, Freedom and the Spirit: The Economic
Trinity in Barth, Torrance and Contemporary Theology.
Downers Grove, IL: IVP Academic; 2015. 212 p.
[36] Wallace BA, and Shapiro SL. Mental balance and wellbeing: Building bridges between Buddhism and Western
psychology. Am Psychol. 2006; 61(7): 690−701.
[37] Torrance, TF. Incarnation: The Person and Life of Christ.
Walker RT, editor. Downers Grove, IL: IVP Press; 2008.
[38] Fenner P. Natural Awakening: An Advanced Guide

Asian J Occup Ther 14: 23−31, 2018

for Sharing Nondual Awareness. Richmond Hill, ON:
Sumeru Press; 2015.
[39] Bodenhamer BG, and Hall LM. The User’s Manual for
the Brain: The Complete Manual for Neuro-Linguistic
Programming Practitioner Certification. Rev. ed. Carmarthen, Wales: Crown House Publishing; 1999, 2000.
[40] Hall LM, and Bodenhamer BG. The User’s Manual for
the Brain, Vol. 2: Mastering Systemic NLP. Carmarthen,Wales: Crown House Publishing; 2003.
[41] Mattingly C, and Fleming MH. Clinical Reasoning:
Forms of Inquiry in a Therapeutic Practice. Philadelphia,
PA: F. A. Davis; 1994.
[42] Schell BAB, and Schell JW. Clinical and Professional
Reasoning in Occupational Therapy. Baltimore, ML:
Lippincott Williams and Wilkins; 2008. 446 p.
[43] Elliot R, Watson JC, Goldman RN, and Greenberg LS.
Learning Emotion-Focused Therapy: The Process Experiential Approach to Change. Washington, DC: American
Psychological Association; 2004.
[44] Kestly, TA. Presence and play: Why mindfulness matters.
Int J Play Ther. 2016; 25(1): 14−23.
[45] Greenberg LS. Emotion-Focused Therapy: Coaching
Clients to Work Through Their Feelings. Washington,
DC: American Psychological Association; 2002.
[46] Hayes SC, Strosahl KD, and Wilson KG. Acceptanceand Commitment Therapy: The Process and Practice of
Mindful Change. 2nd ed. New York, NY and London:
The Guilford Press; 2002.
[47] Kang C, and Whittingham K. Mindfulness: A dialogue

Kang C31

between Buddhism and clinical psychology. Mindfulness.
2010; 1: 161−173.
[48] Kang C. Experiences in meditation. In: The Meditative
Way: Readings in the Theory and Practice of Buddhist
Meditation. Bucknell R and Kang C, editors. Abingdon,
Oxon: Routledge Press; 1997. p.197−207.
[49] Adams F. Paradox and Play: A Study of Therapeutic
Humour and Psychosis. Unpublished doctoral dissertation. City University, London; 2013.
[50] Meyer KJ. The Relationship between Therapists’ Use of
Humour and Therapeutic Alliance. Unpublished doctoral
dissertation. The Ohio State University, Columbus, OH;
2007.
[51] Vergeer G. MacRae A. Therapeutic use of humor in occupational therapy. Am J Occup Ther. 1993; 47(8): 678−
683.
[52] Walsh R. Wise ways of seeing: Wisdom and perspectives.
Integral Review. 2015; 11(2): 156−174.
[53] Kang C. A psychospiritual integration frame of reference
for occupational therapy. Part 1: Conceptual foundations.
Aust Occup Ther J. 2003; 50: 92−103.
[54] Kang C. A psychospiritual integration frame of reference
for occupational therapy. Part 2: Transformative occupations and the change process. Hong Kong J Occup Ther.
2017; 29: 55−64.
[55] Kang C. A psychospiritual integration frame of reference
for occupational therapy. Part 3: Contemplative epistemic
foundations. Unpublished manuscript (under review);
2017.

■ORIGINAL ARTICLE

Occupation-Based Intervention to improveself-awareness in persons with acquired brain injury:
A single-case experimental design
Tomoko Miyahara1, Hajime Shimizu2, Shingo Yamane2, Hideaki Hanaoka2
12Community activity support center Wakaba

Institute of Biomedical & Health Sciences, Hiroshima University

Abstract: Introduction. Many researchers have indicated a need for interventions to improve self-awareness in people
with acquired brain injury, but the intervention methods are still in its developmental stage. The purpose of this study
was to investigate the effectiveness of an original awareness intervention using a single-case experimental design witheach subject’s individual occupation. Methods. We used the ‘alternating treatments design’, two types of interventions(ordinary occupational intervention and awareness intervention) were administered 10 times each (a total of 20 interventions) to four subjects. In the original awareness intervention, the subject participated in activities with self-prediction and self-evaluation before and after participating in activities and a therapist assists them to reinforce appropriate
strategies. The Japanese version of the Self-Regulation Skills Interview (SRSI) was administered after each occupation
experience, scores and responses for each of the ten interventions were compared between two interventions. Results.
Three of the four subjects showed significantly lower SRSI scores in the awareness intervention that indicated theirawareness were higher than the ordinary intervention and the details of their responses also indicated higher awarenessduring the awareness intervention. One subject who showed the lowest score of the Wechsler Adult Intelligence ScaleThird Edition (WAIS-III) in the subjects didn’t show any major change. Conclusion. The results would suggest theeffective of the awareness intervention. Future studies require a larger number of subjects, and investigation of the necessary level of subject’s cognitive functions.
Keywords: brain injury, occupational therapy, self-awareness, strategies(Asian J Occup Ther 14: 33−41, 2018)

Introduction
People with acquired brain injury often lack selfawareness, often making it difficult for them to recognise the compensatory strategies needed for performing
occupations and how to apply these strategies to acquire
occupational skills [1–4]. Importance had been placedon intervention that was focused on self-awareness, often using methods had been designed to educate the subject about his or her deficits directly. However, this typeof intervention has been criticised for causing the subject to lose motivation for the intervention or the subReceived: 17 April 2017, Accepted: 20 May 2018
Corresponding to: Tomoko Miyahara, Community activity support
center ‘Wakaba’, 5-3-43-106 Obayashi, Takarazuka, Hyogo 665-0034,
Japan
e-mail: takarazuka@t-wakaba.org©2018 Japanese Association of Occupational Therapists

ject’s sense of self-efficacy to decline [3, 5, 6]. Thus, inrecent years there has been increased focus on intervention methods that help the subject acquire self-awareness on his or her own initiative through the experienceof occupations [7–9]. These interventions are designed
so that the subject anticipates possible mistakes prior to
the start of the occupation and after the completion of
the occupation, reviews whether those anticipated mistakes were accurate [3, 4, 9]. Some previous studies on
this type of intervention method have used a single-casedesign [4, 10–12] but there is not sufficient evidence
to indicate that self-awareness is adequately improved.
Furthermore, many studies have followed a single-casedesign, there is a need to collect data from more experimental design studies [13].
In previous studies, subjects have anticipated possible mistakes and strategies by themselves, but wethought it was often difficult for subjects to review mistakes appropriately and plan appropriate strategies [1, 2,

34

INTERVENTION TO IMPROVE SELF-AWARENESS

9, 14]. It was reported that subjects overestimated theirability to perform tasks and did not significantly change
their ratings after the task experience [14]. So we considered that a more effective method would be one inwhich subjects attempt self-prediction while in addition
the therapist proposes and reinforces appropriate strategies at the same time. Furthermore, it was reported thatinterventions using errorless learning rather than trialand-error are more effective [15]. We considered it
better for subjects to review occupational experiences in which errors had been prevented by reinforcing
strategies rather than to review errors they made. So wewould propose an original awareness intervention inwhich subjects anticipate mistakes and a therapist assists
them to reinforce appropriate strategies prior to undertaking tasks; after completing their tasks subjects review
their performance.
The purpose of this study was to investigate the effectiveness of an original awareness intervention using
a single-case experimental design with each subject’s
individual meaningful occupation.

Methods
Subjects
The subjects were outpatients at a medical institution who satisfied the following criteria: (a) diagnosed by a physician as brain injury, with the onset ofsymptoms at least one year previously; (b) identified in
medical records and assessment as having impaired selfawareness; (c) physically able to perform the occupations; (d) possessed sufficient linguistic ability to allow
responses to questions and instructions; and (e) provided
their consent to participate in this study.
Procedure
General data collection. We collected data on age,sex, medical history, and neuropsychological assessments. We gathered data on each subject’s daily routinesand former lifestyle via interviews with family members, and data on regarding their habitual occupations
and the occupations they were interested in.
Pre-intervention assessments.
Neuropsychological assessment. We used two typesof assessment: The Japanese Version of the Wechsler
Adult Intelligence Scale-Third Edition (WAIS-III: [16])and Rivermead Behavioural Memory Test (RBMT: [17]).
The WAIS-III assesses a wide range of general cognitive
abilities. It’s Verbal IQ and Performance IQ scores aremeasures of information processing ability via language
and visual input, respectively. These two scores are used
to calculate the Full-Scale IQ. The mean IQ score is set
at 100.

The RBMT assesses the memory functions required
to complete activities of daily living. Its Profile score(maximum 24 points) is calculated from the raw scoresof three stages for each item, and the Screening score(maximum 12 points) is calculated from awarding 0 or 1
point in accordance with the standards of each item. The
test has cut-off points for different age groups.
Assessment of self-awareness. Self-awareness wasassessed using three types of assessments: an Awareness
Questionnaire (AQ: [18]), a Japanese version of theEveryday Memory Checklist (Memory Checklist: [19]),
and a Japanese version of the Self-Regulation Skills
Interview (SRSI: [20]).
The AQ is composed of 17 items related to movement, sensory perception, cognition, behaviour, andemotions. Subjects and others (such as the caregiverand therapist) estimate subject’s abilities on 5-point
scale ( from ‘poor’, 1 point, to ‘very good’, 5 points) as
compared to the premorbid condition. The larger thedifference between the two scores, the greater the selfawareness impairment.
The Memory Checklist assesses the frequency of
episodes in daily life in which the subject has problems
related to memory using 13 items. Subjects and others(such as the caregiver and therapist) estimate subject’s
abilities on 4-point scale ( from ‘Not at all’, 0 points, to‘Always’, 3 points). The larger the difference between
the two scores, the greater the self-awareness impairment. In this study, the AQ and Memory Checklist werescored by the subjects and by occupational therapists
who knew the subjects well, yet with no other involvement in the research. The attending therapists had atleast 15 years’ experience in practise the rehabilitationof people with acquired brain injury.
The SRSI is the Japanese-language version of theoriginal SRSI [20]. The following six items were investigated through interview questions: 1. problems thatarise in the subject’s daily life (emergent awareness),
2. the environment in which the problems arise (anticipatory awareness), 3. the motivation to learn strategies(motivation to change), 4. the generation of strategies(strategy awareness), 5. the use of strategies (strategyuse), and 6. the effectiveness of strategies (strategy
effectiveness). Responses were assigned scores of 0 to
10 points by a therapist who knew the subjects well,apart from the score for item 3, which was assigned onlyby the subject him or herself. Higher scores on item 3
indicated greater motivation to change. Lower scoreson all other items indicate greater self-awareness. Aftercalculating the scores for each item, we calculated thefollowing three component items: component I (Awareness of difficulty), which comprised the mean scoresfor items 1 and 2, component II (Motivation to change),Miyahara T et al.

Asian J Occup Ther 14: 33−41, 2018

which comprised the score for item 3, and component
III (Awareness of strategy), which comprised the meanscores for items 4 to 6.
Choice of individual occupations used in thisintervention. Based on the results of interviews, theprincipal author (the ‘researcher’) discussed with eachsubject the occupations associated with their interestand habit in order to acquire self-awareness and become
motivated through comparing the occupations to theirpremorbid abilities.
Implementing the intervention following thesingle-case experimental method (Fig. 1). Of thevarious single-case experimental methods, we used the‘alternating treatments design’ to avoid continuing one
intervention for a long period. We established two timesof baseline to assess the subject’s baseline occupation

35

abilities without presuming any strategies. Based onthese results, the researcher estimated strategies appropriate to the task of accomplishing the occupation. Afterthe baseline, we started two types of intervention: theOrdinary Intervention and the Awareness Intervention.
One baseline and intervention period was performed
each week, lasting between 40 and 60 minutes.
Analysis of the results.
Subject characteristics. We showed the subjects’general data and neuropsychological assessment andself-awareness assessment in a Table.
The intervention results.
Quantitative analysis: Comparison of the SRSI
scores derived from the ordinary and awareness interventions. We calculated The SRSI component scores foreach intervention. We compared The SRSI component

Baseline (2 times)
1. Perform occupation without presuming
any strategies (2 times).
2. After the 2times of baseline, the researcher
assesses the appropriate strategies.
↓

Ordinary Intervention (10 times)
1. Before starting the occupation:(i) Explain the procedure for theoccupation

Awareness Intervention (10 times)
1. Before starting the occupation:(i) Explain the procedure for theoccupation.
(ii) Subject anticipates difficulties andstrategies by him/herself.
(iii) If the subject had difficulty withdescribing the strategy,
the researcher proposed them.

2. Perform the occupation:(i) If the strategy is not used, indicate it
should be.
(ii) Provide assistance if difficulties
arise.

2. Perform the occupation:(i) If the strategy is not used, indicate it
should be.
(ii) Provide assistance if difficulties
arise.

3. After the occupation:(i) Administer SRSI.

3. After the occupation:(i) Self-assessment of mistakes andstrategies.
(ii) Administer SRSI.

Fig. 1. Procedures for the two types of intervention.
SRSI = The Japanese Version of the Self-Regulation Skills Interview. At baseline, the occupation was performed twice.
Subsequently, the two types of intervention were alternated, with each performed 10 times, 20 times in total (in accordance with the alternating treatments single-case design). Both interventions utilized the same occupation and strategies.

36

INTERVENTION TO IMPROVE SELF-AWARENESS

I to III scores for each of the ten interventions between
the Ordinary and Awareness Interventions using the Wilcoxon t-test. All tests were two-tailed with the standardof significance set at p < 0.05. The statistical analyses
were performed with IBM SPSS Statistics v 21.0J software.
Qualitative analysis: Comparison of the SRSI responses from the Ordinary and Awareness Interventions.
We subjected to qualitative analysis of the SRSI responses.
We compiled the statements made as part of component I (Awareness of difficulty) and component III(Awareness of strategy) in verbatim form, divided into
the smallest units with meanings, and classified into category units with similar meanings. Then we compared
two interventions to discover how many times eachcategory was verbalized. We didn’t analysed Component
II (Motivation to change) because this item was not partof the interviews; instead, the subjects used a self-rating
scale to conduct self-analysis.
To improve the validity of the analytical results, we
calculated The SRSI component scores and created categories by two experienced therapists, the researcher anda therapist who was not involved in this research andhad practised the rehabilitation of people with acquired
brain injury for more than 10 years. In cases in which
we were unable to agree on the details of a category, we
discussed the issues and continued the analysis until no
Table 1.

major differences in opinion remained.
Ethical considerations. Before commencing thisstudy, the researcher provided the subjects with written
descriptions of the purpose of the study and obtained
written consent from each subject. The written descriptions included the following three points. 1. The
researchers would consider both the psychological andphysical aspects of the subjects during their participation in the study. 2. When results were published, nodata that could identify the personal information would
be used. 3. The subjects could withdraw from the study
at any time, and their withdrawal from the study would
not result in any disadvantage to them. This study was
conducted with the approval of the Ethics Committee of
the Graduate School of Health Sciences of Hiroshima
University (No. 0901).

Results
Subject characteristics (Table 1)
Four subjects (four men, age range: 43–64 years)
met the inclusion criteria. The period since onset ranged
between 3.4 years and 14.0 years.
The RBMT results indicated that Subject A and
Subject D had severe memory impairment. The WAISIII results indicated that Subject D’s Verbal IQ and Performance IQ scores were pretty below average. Subject
B’s Full-Scale IQ scores were average, but the Perfor-

Subject characteristics, scores on Neuropsychological tests and self-awareness assessments.
Subject

A

B

C

D

Age
GenderDiagnosis
Time since injury (years)

62
Male
Encephalitis
4.0

43
Male
Traumatic brain injury
14.0

48
Male
Cerebral hemorrhage
3.4

64
Male
Traumatic brain injury
8.0

RBMT
Profile score (cut off score)
Screening score (cut off score)

8/24 (15/16)
2/12 (5/6)

16/24 (16/17)
7/12 (7/8)

20/24 (16/17)
8/12 (7/8)

8/24 (15/16)
2/12 (5/6)

WAIS-III
Verbal IQ
Performance IQ
Full-Scale IQ

96
102
98

105
92
100

99
113
106

88
88
87

AQ (score difference)

24

0

14

19

Memory Checklist (score difference)

−23

−9

−22

−16

SRSI
I (Awareness of difficulty)
II (Motivation to change)
III (Awareness of strategy)

10.0
1.0
10.0

9.0
10.0
9.0

9.0
0.0
8.0

8.5
3.0
8.5

Notes. RBMT = The Japanese Version of the Rivermead Behavioural Memory Test; WAIS-III = Wechsler Adult Intelligence Scale-Third
Edition; AQ = Awareness Questionnaire. AQ and Memory Checklist, Larger difference between the subjects and others scores indicatedlower self-awareness. SRSI = The Japanese Version of Self-Regulation Skills Interview.
Higher scores on component I and III indicated lower self-awareness.
Lower scores on component II indicated lower motivation to change.

Asian J Occup Ther 14: 33−41, 2018

mance IQ score was lower than the Verbal IQ score. The
AQ results indicated that three of the subjects (excluding
Subject B) tended to have high estimates of their own
abilities, and that all four subjects had high estimates of
their memory function on the daily memory checklists.
The SRSI results indicated that, according to component
I (Awareness of difficulty) and component III (Awarenessof strategy), all four subjects scored between 8.0 and
10.0, indicating a marked impairment. In the results forcomponent II (Motivation to change), Subject B scored
10, indicating a high degree of motivation to learn
coping strategies, whereas the other subjects scoredbetween 0.0 and 3.0, indicating a low degree of motivation.
Occupations used for each subject
Subject A indicated the need to be able to organise
his schedule. As he was unable to utilise compensatory
procedures effectively, we determined the occupation
using a paper of instructions as a compensatory procedure. We focused on his strong interest in cooking, andas his intervention time was short, established cooking
preparation as his occupation. The following three tasks
were to be performed each time: creating a recipe, removing the utensils required for cooking from the shelf,
and creating a list of ingredients to give to the researcher. The procedure for the occupation was indicated in
the paper of instructions, and the subject completed theoccupation in accordance with the instruct paper. The
following three strategies were determined: 1. Putting atick in the appropriate box after completing each task.
2. Reading the tasks listed in the instruct paper aloud
before beginning the task. 3. Setting an alarm to makesure he did not forget to give the ingredient list to theresearcher.
Subject B was told by his employer that he wasunable to perform occupations accurately and that heneeded to be taught repeatedly how to do them. He
therefore practiced performing occupations accurately
using notes. Prior to his injury, he worked with electric
power lines; as he was good at occupations that involved
measuring. So the occupation involved measuring thefloor dimensions of a space approximately 4 m2 in area
and accurately recording the figures. The following threetasks were his strategies: 1. Reading the figures on themeasure aloud. 2. Taking notes each time he measured
a location. 3. Once finished, checking to make sure his
figures were correct.
Subject C habitually used a schedule notebook, but
as he did not record enough information, he often forgot
appointments. He therefore practised accurately recording detailed information. Prior to his illness, his work
involved posting advertisements on the Internet. His

Miyahara T et al.

37

occupation therefore consisted of conducting approximately 15-minute Internet searches and recording thesesearches in detail. The following two tasks were his
strategies: 1. Taking notes contents each time the search
page changed. 2. Taking detailed notes of the details hefound.
Subject D presented marked memory impairment
and he was unable to utilise compensatory procedures
effectively. Thus, his occupation consisted of performing multiple tasks using a paper of instructions. Prior
to his injury, he often went out driving. His occupation
was to write down the roads he would drive on to reachdestinations he visited in the past using maps, calculating the required highway tolls and creating a drive plan.
The following four tasks were his strategies: 1. Putting
a tick in the appropriate box once a task was completed.
2. Reading the tasks listed in the instruct paper aloud
before beginning, 3. Setting an alarm to make sure hedid not forget to give the researcher his completed driveplan.
Results of the interventions
The total of intervention was that Subjects A for
8 months and 21 days, Subjects B for 6 months and 21days, Subjects C for 6 months and 6 days, and Subjects
D for 7 months and 11 days.
Differences between SRSI scores following thetwo interventions (Table 2).
Component I (Awareness of difficulty). Subjects A,
B, and C showed significant differences between their
SRSI scores following the two types of interventions ( p= 0.01 and p < 0.01, respectively), showing increased
awareness of problems of daily living after the Awareness Intervention.
Component II (Motivation to change). Subjects
A and C showed significant differences between theirscores for the two types of intervention ( p = 0.02 andp < 0.01, respectively), and they both showed an increased motivation to use strategies after the AwarenessIntervention. As Subject B’s self-assessment score wasalways 10 points, there could be no significant differences.
Component III (Awareness of strategy). Subjects
A and C showed significant differences between theirscores for the two types of interventions ( p = 0.03 andp < 0.01, respectively), and both showed increased
awareness of strategies after the Awareness Intervention.
Differences in SRSI responses between the twointerventions (Table 3).
Component I (Awareness of difficulty). Subject A’s
statements were classified into four categories, including‘Nothing in particular’ and ‘I will forget if it is not written down’. The category ‘Nothing in particular’ indicate

38

INTERVENTION TO IMPROVE SELF-AWARENESS

that he never has considered the problems in his daily
life. He made such statements only during Ordinary
Interventions and not during Awareness Interventions.
The categories ‘Forget it if it is not written down’ and‘Forget if not told’ indicated that he mentioned impaired
memory. These tended to occur more frequently during
the Awareness Interventions than during the Ordinary
Interventions.
Among Subject B’s statements some were categorised as ‘Nothing in particular’ and were seen only
during Ordinary Interventions. The categories ‘Unable
to focus on details’ and ‘Unable to do multiple tasks
simultaneously’ indicated he noticed decreased attention
and cognitive ability. Such statements tended to be more
frequent during Awareness Interventions.
Subject C always made statements categorised as‘Nothing in particular’ during Ordinary Interventions.
On the other hand, many of his statements during Aware­ness Interventions were categorised as ‘Memory is
declining’.
None of Subject D’s statements were categorisedas ‘Nothing in particular’. Although he made statements
categorised as ‘Tell the same thing repeatedly’ and‘Forgets what was said’, which referred to impaired
memory, he made few statements and there was no clear
difference in two interventions.
Component III (Awareness of strategy). Subject A’s
statements were classified into three categories, including ‘Nothing in particular’ and ‘Take notes’. The
category ‘Nothing in particular’ indicates that he could
not make any reference at all for problem strategies and‘Take notes’ indicates that he could state specific examples of strategies. During Ordinary Interventions, statements classified as ‘Nothing in particular’ were madethree times and those classified as ‘Take notes’ weremade six times; but during Awareness Interventions,only one statement classified as ‘Nothing in particular’
was made, whereas those classified as ‘Take notes’
reached nine times.
Among Subject B’s statements, the category‘Nothing in particular’ was made only during Ordinary
Interventions. The categories ‘Check occupations after
performing them’, ‘Take notes’ indicated that he could
refer to specific strategies and these were made more
often during Awareness Interventions. On the other
hand, statements that were inappropriate as strategies
and were categorised as ‘Studies disability in books’and ‘Forced to do what he or she was told’ were madeduring both types of intervention.
Subject C’s statements were classified as ‘Nothingin particular’ eight times during Ordinary Interventions
and as ‘Take notes’ twice. During Awareness Interventions, statements classified as ‘Nothing in particular’

Table 2. Mean and standard deviations for SRSI scores between two
interventions.
Subject

Component I (Awareness of difficulty)

A
B
CD
Subject

AI

7.5 (1.5)
8.3 (0.8)
9.8 (0.6)
8.5 (0.4)

6.3 (0.8)
7.6 (0.6)
8.5 (0.9)
8.2 (0.3)

Component II (Motivation to change)

A
B
C
D
Subject

OI

OI

AI

5.9 (1.3)
10.0 (0.0)
0.0 (0.0)
3.5 (1.6)

8.5 (0.9)
10.0 (0.0)
6.8 (4.1)
4.3 (1.4)

Component III (Awareness of strategy)

A
B
C
D

OI

AI

8.4 (3.6)
8.7 (0.9)9.7 (0.6)
9.0 (0.5)

8.0 (1.8)
8.6 (1.0)
8.4 (0.7)
8.7 (0.7)

P< 0.01**0.01*< 0.01**
0.06
P
0.02*
1.00
< 0.01**
0.15
P
0.03*
0.43
< 0.01**
0.09

Notes. O I = ordinary intervention; A I = awareness intervention Scoresfor each of the ten interventions were compared between the O I and
the A I using the Wilcoxon t-test, two-tailed.
Lower scores on component I and III indicated greater self-awareness.
Higher scores on component II indicated greater motivation to change.
*P < .05. **P < .01.

decreased to four and those classified as ‘Take notes’
increased to six.
Subject D’s statements characteristic of him was‘Contents unrelated to strategies’, which indicated that
responses unrelated to strategies were observed during
both types of intervention.

Discussion
SRSI score results (Table 2)
Our investigation of SRSI scores indicated that
Subjects A, B, and C had significantly lower scores (Itmeans good awareness) for component I (Awareness ofdifficulty) and subjects A and C had significantly lower
scores for component III (Awareness of strategy) during
the Awareness Interventions than during Ordinary Interventions. People with acquired brain injury can havea diminished ability to self-monitor in order to modify
their behaviour as a result of mistakes [5, 9], so it would
be necessary to include appropriate assistance provided
by the therapist.
Conversely, although Subject B became moredeeply aware of problems in daily life as a result ofAwareness Intervention, he did not become sufficiently
able to devise appropriate strategies for those problems.

Miyahara T et al.

Asian J Occup Ther 14: 33−41, 201839

Table 3. Comparison of SRSI statements between two interventions: numbers of Categories after the classification.
Component I [Awareness of difficulty]
Subject A

Component III [Awareness of strategy]
OI

AI

OI

AI

4
5
1
2

0
10
3
0

3
6
1

1
9
0

Subject B

OIAI

Subject B

OIAI

Nothing in particular
Unable to focus on details
Unable to do multiple tasks simultaneously
Unable to follow the procedure for the occupation

2
6
2
1

0
7
5
2

Nothing in particular
Check occupations after performing themTake notes
Does not think about details
Studies by reading books
Forced to do what he was told

2
1
1
2
2
2

0
2
4
1
1
2

Subject C

OIAISubject C

OIAI

Nothing in particular
Forget the time
Memory is declining
Poor handwriting

10
1
0
0

1
0
8
1

Nothing in particularTake notes

8
2

4
6

Subject D

OIAISubject D

OIAI

Tell the same thing repeatedly
Always asks his wife
Forget what he was told
No sense of meal times
In a daze

1
2
4
2
3

1
1
4
4
0

Nothing in particularTake notes
Does important thing firstContents unrelated to strategy

1
1
3
5

1
2
5
3

Nothing in particular
Forget if not written down
Forget if not told
Become idle

Subject A
Nothing in particularTake notes
Is told by someone

Notes. O I = ordinary intervention; A I =awareness intervention.
The SRSI statements for the two interventions were classified into categories.
The number of times each category appeared were compared between two interventions.
As the numbers of times a category appeared during one intervention were not the same, in some cases the total number of categories
exceeds 10.

Subject B had suffered traumatic brain injury and, as
shown by his Performance IQ of WAIS-III results, he
had diminished information processing and reasoning
abilities for specific situations. It has been noted that it
is more difficult to gain awareness of a strategy than togain awareness of problems [9]. The intervention period
in this study may be insufficient.
Subject D did not show any change in his awareness of problems or strategies even when AwarenessIntervention was used. Subject D had a markedly low
Verbal and Performance IQ in his WAIS-III results. Cognitive functions are divided into a seven-step pyramidand self-awareness requires the highest level of all cognitive functions [22]. It is possible that the task of using
Awareness Intervention to assess his own performanceand talk about himself were too difficult for Subject D.
SRSI responses (Table 3)
The results of our qualitative comparison of SRSI
responses indicated that for component I (Awareness ofdifficulty) and component III (Awareness of strategy),
three of the four subjects (A, B, and C) were often

unable to verbalise problems and strategies during theOrdinary Intervention, but they made numerous statements of disabilities and appropriate strategies during
the Awareness Intervention. As statements classified
as ‘Nothing in particular’ indicated that there was noawareness at all, the results of this study suggest thatthe intervention method utilised may be effective evenfor people who, like the subjects in this study, have extremely reduced self-awareness.
Although Subject B’s SRSI score for component III(awareness of strategy) showed no significant difference
between the two types of intervention (Table 2), he madea larger number of appropriate statements regarding
strategy during Awareness Intervention. We consideredthat this was because during both types of intervention
he made inappropriate statements, such as ‘Forced to
do what he was told’, which affected his SRSI score.
It has been reported that subjects with brain injuries,
especially traumatic brain injuries, have a diminishedability to judge situations [1, 2, 9] and sometimes makestatements designed to obscure mistakes to protect
themselves [9]. Subject B may have shown a tendency

40

INTERVENTION TO IMPROVE SELF-AWARENESS

to obscure mistakes.
Subject D showed no marked change in his statements because of the type of intervention. His statements
showed he often changed the topic from his responseto the question. This behaviour suggests that the task ofreviewing his task and conducting self-analysis was too
difficult for him.
Qualitative analysis of SRSI responses brought discovery of awareness that was not reflected in subjects’scores. Based on this, we obtained suggestions as to how
to utilize occupational therapy. For example, for Subject
B, further research is necessary whether continuingintervention will decrease the number of statements designed to obscure mistakes and increase the number ofstatements related to failures and appropriate strategies.
In addition, for Subject D, we discovered that it is necessary to find interventional methods other than having
the subject review himself and talk.
When assessing awareness, it would be more effective to use a method that directly assesses the subjects’statements rather than using only a questionnaire basedon the scale.
Usefulness of the tasks undertaken by the subjects(Table 3)
The tasks to be undertaken by each subject in thisstudy were determined based on the subjects’ previous
habits. Brain injury patients often shift the blame for
their failures and mistakes made during occupational
therapy [9]. Furthermore, even if patients recognize theirfailures during occupational therapy, they have difficultyin transferring this recognition to their daily lives [9].
The results of the present study indicate that the subjects
recognized their failure of tasks and the strategies employed to accomplish these tasks in the same manner asin their daily lives. In terms of the subjects’ recognitionof their disabilities, Subject A mentioned “I forget things
if I do not write them down,” Subject B mentioned“I cannot do multiple tasks simultaneously,” and Subject
C mentioned “My memory is declining,” which signified their recognition of their failures of tasks in their
daily lives (Table 3). As for recognition of strategies,
subjects A, B and D said they “take notes” and Subject
B said, “I check occupations after performing them,” asstrategies employed during tasks which were recognizedin the same manner as in their daily lives (Table 3).
These findings suggest that the subjects may have foundit easier to recognize their own problems by comparing
their present performance with their past performancethrough undertaking familiar tasks instead of shifting theblame for their failures. This is consistent with the findings of previous studies [4, 9]. However, in this study,
the tasks to be undertaken were determined through in-terviews between the subjects and researchers. Moving
forward, tasks will need to be determined using additional standardized methods of evaluation, including theCanadian Occupational Performance Measure.

Limitations and future studies
As this study had only a small number of subjects
and the intervention period was short , a future study
with a larger numbers of subjects and longer periodsof intervention is required . Of the four subjects in the
study, one did not show a sufficient effect resulting fromintervention. Thus, it is necessary to investigate the levelof cognitive function required for a subject to participate
in awareness intervention. Furthermore, the occupational tasks used in the intervention should be determinedusing standardised evaluations added to interviews.

Conclusion
The results of this study indicate the effectivenessof occupational therapy focused on awareness, thesubject anticipate his or her mistakes and strategies withthe therapist’ assistant prior to performing a task andreview performance after the task is completed. It would
be effective that the therapist assists them to reinforce
appropriate strategies prior to undertaking tasks. Furthermore, when assessing awareness, it would be more
effective to use a method that directly assesses subjects’statements and qualitative analysis rather than using
only a questionnaire based on the scale.

Acknowledgements
We would like to offer our sincere appreciation
to all the outpatient subjects at participating medical
institutions as well as to their family members and the
medical staff members.

Conflict of interest
None declared.

References[1] Sherer M, Bergloff P, Levin E, High WM Jr, Oden KE,
and Nick TG. Impaired awareness and employmentoutcome after traumatic brain injury. J Head Trauma
Rehabil. 1998a; 13(5): 52−61.
[2] Trudel TM, Tryon WW, and Purdom CM. Awareness of
disability and long-term outcome after traumatic brain
injury. Rehabil Psychol. 1998; 43(4): 267−81.
[3] Toglia J, and Kirk U. Understanding awareness deficits

Asian J Occup Ther 14: 33−41, 2018

following brain injury. NeuroRehabilitation. 2000; 15(1):57−70.
[4] Fleming JM, Lucas SE, and Lightbody S. Using occupation to facilitate self-awareness in people who haveacquired brain injury: A pilot study. Can J Occup Ther.
2006; 73(1): 44−55.
[5] Fleming JM, Strong J, and Ashton R. Cluster analysis ofself-awareness levels in adults with traumatic brain injury
and relationship to outcome. J Head Trauma Rehabil.
1998; 13(5): 39−51.
[6] Ownsworth TL, McFarland K, and Young RM. Selfawareness and psychosocial functioning following acquired brain injury: An evaluation of a group support programme. Neuropsychol Rehabil. 2000a; 10(5): 465−84.
[7] Fleming J. Metacognitive Occupation-Based Training inTraumatic Brain Injury. In: Derback S, editor. Handbookof Occupational Therapy Interventions, 20th ed. Switzerland: Springer Science+Buisiness Media; 2009; 225−31.
[8] Schmidt J, Lannin N, Fleming J, and Ownsworth T. Feedback interventions for impaired self-awareness following
brain injury: A systematic review. J Rehabil Med. 2011;
43(8): 673−80.
[9] Toglia J. A Dynamic Interactional Approach to Cognitive Rehabilitation. In: Katz N, editor. Cognition andOccupation across the life span, 2nd ed. United States ofAmerica: American Occupational Therapy Association;
2006; 29−72.
[10] McGraw-Hunter M, Faw GD, and Davis PK. The useof video self- modelling and feedback to teach cooking
skills to individuals with traumatic brain injury: A pilot
study. Brain Inj. 2006; 20(10): 1061−8.
[11] Ownsworth T, Quinn H, Fleming J, Kendall M, andShum D. Error self-regulation following traumatic brain
injury: A single case study evaluation of metacognitive
skills training and behavioural practice interventions.
Neuropsychol Rehabil. 2010; 20(1): 59−80.
[12] Toglia J, Johnston MV, Goverover Y, and Dain B. A
multicontext approach to promoting transfer of strategy
use and self-regulation after brain injury: An exploratory

Miyahara T et al.

41

study. Brain Inj. 2010; 24(4): 664−77.
[13] Schrijnemaekers AC, Smeets SM, Ponds RW, van Heugten CM, and Rasquin S. Treatment of unawareness of
deficits in patients with acquired brain injury: A systematic Review. J Head Trauma Rehabil. 2014; 29(5): E9−E30.
[14] Rotenberg-Shpigelman S, Rosen-Shilo L, and Maeir A.
Online awareness of functional tasks following ABI: The
effect of task experience and associations with underlying
mechanisms. NeuroRehabilitaion. 2014; 35(1): 47−56.
[15] Wilson BA. Case studies in neuropsychological rehabilitation. Oxford: Oxford University Press; 1999.
[16] Wechsler D. Technical Manual for the Wechsler Adult
Intelligence Scale. 3rd ed (in Japanese). Tokyo: NCS
Pearson, Inc; 2006.
[17] Kazui H, Watamori T, Honda R, Tokimasa A, Hakuno S,
and Mori E. The Validation of the Japanese Version of theRivermead Behavioural Memory Test–A test for everyday memory– (in Japanese). Shinkei Kenkyu No Shimpo.
2002; 46(2): 307−18.
[18] Sherer M, Bergloff P, Boake C, High W Jr, and Levin E.
The awareness Questionnaire: factor analysis structure
and internal consistency. Brain Inj. 1998b; 12(1): 63−8.
[19] Kazui H, Watamori T, Honda R, and Mori E. The Validation of a Japanese Version of the Everyday Memory
Checklist (in Japanese). No To Shinkei. 2003; 55(4):317−25.
[20] Miyahara T, Shimizu H, Hanaoka H, Yamane S, Kawa­
hara K, and Moriyama K. Development of Self-Regulation Skills Interview in Japan: reliability and validity (inJapanese). Sogo Rehabil. 2012; 40(8): 1117−26.
[21] Ownsworth TL, McFarland KM, and Young RM. Development and standardization of the self-regulation skills
interview (SRSI): A new clinical assessment tool for
acquired brain injury. Clin Neuropsychol. 2000b; 14(1):76−92.
[22] Ben-Yishay Y, and Diller L. Cognitive remediation in
traumatic brain injury. Update and issues. Arch Phys Med
Rehabil. 1993; 74(2): 204−13.

■ORIGINAL ARTICLE

The Impact of NEURO-15 on Performance Skills
and Related Factors in Activities of Daily Living
in Patients in the Chronic Phase of Stroke
Shingo Yamane1, Naoki Urushidani2, Hiroaki Tamashiro2, Takashi Kurushima2,
Masahiro Abo3, Takatsugu Okamoto2, Hideaki Hanaoka1
1Institute of Biomedical & Health Sciences, Hiroshima University
Nishi-Hiroshima Rehabilitation Hospital
3
The Jikei University School of Medicine
2

Abstract: NEURO-15 is a 15-day program that combines low-frequency repetitive transcranial magnetic stimulation(rTMS) and intensive occupational therapy for patients with chronic hemiparesis following stroke. Though the evaluation of upper-limb function has been used in the past to verify the effects of NEURO-15, the reacquisition of performance skills required for daily living has not been sufficiently evaluated.
Therefore, we conducted this study with an objective of clarifying the effectiveness of NEURO-15 from the viewpoint of regaining performance skills in daily living. We conducted the Assessment of Motor and Process Skills (AMPS)
and evaluated upper-limb function before and after NEURO-15 to evaluate performance skills in activities of dailyliving (ADL) in 20 patients with chronic hemiparesis after stroke.
Our results found that not only upper-limb function performance, but also ADL performance skills changed significantly. Significant difference was found in the Wolf Motor Function Test (WMFT) log performance time, the Simple
Test for Evaluating Hand Function (STEF), and paralysis of the dominant hand between those who improved and not
improved on the AMPS. In particular, the results of this study on dominant hands would be a key findings for applying
NEURO-15.
This study showed the effectiveness of NEURO-15 in patients with chronic hemiparesis after stroke from the viewpoint of regaining performance skills.
Keywords: NEURO-15; AMPS; cerebrovascular disease(Asian J Occup Ther 14: 43−52, 2018)

Introduction
Over 85% of stroke patients develop hemiplegia,
55−75% of who are left with upper-limb dysfunction [1].
Since upper-limb function is closely related to functionsof daily living, patients strongly desire improvement insuch functions, and approaches to improve upper-limb
functions in hemiplegic patients are actively being studied.
Received: 8 November 2017, Accepted: 10 July 2018
Corresponding to: Shingo Yamane, Department of Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi,
Minami-ku, Hiroshima-shi, Hiroshima 734-8553, Japane-mail: shingoyamane@hiroshima-u.ac.jp©2018 Japanese Association of Occupational Therapists

In recent years, many interventions have been attempted based on research involving the plasticity of thebrain and functional restructuring of cranial nerves, suchas robot-assisted training [2], constraint-induced movement therapy [3], repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation [4].
Among these approaches, rTMS has especially garneredattention due to its low invasiveness to subjects. rTMS
stimulates cerebral cortical neurons noninvasively andwithout pain, high-frequency rTMS enhances local
nerve activity at the stimulated site and low-frequency
rTMS works to inhibit local nerve activity at the stimulated site [5]. Using low-frequency rTMS, the unaffected side of the cerebrum is stimulated. By weakening theinterhemispheric interactions from the unaffected side to
the affected side of the cerebrum, functional compensa-

44

THE IMPACT OF NEURO-15 ON PERFORMANCE SKILLStion by the affected side of the cerebrum is promoted. In
recent studies, the application of rTMS in the treatmentof upper-limb function in patients with upper-limb
paralysis following the chronic stage of stroke has beenreported [6, 7]. Fregni et al. performed continuous
stimulation using rTMS for five days, and found it to besafe and effective in improving upper-limb function [7].
A meta-analysis of rTMS treatment for stroke patients
reported when comparing the low-frequency and thehigh-frequency rTMS in the subgroup analysis, theeffect size was 0.69 and 0.41, respectively, which meansthat low-frequency rTMS is superior [8].
Kakuda et al. developed NEURO-15 as a rehabilitation intervention that uses low-frequency rTMS for
patients in the chronic phase of stroke [9, 10]. NEURO15 is a 15-day intervention program that combines lowfrequency rTMS and intensive occupational therapy.
After increasing the plasticity of the cerebrum with
low-frequency rTMS, an occupational therapist uses
a one-on-one approach of intensive frequency to improve the use of the upper limbs in daily living throughintensive occupational therapy. High effectiveness of
NEURO-15 in patients in the chronic phase of stroke
has been reported in a randomized comparative study
that used constraint-induced movement therapy as thecontrol group [11]. Kakuda et al. [12] reported on thesafety and improved upper-limb function in a comparative study of over 1,700 stroke patients in the chronic
phase of stroke.
However, there are some issues with NEURO-15
that have not been sufficiently examined. Though theeffects of NEURO-15 on upper limb function have beenverified in the past, there has not been sufficient evaluation of the reacquisition of performance skills in dailyliving.
The objective of this study was to show the effectiveness of NEURO-15 for patients with chronic
hemiparesis after stroke from the viewpoint of not only
upper-limb functions but also regaining performanceskills in daily living. We examined if the significant
difference was found in upper limb function evaluation
with NEURO-15 and subject characteristics between
those who improved and not improved on the AMPS.

Methods
Schedule (Fig. 1)
Evaluation was performed on the day of admission, and treatment sessions began the following day.
NEURO-15 consisted of two sessions per day, one in
the morning and one in the afternoon. Patients were
given Sundays off, so 15 days of hospitalization resulted

Fig. 1. The schedule of 15-day combination protocol of low-frequency rTMS and intensive OT.
Two sessions of 20-min rTMS and 120-min Intensive OT are provided daily, except for Sundays and the days of admission/discharge.

Yamane S et al.

Asian J Occup Ther 14: 43−52, 2018

in 21 treatment sessions. Patients were re-evaluated the
day prior to discharge. Evaluations at admission and atdischarge were performed in the same order.
Subjects
In this study, we used the inclusion criteria for
NEURO-15 established by Kakuda et al. [9] (Table1). The study population consisted of 20 patients who
were hospitalized for NEURO-15 in our hospital for the
research period (2016.09.01−2017.08.31) approved by
the ethics committee of Nishi-Hiroshima Rehabilitation
Hospital. Table 2 shows the pre-treatment demographic
information. Nine males and 11 females were includedin the study, and had a mean age of 64.85 ± 8.52 years.
The mean time from stroke onset to study enrollment
was 37.95 ± 29.76 months. There were 11 individuals
with right hemiplegia and nine with left hemiplegia inthe study population. The Brunnstrom Recovery Stage(BRS) score for the upper limbs was III for two, IV
for eight, V for six, and VI for four subjects. The BRS
score for the fingers was III for four, IV for nine, and V
for seven subjects. All subjects lived in the area, were
not hospitalized or in a facility, and were independent
in terms of personal activities of daily living (PADL) in
their own homes.
Informed consent for the study and treatment was
obtained from all patients. The ethics committee of
Nishi-Hiroshima Rehabilitation Hospital approved theimplementation of this study.

ProcedureLow-frequency rTMS
For low-frequency rTMS, we used a coil in the
shape of a figure eight with a diameter of 70 mm anda Mag Pro R30 Mag Venture stimulator (Farum, Denmark). For each rTMS session, 1 Hz low-frequency
rTMS was applied to the motor cortex of the unaffectedside of the cerebrum for 20 minutes (1,200 stimulations
total). The area stimulated by the low-frequency rTMS
corresponded to the fingers in the motor cortex of theunaffected side of the cerebrum; in other words, the area
in which the motor evoked potential (MEP) of the firstdorsal interosseous muscle in the unaffected upper limb
was induced at its maximum on the electromyogram(EMG) (Fig. 2). The intensity of stimulation was set at
90% of the motor threshold (the minimum intensity ofstimulation able to induce MEP in the stimulation site).
Subjects were seated in reclining wheelchairs, and theirheads were fixed during stimulation.
Intensive occupational therapy
Intensive occupational therapy consisted of one 60-

45

Table 1. Inclusion Criteria for NEURO-15
1

More than 12 months since stroke onset.

2

Brunnstrom stage 3−5 for hand–fingers of the affected upper
limb (ability, at least subjectively, to flex the fingers with/without extension).

3

Attainment of a plateau state of motor functional recovery
at study entry. Confirmation of the plateau state of recovery
established by an experienced physician and occupational therapist.

4

History of a single stroke only (no bilateral cerebrovascularlesions).

5

No history of seizure. No documented epileptic discharge on
the pretreatment electroencephalogram.

6

No cognitive impairment (i.e., pretreatment Mini Mental State
Examination Score of 26).

7

High level of motivation toward rehabilitation.

8

Sufficiently understands the theory and content of NEURO-15,
and consents to its implementation.

9

Independent ADL at home.

10 No pathological conditions referred to as contraindications for
rTMS in the guidelines suggested by Wasserman (e.g. cardiac pacemakers, intracranial implants, implanted medication
pumps, epilepsy, pregnancy)13).

Table 2. Demographic data of the study population
M ± SD/N (%)
Age at admission (years)
GenderMale
FemaleDiagnosis
Cerebral infarction
Intracerebral hemorrhage
Affected side
Right
Left
Brunnstrom stage
upper limb
III
IV
V
VI
hand–fingers
III
IV
V
Handedness
Right
Left
Hemiparesis of dominant upper limb
Time since stroke onset (months)

64.85 ± 8.52
9 (45)
11 (55)8 (40)
12 (60)11 (55)9 (45)
2 (10)
8 (40)
6 (30)
4 (20)
4 (20)
9 (45)
7 (35)
18 (90)2 (10)
11 (55)37.95 ± 29.76

Values are numbers (%) or mean ± standard deviation.

minute individual occupational therapy session and one
60-minute voluntary training session. The objective of
the intensive occupational therapy was to improve thefunction of the paralyzed upper limb and reacquire theperformance skills required for activities of daily living(ADL). The training was determined by an occupational
therapist upon obtaining relevant information from physicians, nurses, and medical social workers, and consid-

46

THE IMPACT OF NEURO-15 ON PERFORMANCE SKILLS

Assessment Tools

Cz

Slightly forward

Approximately 2-5 ﬁnger breadths

Fig. 2. Stimulation site for low frequency rTMS.
Stimulate the motor center for the hand and finger
which is located about 2−5 finger breadths away fromCz (vertex) based on the international 10−20 method,and slightly forward.

ering the needs, living condition, and degree of disorderof the subjects. Training differed slightly depending on
the skills and conditions of the subjects. However, thepurpose of the training was common, and the durationof training was the same for all subjects.
In actual individual occupational therapy, an occupational therapist with at least five years of experience
working with cerebrovascular disease patients worked
with patients one-on-one, while a team of occupational
therapists worked with each patient. The occupational
therapists discussed the development of each program.
Specific training was based on the evaluation of skeletalalignment and muscle tone of the upper limbs and torso
for each subject, and aimed to improve support for theupper limbs and extend the functional range of motion
in joints. For the upper extremities, group flexion andextension exercises and movements that separated thefingers were used depending on the characteristics of thesubject. As the upper limb function of subjects changed,
training was focused on upper limb use in actual dailyliving.
After individual occupational therapy, subjects
performed voluntary training for 60 minutes in an
individual booth within the occupational therapy room.
The occupational therapist and subjects discussed thecreation of the individual occupational therapy plan.
Specifically, training began with stretching as warm up,
followed by actual training using daily items related to
ADL and APDL.

Upper limb evaluation
Evaluation of the upper limbs included upper limb
items of the Fugl-Meyer Assessment (FMA), the Wolf
Motor Function Test (WMFT), the Simple Test for Evaluating Hand Function (STEF), and the Modified Ashworth Scale (MAS) for elbow flexors, wrist flexors, andfinger flexors, and was implemented by the occupational
therapist in charge.
The FMA is a comprehensive evaluation battery for
motor function that can comprehensively evaluate upperand lower limb dysfunction from voluntary movement,balance, sensation, and range of motion. The reliability
and validity of the FMA have been confirmed [14]. In
this study, we implemented 33 items from upper limb
items: A (shoulder, elbow, and forearm, with a maximum
score of 36); B (wrist, with a maximum score of 10); C(hand, with a maximum score of 14); and D (cooperationand speed, with a maximum score of 6). As each item
was rated on a three-point ordinal scale (0 = cannot perform, 1 = can perform partially, 2 = can perform fully),
the maximum motor performance score for the upper
limbs was 66 points.
The WMFT is an objective evaluation created toevaluate functions of the paralyzed upper limb before
and after CIMT. The reliability and validity of the
WMFT has been confirmed [15]. It consists of 15 items:
6 motor items and 9 object operation items. The time
taken for each task was measured and the total time usedas the score. However, since the total time score needed
to perform the 15 tasks has bias, in this study, similar
to Wolf et al. [16], we used the natural logarithm of thetime taken to perform tasks. The quality of such movements can be evaluated on a six-point scale, such as the
Functional Ability Scale (FAS), which ranges from 0 (noattempt) to 5 (normal movement).
The STEF measures the time taken to move or operate 10 different types of objects, and evaluates using
a ten-point scale to calculate the total score. It is widelyused as a highly reliable test for patients who are in theprocess of recovering upper limb function [17]. The
scores range from 10−100.
The MAS is a semi-quantitative scale that evaluates
the degree of spasticity. Bohannon improved the scale
developed by Ashworth as a six-step evaluation methodby adding “grade +1”, and many have reported its highreliability [18]. In this study, we measured elbow flexors, wrist flexors, and finger flexors and converted “1+”in MAS to 1.5 according to the method of Kaji et al. [19].
Higher scores indicate higher muscle tone.

Yamane S et al.

Asian J Occup Ther 14: 43−52, 2018

Evaluation of performance skills in ADL
In this study, to evaluate performance skills in dailyliving, we used the assessment of motor and processskills (AMPS) [20], which evaluates performance skills
in PADL and instrumental activities of daily living(IADL). The AMPS has been standardized using multifaceted Rasch analysis, and there are no significant differences in mean ADL ability measure (logits) in AMPS
between persons with right or left hemispheric stroke,
despite hemisphere-specific differences in underlying
cognitive and physical impairments [21].
The AMPS has 125 daily living tasks that are standardized at different difficulties, and subjects choose andperform at least two tasks they feel are familiar fromtheir daily living. The evaluator evaluates 16 motor skill
items and 20 process skill items on a four-point scale
through observation. Motor skill items are a group ofskill items that indicate the action of moving themselves
or objects when interacting with objects and the environment during tasks. Process skill items are a groupof skill items that indicate the actions of choosing andusing tools and materials, logically advancing actions
and tasks, and correcting actions when there is a problem. Results of the AMPS are indicated in the ADL
motor scale and the ADL process scale. These measuresreflect the relative impact of motor and process skill
deficits on IADL performance [20, 21]. The cut-off
value of effectiveness for the ADL motor scale was 2.0
logit, and 1.0 logit for the ADL process scale. A changeof 0.3 logit indicates that there was a clinical and observational change. A change of 0.5 logit indicates that
there was a statistically significant change [21]. Evaluation of the AMPS was performed by an occupational
therapist certified in AMPS evaluation and not involved
with the implementation of Neuro-15 at our hospital.
Analysis
To confirm the effectiveness of NEURO-15, weused the Wilcoxon signed-rank test and examinedchanges in performance skills in ADL and upper limb
function before and after NEURO-15.
To confirm what subject characteristics were involved with changes in performance skills in ADL, weassigned subjects who had a change in the ADL motor
scale of 0.3 logit or more (clinical and observationalchange) into the changed group, and those who did notshow such changes into the unchanged group.
We then examined if the significant difference wasfound in changes in upper limb evaluation and subject
characteristics (age, gender, time from stroke onset,
BRS, and paralysis in the dominant hand) between those
who improved and not improved on the AMPS using theMann-Whitney U test, Fisher’s exact probability test, or

47

Student’s t-test.
For changes in upper limb evaluation, we subtracted the values before and after the implementation sothat positive numbers indicated improvement (for the
WMFT log performance time, the amount of change =value after implementation – value before implementation). All statistical analyses were performed using
SPSS version 19.0 (SPSS Inc., Chicago, IL).

Results
Changes before and after implementation of NEURO-15(Table 3)
The ADL motor scale of the AMPS increased significantly ( p < 0.001). Figure 3 shows individual changes. The ADL motor scale index of the AMPS indicatedthat two subjects were within the range of questionable
to mild clumsiness and/or increased physical effort(1.7−1.9 logit) and 18 subjects were within the range ofmild to moderate clumsiness and/or increased physicaleffort or fatigue (0.5−1.6 logit) before implementationof NEURO-15. After NEURO-15, six subjects were
within the range of questionable to mild clumsiness and/or increased physical effort (1.7−1.9 logit) and 14 subjects were within the range of mild to moderate clumsiness and/or increased physical effort or fatigue (0.5−1.6
logit).
The ADL process scale of the AMPS increased
significantly ( p = 0.011). Data are presented in Fig. 3.
Before the implementation of NEURO-15, two subjects
were within the range of efficient (1.3−2.1 logit), 16
subjects were within the range of questionable inefficiency/disorganization (1.0–1.2 logit), and two subjects
were within the range of questionable to mild inefficiency/disorganization (0.7−0.9 logit). After NEURO15 implementation, two subjects were within the rangeof efficient (1.3−2.1 logit), 17 subjects were within therange of questionable inefficiency/disorganization (1.0−
1.2 logit), and one was within the range of questionable
to mild inefficiency/disorganization (0.7−0.9 logit).
The total score of the FMA increased significantly( p < 0.001) and the category A, B, C, and D scoreschanged significantly ( p = 0.003, p = 0.034, p = 0.004,
and p = 0.046, respectively).
The WMFT log performance time decreased significantly ( p = 0.001) and the FAS score increased significantly ( p = 0.001). The total STEF score also increased
significantly ( p = 0.04). The elbow joint, wrist, andfingers in the MAS score showed a significant decreasein muscle tone ( p = 0.008, p = 0.015, p = 0.001, respectively).

48

THE IMPACT OF NEURO-15 ON PERFORMANCE SKILLS

Table 3. Changes in evaluation items before and after Neuro-15
At admission

At discharge

P-value*

Evaluation of performance skills in daily living
AMPS
ADL motor scale
ADL process scale

1.16 ± 0.37
1.09 ± 0.13

1.40 ± 0.34
1.14 ± 0.11

< 0.001*
0.011*

Upper limb function evaluation score
The FMA
The total scorecategory A
category B
category C
category D

43.90 ± 12.55
26.65 ± 5.76
5.10 ± 3.73
9.55 ± 3.79
2.65 ± 1.81

46.35 ± 12.21
27.70 ± 5.23
5.40 ± 3.73
10.40 ± 3.44
2.85 ± 1.81

< 0.001*
0.003*
0.034*
0.004*
0.046*The WMFT log performance time
The FAS score2.98 ± 1.41
42.00 ± 14.80

2.74 ± 1.47
43.85 ± 14.49

0.001*
0.001*The total STEF score20.30 ± 31.98

22.75 ± 33.71

0.041*The MAS scoreelbow flexors
wrist flexors
finger flexors

1.15 ± 0.76
1.13 ± 0.74
1.18 ± 0.85

0.88 ± 0.65
0.88 ± 0.67
0.85 ± 0.69

0.008*
0.015*
0.001*

Values are number or mean±standard deviation.
AMPS, Assessment of Motor and Process Skills; FMA, Fugl-Meyer Assessment; WMFT, Wolf Motor
Function test; FAS, Functional Ability Score; STEF, The Simple Test for Evaluating Hand Function;
MAS, Modified Ashworth Scale.
By Wilcoxon signed-rank test.
*P values < 0.05 were considered statistically significant.

2

ADL motor scale－Changed group(n=10)---Unchanged group(n=10)
Questionable to mild clumsiness
and/or increased physical eﬀort

1.4
1.2

1.4

Eﬃcient- timely and spatially organized

1.3

1.8
1.6

ADL Process scale （n = 20）

Questionable ineﬃciency/disorganization
Mild tomoderateclumsiness and/orincreased
physicaleﬀort orfatigue

1.2

1.1

1

1

0.8

Questionable to mild
ineﬃciency/disorganization

0.9

0.6
0.4
beforeafter

Fig. 3. Changes in ADL Motor/Process Scale.

0.8

beforeafterAsian J Occup Ther 14: 43−52, 2018

Comparison of changes in upper limb evaluation andsubject characteristics between the changed group andthe unchanged group (Table 4)
The changed group in the AMPS scores tended tobe those with paralysis of the dominant hand comparedwith the unchanged group, and whether the dominant
hand was paralyzed was significantly involved with thechanges in performance skills ( p = 0.035). In the upper
limb evaluation, there was no significant difference
between the two groups before the implementation of
NEURO-15; however, after NEURO-15 the changed
group had shorter WMFT log performance times compared to the unchanged group, while the total STEF
scores increased. Results of these two upper-limb
function evaluations were significantly involved withchanges in performance skills ( p = 0.006 and p = 0.039,
respectively).

Discussion
Effects of NEURO-15 on upper limb function and performance skills in daily living
For upper limb evaluation, A, B, C, D, the total
FMA score, the time taken to perform tasks in the
WMFT, FAS, and the STEF, and the MAS score showedsignificant changes before and after the implementationof NEURO-15, showing improvement in upper limb
function as a result of NEURO-15. These results are
similar to those found in previous studies [9, 10].
There was significant improvement in the ADL
motor scale in the AMPS after the implementation of
NEURO-15, and ten of 20 subjects showed a 0.3 logit
or higher change indicative of an observational change.
NEURO-15 aims to improve the use of upper limbs
in daily living through intensive occupational therapy
after increasing the plasticity of the cerebrum throughlow-frequency rTMS; therefore, in the AMPS, thescores of the skill items for the patients’ movements ofthemselves or objects when interacting with objects andthe environment during performing tasks are reflected[21]. Thus, our results confirm that there were changes
in the ADL motor scale. The reason that improvement
was observed in the performance skills in addition to theupper limb function was because the intervention approach that values the use of upper limbs in actual dailyliving in response to changes in upper limb function ofsubjects through intensive occupational therapy waseffective.
On the other hand, though there was significant
improvement in the process skill items after NEURO15, none of the subjects met the 0.3 logit change thatindicates both a clinical and an observational change.
Process skill items are sensitive to whether subjects can

Yamane S et al.

49

live independently at home [21]. Subjects in this study
lived in the area, were not hospitalized or in a facility,
and received NEURO-15 of their own volition; thus,
they were able to choose the required two-week hospitalization on their own. In actuality, the mean ADL
process scale of subjects before NEURO-15 was 1.09
logit, which was above the cut-off value of effectiveness(1.0 logit) [21]. Therefore, the high skill level present
prior to NEURO-15 and the ceiling effect both impacted
the poor change in the scores.
As such, NEURO-15 not only improved upper
limb function for patients with chronic hemiparesis after
stroke, but also had effects on the reacquisition of performance skills in daily living.
Significant difference in the change in upper limb function evaluation and subject characteristics between thechanged group and the unchanged group
Our results showed that changes in the WMFT
log performance time and the total STEF score weresignificantly larger in the changed group compared withthe unchanged group, and were involved in upper limb
function evaluation. The characteristics of upper-limb
function evaluation used in this study were as follows:
FMA calculates the total score by comprehensively evaluating upper limb function, while MAS is an evaluation
specialized for muscle tone. The WMFT and STEF arecharacterized by calculating the score by measuring thetime to perform specific tasks, including elements suchas pinching and operating using actual objects, as well
as reaching into various spaces [14, 16]. On the other
hand, the ADL motor scale of the AMPS scores thequality of performance, such as physical effort and awkwardness, through the observation of specific tasks; thus,
the time taken to perform these tasks are reflected in thescores. In other words, the reason that only the WMFT
log performance time and the STEF showed significant
differences between the two groups was because theevaluation method measured the time taken to perform
specific tasks. Therefore, to improve performance skills
in ADL in future interventions, actual objects should be
used in intensive occupational therapy, and the speed ofperformance should be taken into consideration.
Compared with the unchanged group, the changed
group had significantly more subjects with a paralyzed
dominant hand. Subjects without paralysis in the nondominant hand, who were common in the unchanged
group, probably used their dominant hand to performtasks in daily living, and were already capable of performance skills in daily living. Therefore, compared to subjects whose dominant hand was paralyzed, the impact ofimproved upper limb function by NEURO-15 was difficult to observe in the ADL motor scale of the AMPS.

50

THE IMPACT OF NEURO-15 ON PERFORMANCE SKILLS

Table 4. Comparison of changes in upper limb evaluation and subject characteristics between the changed group and the unchanged group
The changed group (n = 10)

The unchanged group (n = 10)

P-value*

Males
Females

5
5

4
6

0.5

Handedness

Right
Left

9
1

9
1

0.763

Affected side

Right
Left

7
3

4
6

0.185

Side of upper limb hemiparesis

Dominant handNon dominant hand

8
2

3
7

0.035*

III
IV
V
VI

1
2
4
3

1
6
2
1

0.300

III
IV
V
VI

2
4
2
2

2
5
2
1

0.931

Age at admission(years)

65.80 ± 7.89

63.90 ± 9.43

0.879Time since stroke onset (months)

28.60 ± 23.98

47.30 ± 33.19

0.130

Upper limb function evaluation score before Neuro-15
The FMA
The total scorecategory A
category B
category C
category D

44.90 ± 14.18
26.90 ± 6.47
5.40 ± 3.72
9.70 ± 4.06
3.00 ± 1.76

42.90 ± 11.36
26.40 ± 5.30
4.80 ± 3.91
9.40 ± 3.72
2.30 ± 0.189

0.762
0.820
0.732
0.760
0.415

The WMFT log performance time
The FAS score2.74 ± 1.45
45.00 ± 15.08

3.22 ± 1.41  39 ± 14.67

0.545
0.430

The total STEF score23.60 ± 31.44

17.00 ± 33.86

0.302

The MAS scoreelbow flexors
wrist flexors
finger flexors

1.05 ± 0.80
1.15 ± 0.85
1.15 ± 0.88

1.25 ± 0.75
1.10 ± 0.66
1.20 ± 0.86

0.558
0.638
0.968

JASID
amount of use
quality of movement

37.49 ± 15.66
39.08 ± 19.46

47.11 ± 31.76
39.66 ± 22.47

0.791
0.880

Changes in upper limb function evaluation score before and after Neuro-15
The FMA
The total score3.10 ± 2.81
category A
1.40 ± 1.51
category B
0.40 ± 0.52
category C
1.00 ± 1.33
category D
0.20 ± 0.42

1.80 ± 1.62
0.70 ± 0.95
0.20 ± 0.63
0.70 ± 0.82
0.20 ± 0.42

0.374
0.259
0.194
0.775
1.000

The WMFT log performance time
The FAS score0.37 ± 0.27
2.60 ± 2.88

0.09 ± 0.21
1.10 ± 1.73

0.006*
0.131

The total STEF score5.10 ± 4.98

−0.20 ± 3.36

0.039*The MAS scoreelbow flexors
wrist flexors
finger flexors

0.25 ± 0.49
0.25 ± 0.42
0.20 ± 0.26

0.30 ± 0.35
0.25 ± 0.35
0.45 ± 0.44

0.461
0.823
0.147

Demographic data
GenderBrunnstrom Stage (at admission)
Upper limb

Hand-fingers

Values are number or mean ± standard deviation.
FMA, Fugl-Meyer Assessment; WMFT, Wolf Motor Function test; FAS, Functional Ability Score; STEF, The Simple Test for Evaluating Hand
Function; MAS, Modified Ashworth Scale.
By the Student’s t-test or Fisher’s exact probability test or Mann–Whitney U test.
*P values < 0.05 were considered statistically significant.

Asian J Occup Ther 14: 43−52, 2018

There is a possibility that subjects whose non-dominant
hand was paralyzed need further strategies by which totransfer improved upper limb function to skills in dailyliving.
Limitations
The limitations of this study were the lack of acontrol group, since subjects were all voluntarily hospitalized for NEURO-15, the variation of the characteristics of subjects and the mixture of stroke patients withdifferent levels of motor abilities and side of heimplegia.
The effect of NEURO-15 in terms of upper limb
improvement was high in subjects whose BRS wasfour. Since there were a small number of subjects inthis study, we were unable to make comparisons basedon BRS. In the future, the number of subjects should
be increased in order to examine if the contribution of
NEURO-15 in the reacquisition of performance skills in
daily living changes depending on the degree of paralysis.

Conclusions
We were able to show the effectiveness of NEURO15 for patients with chronic hemiparesis after stroke,
not only for the improvement of upper limb function but
also for the reacquisition of performance skills in dailyliving. We also showed that the significant difference
was found in improved task performance speed andparalysis of the dominant hand between those who
improved and not improved on the performance skills in
ADL after NEURO-15.

Declaration of interests
The authors report no conflicts of interest. The
authors alone are responsible for the content and writingof the present paper.

Acknowledgements
On behalf of the NEURO investigators of the
Nishi-Hiroshima Rehabilitation Hospital, the authors
gratefully acknowledge the support and participation of
the patients in the present study.

References[1] Yavuzer G, Selles R, Sezer N, Sütbeyaz S, Bussmann JB,
Köseoğlu F, et al. Mirror therapy improves hand function
in subacute stroke, A randomized controlled trial. Arch
Phys Med Rehabil. 2008; 89(3): 393−8.
[2] Lum PS, Burgar CG, Shor PC, Majmundar M, Van der

Yamane S et al.

51

Loos M. Robot-assisted movement training comparedwith conventional therapy techniques for the rehabilitation of upper-limb motor function after stroke. Arch Phys
Med Rehabil. 2002; 83(7): 952−9.
[3] Wu CY, Chen CL, Tsai WC, Lin KC, Chou SH. A randomized controlled trial of modified constraint-induced
movement therapy for elderly stroke survivors: changes
in motor impairment, daily functioning, and quality oflife. Arch Phys Med Rehabil. 2007; 88(3): 273−8.
[4] Hummel F, Celnik P, Giraux P, Floel A, Wu WH, Gerloff
C, et al. Effects of non-invasive cortical stimulation on
skilled motor function in chronic stroke. Brain. 2005;
128(Pt 3): 490−9.
[5] Muellbacher W, Ziemann U, Boroojerdi B, Hallett M.
Effects of low-frequency transcranial magnetic stimulation on motor excitability and basic motor behavior. Clin
Neurophysiol. 2000; 111(6): 1002−7.
[6] Mansur CG, Fregni F, Boggio PS, Riberto M, GallucciNeto J, Santos CM, et al. A sham stimulation-controlled
trial of rTMS of the unaffected hemisphere in stroke
patients. Neurology. 2005; 64(10): 1802−4.
[7] Fregni F, Boggio PS, Valle AC, Rocha RR, Duarte J, Ferreira MJ, et al. A sham-controlled trial of a 5-day courseof repetitive transcranial magnetic stimulation of theunaffected hemisphere in stroke patients. Stroke. 2006;
37(8): 2115−22.
[8] Wan-Yu Hsu, Chia-Hsiung Cheng, Kwong-Kum Liao,
I-Hui Lee and Yung-Yang Lin. Effects of Repetitive
Transcranial Magnetic Stimulation on Motor Functions inPatients With Stroke: A Meta-Analysis. Stroke 2012; 43:
1849−57.
[9] Kakuda W, Abo M, Kaito N, Ishikawa A, Taguchi K,
Yokoi A. Six-day course of repetitive transcranial magnetic stimulation plus occupational therapy for poststroke patients with upper limb hemiparesis: a case series
study. Disabil Rehabil. 2010; 32(10): 801−7.
[10] Kakuda W, Abo M, Shimizu M, Sasanuma J, Okamoto
T, Yokoi A, et al. A multi-center study on low-frequency
rTMS combined with intensive occupational therapy for
upper limb hemiparesis in post-stroke patients. J Neuroeng Rehabil. 2012; 9(1): 4.
[11] Abo M, Kakuda W, Momosaki R, Harashima H, Kojima
M, Watanabe S, etal. Randomized, multicenter, comparative study of NEURO versus CIMT in poststroke patientswith upper limb hemiparesis: the NEURO-VERIFY
Study. Int J Stroke. 2014; 9(5): 607−12.
[12] Kakuda W, Abo M, Sasanuma J, Shimizu M, Okamoto T,
Kimura C, et al. Combination treatment of low-frequency
rTMS and Intensive Occupational Therapy for Poststroke Upper limb hemiparesis: a 6-year Experience ofMore Than 1700 Japanese Patients. Transl Stroke Res.
2016; 7(3): 172−9.
[13] Wassermann EM. Risk and safety of repetitive transcranial magnetic stimulation: Report and suggested guidelines
from the international workshop on the safety of repetitive transcranial magnetic stimulation, June 5−7, 1996.
Electroencephalogr Clin Neurophysiol. 1998; 108(1): 1−

52

THE IMPACT OF NEURO-15 ON PERFORMANCE SKILLS

16.
[14] Platz T, Pirkowski C, van Wijck F, Kim IH, di Bella P,
Johnson G. Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer
Test, action research arm test and box and block test: a
multicenter study. Clin Rehabil. 2005; 19(4): 404−11.
[15] Morris DM, Uswatte G, Crago JE, Cook EW, Taub E.
The reliability of the wolf motor function test for assessing upper extremity function after stroke. Arch Phys Med
Rehabil. 2001; 82(6): 750−5.
[16] Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte G,
Morris D, et al. Effect of constraint-induced movement
therapy on upper extremity function 3 to 9 months after
stroke: the EXCITE randomized clinical trial. JAMA.
2006; 296(17): 2095−104.

[17] Shindo K, Oba H, Hara J, Ito M, Hotta F, Liu M. Psychometric properties of the simple test for evaluating handfunction in patients with stroke. Brain Inj. 2015; 29(6):772−6.
[18] Bohannon RW, Smith MB. Interrater reliability of a
Modified Ashworth Scale of Spasticity. Phys Ther. 1987;
67(2): 206−7.
[19] Kaji R, Osako Y, Suyama K, Maeda T, Uechi Y, Iwasaki
M. Botulinum toxin type A in post-stroke lower limb
spasticity: a multicenter, double-blind, placebo-controlled
trial. J Neurol. 2010; 257(8): 1330−7.
[20] Fisher AG. The assessment of IADL motor skills: anapplication of many-faceted Rasch analysis. Am J Occup
Ther. 1993; 47(4): 319−25.
[21] Fisher AG. Assessment of motor and process skills. 7th
ed revised. Fort Collins: Three Star Press; 2012.

■ORIGINAL ARTICLE

Development of a Method that Uses Reaction Timeto Evaluate Attention Deficit Associatedwith Changes in Dynamic Visual Stimuli
Kunihiro Kanaya1, 2, Toshio Ohyanagi3, Kyohei Yamada2, 4,
Sonomi Nakajima5, Tetsuyoshi Sakaue6, Yasuhito Sengoku5
1

Department of Rehabilitation Medicine, Sasson-Sugata Clinic
Visiting Research Fellow, Sapporo Medical University
3
Department of Liberal Arts and Sciences, Center for Medical Education, Sapporo Medical University
4
Division of Occupational Therapy Science, Department of Rehabilitation, Faculty of Health Science, Hokkaido Chitose College
of Rehabilitation
5
Department of Occupational Therapy, Sapporo Medical University
6
Department of Occupational Therapy, School of Rehabilitation Sciences, Health Science University of Hokkaido
2

Abstract: Attentional functions are essential to safely and smoothly perform activities of daily living. A range of different symptoms is observed in patients with impairments of attentional functions. Thus, the same patient may show
differences in symptoms depending on the environment in which he or she is situated. In this study, we sought a means
to characterize attention deficit with higher sensitivity than conventional neuropsychological tests, such as the Trail
Making Test (TMT) and the Clinical Assessment for Attention (CAT), do. We developed two reaction time (RT) tasks:
a simple task and a speed change task. We then enrolled 10 right-handed healthy older adults with no history of brain
injury and 10 right-handed patients with stroke to perform the RT tasks. In addition, the stroke group underwent the
TMT, the CAT and behavioral observation by an occupational therapist to identify symptoms characteristic of attention
deficits. Results for findings of attention deficits on standard neuropsychological tests had a sensitivity of 25% in static
situations (e.g., desk activities) and 33% in dynamic situations (e.g., walking or moving). In contrast, when applied tostatic situations, the simple and speed change RT tasks achieved a sensitivity of 75% and 100%, respectively. The sensitivity in dynamic situations was 33% to 44% for the simple task and 100% for the speed change task. These results
suggest that the RT tasks developed in this study are capable of identifying attentional deficits in patients with stroke,and may be more sensitive than neuropsychological testing combined with behavioral observations.
Keywords: Assessment, Attention, Reaction time methods, Visual search(Asian J Occup Ther 14: 53−60, 2018)

Introduction
During the course of our daily activities, we areable to pay general attention to our surroundings to findtarget objects while avoiding obstacles. At the sametime, we are also able to continue performing target
activities without being distracted more than necessary
Received: 6 November 2017, Accepted: 10 July 2018
Corresponding to: Kunihiro Kanaya, Sasson-Sugata Clinic, 2-29-3,
Midori, Otaru-shi, Hokkaido 047-0034, Japane-mail: kanayak225@gmail.com©2018 Japanese Association of Occupational Therapists

by things in our surroundings that are not relevant to
the task at hand. These functions are called attentional
functions, and they are essential to safely and smoothly
perform activities of daily living (ADL) and activities
parallel to daily living (APDL). A range of different
symptoms is observed in patients with impairments inthese attentional functions. Thus, the same patient may
show different symptoms depending on the environment
in which he or she is placed. Moreover, medical professionals do not fully understand this pathology. The
conventional methods for clinical evaluation of attention
deficit use written neuropsychological screening tests
and combine them with behavioral observations. How-54

EVALUATION METHOD FOR ATTENTION DEFICIT

ever, it has been reported that some patients who scorehigher than the standard for impairment on these written
tests, nevertheless exhibit attention deficits in real-lifesituations such as falling while walking, getting into
automobile accidents, etc [1]. Therefore, it has become
clear that in some patients a difference exists between
their results on existing clinical tests and the actual
symptoms encountered in daily living.
Towards better diagnosing and understanding attentional deficits, there are prominent examples of scorable
behavioral observation evaluation methods, including
the Ponsford and Kinsella's Attentional Rating Scale(ARS), developed by Ponsford and Kinsella (1991) [2],and the Moss Attention Rating Scale (MARS), developed by Whyte, Hart, Ellis, and Malec (2003, 2008)[3, 4] being used in combination with written clinicaltests of attention. However, evaluation by behavioral
observation depends greatly on the experience of theevaluator, and it is difficult to eliminate the possibility
that an occupational therapist with little experiencemight overlook clinical findings of attention deficit.
Furthermore, evaluation results for the same patient on
the same day may differ depending on the environment
in which the patient is observed; thus, the effect of environmental dependence must also be studied.
In the fields of psychology and brain science,
attention is classified from the perspective of visual
information processing, and efforts to understand its
mechanisms are underway. These classifications include
stimulus-driven (bottom-up) attention and voluntary(top-down) attention [5]. The sequence in which bottom-up attention is processed is believed to change
based on the salience of visual stimuli, and this fact
is considered to be extremely important for avoiding
danger in situations where the surrounding environment
is constantly changing, as it is in real, everyday life [6].
When the characteristics of the existing tests are examined according to this classification of attention, it isclear that the tests include many elements of top-down
attention, in which cognitive processing is performedby focusing attention on a visual target such as letters or
figures printed on a sheet of paper. A small percentageof the elements in these tests also involve aspects ofbottom-up attention, as the salience of changing stimuli
is continually processed. We postulate that these characteristics are one reason why the results of the existing
tests often do not agree with attention deficit occurringin daily life.
Therefore, we endeavored to develop an attention
deficit evaluation method based on reaction time (RT) asa means of understanding the mechanism of attentional
function from the standpoint of visual information processing [7]. In our previous research, two types of tasks

in which the placement or flashing pattern of displayed
visual stimuli were changed were used together withsimple, conventional RT tasks. The results of the RT
tasks were then compared with the attention deficit findings from daily life and conventional neuropsychological tests. The results showed that the RT tasks reflected a
subject's attention deficit findings with higher sensitivity
than the conventional neuropsychological tests, but
could not detect attention deficit in subjects suspected ofhaving mild disability [7]. This is believed to be because
the two RT tasks that were used only utilized changes inthe visual stimuli characteristic of brightness and therefore did not completely reflect the previously describedbottom-up attention elements. In a study by Viviani and
Aymoz (2001) that used reaction time (RT) to assessthe difficulty of perceiving changes in the elementsof shape, color, and movement, it was discovered thatmovement changes were difficult to perceive [8].
In light of the study by Viviani and Aymoz (2001)[8] and in an effort to develop an evaluation method
capable of appropriately reflecting attention deficit, wedeveloped an RT task in which the speed of displayed
visual stimuli changed. We then studied how the resultsof this task related to attention deficit findings.

Subjects and Methods
Subjects
The subjects were ten right-handed healthy older
adults with no history of brain injury (mean age, 71.3
± 6.1 years; 6 males, 4 females) and ten right-handed
patients with stroke (mean age, 70.4 ± 6.4 years; 7 men,
3 women). Both the healthy older adults and the stroke
patients were selected only if they had no overt decline
in cognitive function, with a Mini-Mental State Examination (MMSE) score of 24 points or higher. Additional
exclusion criteria among the stroke patients were:motor function impairment severe enough to interfere
either with carrying out the touch sensor operations or
performing neurological tests using the arms, hands, andfingers of the unaffected side of their body (at or below
the standard value in the Simple Test for Evaluating
Hand Function [STEF]); observation of hemispatial
neglect; a total score below the standard value on either
a conventional test or a behavioral test listed in theJapanese version of the Behavioral Inattention Test; andvisual field impairment. A detailed profile of the patientsis shown in Table 1.
Task Methods
Procedure. The subjects were asked to perform two
types of RT tasks (a simple reaction task and a speed
change task). In addition, the stroke patients were asked

Kanaya K et al.

Asian J Occup Ther 14: 53−60, 201855

Table 1. Characteristics of the patients with stroke
Case

Age

Sex

Diagnosis

Time period
from the onset

Brunnstrom
stage

FIM

STEF

BIT

Visual field
defect

1
2
3
4
5
6
7
8
9
10

68
61
74
80
64
64
78
70
67
78

Male
Female
Male
Male
Male
Male
Male
FemaleMale
FemaleCerebral infarction (left side)
Subarachnoid cerebral hemorrhage
Cerebral infarction (left side)
Cerebral infarction (left side)
Cerebral hemorrhage (right side)
Cerebral infarction (right side)
Cerebral hemorrhage (left side)
Cerebral infarction (right side)
Cerebral infarction (left side)
Cerebral infarction (right side)

153M
130M
103M
132M
69M
104M
348M
20M
156M
132M

IV
III
III
IV
III
IV
III
V
IV
VI

126
105
118
123
120
126
104
116
126
126

92
89
88
81
92
90
86
94
90
86

143
141
141
144
145
139
141
138
144
141

None
None
None
None
None
None
None
None
None
None

to perform the TMT and the CAT, which are usuallyused as neuropsychological tests.
The TMT consists of two types of tests, a part A(TMT-A) and a part B (TMT-B). TMT-A is a task inwhich numbers randomly placed on a sheet of paper are
to be connected in order starting with 1. The TMT-B isa task in which number sequences and letter sequences(Hiragana) placed randomly on a sheet of paper are to
be connected in alternation. In the TMT, the time (seconds) required to complete the task was measured, andan evaluation was performed using that time.
The visual cancellation task is one of the tests in theCAT, and it involves searching for the target hiragana (atype of syllabary in the Japanese language) from among
stimuli of hiragana arranged in 6 rows and 52 columns
on an A3-sized sheet of paper. The paper contains 114
targets. As for the results, the percentage of correct responses was calculated by referring to the CAT scoring
criteria.
In addition, an occupational therapist with 10 ormore years of clinical experience also made behavioral
observations of the patients in doing desk activities,
walking or moving to identify characteristic symptoms
of attention deficit in an occupational therapy setting.
RT tasks. The equipment used consisted of a 27inch iMac manufactured by Apple, a SMART device anda chin support developed by Ohyanagi and Sengoku(2010), and a mouse-type touch sensor, which wasincorporated into the SMART device to register motor
responses to stimuli displayed on the screen [9]. The
subjects began by touching the touch sensor with theindex finger of their right hand or the hand on the unaffected side of their body. When they saw the target
stimulus on the screen, they released their index finger
from the touch sensor as quickly as possible to respond.
As it was confirmed that the RTs can be measured withmillisecond accuracy by using the SMART device andthe touch sensor, the data collected by conducting the
RT tasks are reliable.

In the simple reaction task, a black backgroundscreen was displayed at random intervals of time for aperiod of 3 to 5 sec, and afterward, a target stimulus (redcircle with a diameter of 1 degree in visual angle) was
displayed in the center of the screen. The amount of timefrom when the target stimulus was displayed until thesubject's finger was released from the touch sensor wasrecorded. Note that if the subject did not react within 1.5
sec after the target stimulus was displayed, the present
trail was discontinued. This trial was run 24 times.
In the speed change task, after a black backgroundscreen was displayed, 36 red circles with a diameterof 1 degree in visual angle appeared on the screen (thescreen had a width with a visual angle of 45 degrees
and a height with a visual angle of 26 degrees). All of
the red circles moved at a speed of a visual angle of 10
degrees in a randomly determined direction in the up or
down and left or right directions (Fig. 1B). After 1.0 or
1.5 sec, the movement of one of the 36 red circles (thetarget) slowed by 5 degrees every second. As soon as
the subject noticed the target, he or she would respondwith the sensor. The time from when movement speedof the single target red circle began to change until thepatient responded was recorded (Fig. 1A). However,in order to measure the accuracy of the responses, trial
runs in which the movement speed did not change wererandomly included, and the subject was instructed not to
respond in these cases. If the movement speed changed
and the subject did not respond within 3.5 sec, thesubject was considered to have overlooked the target,and if the movement speed did not change, the run was
finished after 3.5 sec. There were 36 trials in total, 24 inwhich the movement speed of the target changed, and
12 in which the movement speed did not change. The
36 red circles are arranged one by one in randomly predetermined positions in each area obtained by dividing
the display into 36 equal parts (4 × 9). Twenty-four red
circles arranged in the central areas were randomly selected once for each as a moving target whose direction

56

EVALUATION METHOD FOR ATTENTION DEFICIT

Fig. 1. Speed change RT task.
A. Interval of (1) and (2) is 2.5 sec. Direction of movement (2) is set at random for each trial (the number of occurrences of eachdirection is the same). Interval of (2) and (3) is 1 sec or 1.5 sec at random (the number of occurrences of each interval is thesame). Reaction time is the interval of (3) and (4).
B. There are 4 patterns of 36 red circles moving from left to right, right to left, top to bottom, and bottom to top.

was also determined randomly but the total number of
each direction was equally set. Therefore, there was no
spatially biased throughout the experiment.
Analytical methods. The mean and standard deviation (SD) of the number of trials that the subject completed successfully without overlooking the target were
calculated for each task and used as the results of the RT
tasks. In addition, the number of speed change task trials
that each subject could not complete were quantified.
Then three values, the mean + 1.5 x SD, the mean +2 x SD, and the mean + 2.5 x SD, were calculated as
candidates for standard values reflective of the resultsof the healthy elderly individuals, and a determination
was made as to whether the reaction times of the stroke
patients were slower than these standard values. The
validity of the three candidates is discussed according to
the sensitivity and specificity for attention deficits of thepatients.
For the TMT, we referred to the mean value measured in 29 healthy older adults (68 to 94 years old) by
Sugimoto, et al. (2014) [10] in which the mean ± SD
was 174.0 ± 69.3 sec for TMT-A and 320.8 ± 152.4 sec
for TMT-B. The mean +1.5 x SD, the mean + 2 x SD,
and the mean + 2.5 x SD were similar to the RT task

results; the specific results for TMT-A were 278.0 sec,
312.6 sec, and 347.3 sec, respectively, and the resultsfor TMT-B were 549.4 sec, 625.6 sec, and 701.8 sec,
respectively. These values were adopted as standard
values of the TMT and were used to judge the existenceof attention deficit.
For the visual cancellation task in CAT, standard
values for the percentage of correct responses for subjects in their sixties and seventies are 92.9% and 91.7%,
respectively. There was no standard set in the CAT for
subjects in their eighties, so we used an accuracy rate of
91.7% as the standard value for persons in their seventies and older.
The observational evaluation was a qualitativeevaluation of whether findings of attention deficit wereshown in static situations, such as during desk activities,
or whether attention deficit was shown in dynamic situations, such as when walking or operating a wheel chair.
Because the stroke patients performed the RT task
and neuropsychological tests with their dominant handor the hand on the unaffected side of their body and they
had scored values higher than the standard for their age
group in the STEF, their upper limb function was judged
to have no effect on the results of any of the tasks. Thus,

Kanaya K et al.

Asian J Occup Ther 14: 53−60, 2018

no corrections for the results of the tasks and the tests
were implemented.
All of the results for the RT tasks, the pre-existingneuropsychological tests, the TMT, and the visual cancellation task, were compared with the results from thebehavioral observations, and sensitivity and specificity
were calculated.
Ethical approval
This study was approved through an ethical review
by the Ethics Committee of Sapporo Medical University. In addition, this study was performed in compliancewith the Declaration of Helsinki and placed carefulattention on protecting the privacy and human rights ofthe subjects.
When data were measured, the subjects were provided with oral and written explanations of the study
purpose, methods, procedures, subjects, anticipatedrisks, matters related to the human rights of the subjects,
the rights of the subjects in the event that they did notprovide consent, etc. After this information was provided, the signatures of the individuals who consented
to the study were obtained, and only individuals fromwhom informed consent was obtained were used as subjects in this study. The subjects were also told that they
could withdraw consent to participate in the study ifthey requested such during the study or after the study.

Results
RT tasks
The results of RT task of the healthy older subjects
are shown in Table 2. The overall reaction time for thehealthy older subjects was 250.1 ± 33.7 msec in thesimple reaction task and 479.1 ± 40.9 msec in the speed
change task. There were 2 healthy older subjects who
overlooked the target once in the speed change task.
When convenient standard values were calculated
from these results, the mean + 1.5 x SD, the mean + 2 x
SD, and the mean +2.5 x SD in the simple reaction task
were 300.7 msec, 317.4 msec, and 334.4 msec, respectively. The mean + 1.5 x SD, the mean +2 x SD, and themean +2.5 x SD in the speed change task were 540.5
msec, 560.9 msec, and 581.4 msec, respectively.
The results of RT tasks of the stroke subjects areshown in Table 2. In the simple reaction task, the reaction time was delayed in patients 1, 2, 3, 6, and 10 when
the standard value was considered to be the mean + 1.5
x SD. When the standard value was considered to be
the mean + 2 x SD or + 2.5 x SD, the reaction time wasdelayed in patients 1, 2, and 3.
In the speed change task, the reaction time wasdelayed in all patients when the standard value was con-57

Table 2. Results of the RT task
Subjects

Simple RT
M

SD

Speed change RT
M

SDOmission

Healthy elderly
1
2
3
4
5
6
7
8
9
10
mean

272.8
42.2
322.1
49.1
252.0
49.2
258.1
34.1
213.8
18.7
198.8
28.5
231.1
31.0
232.2
34.4
240.8
31.1
279.3
39.4
250.1 ± 33.7

484.6
89.0
498.2
67.4
402.8
59.8
432.3
65.8
501.4
82.0
447.3 128.1
462.4
86.9
539.7 111.8
490.5
90.5
531.7
67.6
479.1 ± 40.9

0
0
0
0
1
0
0
1
0
0

Stroke patients
1
2
3
4
5
6
7
8
9
10
mean

349.4
75.1
438.7
34.7
365.9 128.2
215.5
31.3
226.4
13.6
312.6
85.1
211.5
34.8
287.0
55.2
281.7
72.6
302.1
50.3
299.1 ± 68.6

1879.7 708.3
1326.1 729.2
660.1 125.0
802.6 428.3
606.0 256.8
595.5 156.3
1024.7 742.3
843.8 294.1
814.4 328.6
548.4
75.1
910.1 ± 391.9

7
0
0
1
0
3
1
0
0
0

M (msec), Omission (number of incidences).

sidered to be the mean + 1.5 x SD. When the standard
value was considered to be the mean + 2 x SD or + 2.5 x
SD, the reaction time was delayed in all patients except
patient 10. Patients 1 and 6 overlooked the target more
often than the healthy older subjects.
Neuropsychological tests
The results of the TMT and the visual cancellation
task are shown in Table 3. No matter which standard
value was used, none of the subjects showed findings ofattention deficit in the TMT. In the visual cancellationtask, patients 1, 4, and 9 showed findings of attention
deficit.
Behavioral observations
The results of the behavioral evaluation are shownin Table 4. In static situations, such as during desk activities, 3 of 10 patients (patients 1, 2, and 3) showed overt
attention deficit findings. Note that patient 8 showedfindings suggestive of attention deficit. In addition, in
dynamic situations in which visual information changes,
such as operating a wheel chair, walking, etc., 9 patients(all patients except patient 10) showed attention deficit
findings.

58

EVALUATION METHOD FOR ATTENTION DEFICIT

Table 3. Results of neuropsychological tests of patients with stroke
Case
1
2
3
4
5
6
7
8
9
10

Neuropsychological test
TMT-A

TMT-B

Cancellation task

187
107
92
126
87
265
127
184
206
170

201
153
216
194
139
347
321
267
372
196

86.8*
97.4
98.2
91.2*
96.5
99.1
95.6
94.7
92.1*
94.7

TMT-A Trail Making Test part A (sec), TMT-B Trail Making Test partB (sec), Cancellation task: Visual cancellation task (rate of cancellation %), *outside of normal range.

Sensitivity and specificity of the neuropsychological tests
and RT tasks for the attention deficit findings of the behavioral observation results
In order to verify that the RT tasks developed inthis study reflected the attention deficit findings from thebehavioral observations better than the existing neuropsychological tests, the sensitivity and specificity of thejudgments of attention deficit findings in the RT tasks,
TMT, and visual cancellation test were calculated withrespect to the attention deficit findings from the behavioral observations of a total of 20 healthy older subjects
and stroke patients in static and dynamic situations. The
results are shown in Table 5.
In the TMT-A, at all of the standard values, the sensitivity and specificity were 0% and 100%, respectively,
for attention deficit findings in static situations, and 0%
and 100%, respectively, for attention deficit findings indynamic situations. In the TMT-B, at all of the standard
values, the sensitivity and specificity were also 0%
and 100%, respectively, for attention deficit findings instatic situations and in dynamic situations. In the visualcancellation test, sensitivity and specificity were 25%
and 88%, respectively, in static situations and 33% and100%, respectively, in dynamic situations.
In static situations in the simple reaction task, sensitivity and specificity were 75% and 81%, respectively,
when the standard value was the mean + 1.5 x SD; 75%
and 94%, respectively, when the standard value was themean + 2 x SD; and 75% and 100%, respectively, when
the standard value was the mean + 2.5 x SD. In dynamic
situations in the simple reaction task, sensitivity andspecificity were 44% and 82%, respectively, when thestandard value was the mean + 1.5 x SD; 33% and 91%,
respectively, when the standard value was the mean + 2
x SD; and 33% and 100%, respectively, when the standard value was the mean + 2.5 x SD.
In static situations in the speed change task, sensitivity and specificity were 100% and 63%, respectively,
when the standard value was the mean + 1.5 x SD;
100% and 69%, respectively, when the standard value
was the mean + 2 x SD; and 100% and 69%, respectively, when the standard value was the mean + 2.5 x SD. In
dynamic situations in the speed change task, sensitivity
and specificity were 100% and 91%, respectively, when
the standard value was the mean + 1.5 x SD; 100% and100%, respectively, when the standard value was themean + 2 x SD; and 100% and 100%, respectively, when
the standard value was the mean + 2.5 x SD.

Table 4. Qualitative clinical observations by occupational therapists
Case
1
2

Static scene(e.g. activities on the desk)

3

Talkativeness, Distractibility, Restless
Overlook small part caused by lack ofconfirmation during handwork.
A little delay in the start of the action.

4

No particular problem

5
6
7
8

No particular problem
No particular problem
No particular problem
Sometimes mistaken for voice overincreases during handwork.
No particular problem
No particular problem

910

Dynamic scene(e.g. driving wheel chair, walking)Field of view is narrow when moving. Sense of distance is abnormal.
Hit surroundings during wheelchair operation.
The sense of distance between the object being small when walking.
Action can be modified to be careful.
Cannot find a person when walking.
Possible to notice defects immediately in the voice over.
Rarely, not aware of the objects on the floor.
Sense of distance is abnormal during walking. Never hit surroundings.
Sometimes hit surroundings.
Sense of distance is abnormal. Almost always hit surroundings.
Do not try to avoid obstacles even if there is a person or an object, delay in avoiding.
No particular problem

Kanaya K et al.

Asian J Occup Ther 14: 53−60, 201859

Table 5. Sensitivity and specificity for inattention syndrome (the reference value is changed)
Scene

Reference Value

StaticDynamic

Neuropsychological test

RT tasks

TMT-A

TMT-B

Cancellation task

Simple RT

Speed change RT

M + 1.5SD
M + 2.0SD
M + 2.5SD

0/100
0/100
0/100

0/100
0/100
0/100

25/88

75/81
75/94
75/100100/63
100/69100/69M + 1.5SD
M + 2.0SD
M + 2.5SD

0/100
0/100
0/100

0/100
0/100
0/100

33/10044/82
33/91
33/100100/91
100/100
100/100

The value in the table, Sensitivity (%)/Specificity (%).

Discussion
Attention deficit findings of the patients and results ofexisting neuropsychological tests
The results of the existing neuropsychological tests
used in this study showed that the TMT was unable
to detect attention deficit findings and that the visualcancellation task was able to detect attention deficit
findings. However, the sensitivity was 25% in static situations and 33% in dynamic situations, which are very
low values. These results support the previous studies[1] that reported a difference between the results of theneuropsychological tests and symptoms observed in situations such as driving a vehicle or walking. The reason
for this is considered to be that the neuropsychologicaltests involve few changes in visual stimuli and thus are
low-salience tasks with narrow display ranges. This suggested that the existing neuropsychological tests alone
did not completely reflect the clinical attention deficit
findings in either static or dynamic environments.
Attention deficit findings of the patients and the resultsof RT tasks
In the RT tasks used in this study, the sensitivity
toward attention deficit findings in static situations
was 75% for simple responses and 100% for the speed
change task, both of which were high values. In addition, the sensitivity in dynamic situations was 33%
to 44% for simple responses and 100% for the speed
change task. The RT tasks used in this study did not contain very many cognitive elements such as letters andnumbers, rather they asked subjects to find and respondto targets in an environment where the brightness andspeed of visual stimuli changed. Therefore, these tasks
were considered to be capable of reflecting attention
deficit mainly in dynamic environments, and the sensitivity of the speed change task is considered to support
that. We posit that the low sensitivity of the simple reaction task, which is in contrast to the speed change task,
may owe to the simple reaction task using only changes

in the simple flashing of visual stimuli. This implies thatthe amount of change of dynamic visual stimuli may
have greatly affected the results. Therefore, judging
from the sensitivity and specificity of the behavioral
observations, a more appropriate evaluation is considered to be one that combines a simple reaction task, inwhich the change in visual stimuli is relatively small andreflects attention deficit in static situations, with a speed
change test, in which the change in visual stimuli islarge and reflects attention deficit in dynamic situations.
Standard values
Though there have been a lot of studies aimed
at evaluating attention disorders and clarifying theircharacteristics using RT tasks, no standard value has
been clearly determined so far [1, 11]. This is why threecandidates for standard values reflective of the results of
the healthy older adults are introduced in this study. As
a result, the neuropsychological tests in both static anddynamic scenes and the simple reaction task in dynamic
scene showed low sensitivity and high specificity forthree candidates for standard values, while the simple
reaction task in static scene and speed change task inboth scenes showed high sensitivity and high specificity
for them. From these results, it may be reasonable to set
any of the three reference values as the standard value
for the RT tasks but more data collection is necessary toconclude it.
Limitation of research and Future outlook
Since the observation scene and activities were limited in this research, only a part of daily life of attention
disorder patient could be examined. Previous studies
that used RT tasks also contained little information
about setting standard values; thus, we think that theestablishment of standard values is important in futurestudies. In addition, the functional structures inside thebrain responsible for processing the speed of movementof visual stimuli have recently been discovered [12–14].
If this new information can be exploited to perform

60

EVALUATION METHOD FOR ATTENTION DEFICITa more functionally segmented clinical evaluation of
attention deficit, we believe that more highly individualized occupational therapy could be provided. However,the behavioral observations in our study had many
qualitative elements and did not contain a quantitative
method. Therefore, they did not allow for such segmentation. In the future, we also hope to study ways inwhich behavioral observations of attention deficit canbe performed in a more quantitative manner. We would
also like to enroll a larger number of subjects in order tostudy the step-wise correlations between RT tasks andvarious symptoms and the relationship with actual reallife activities.

Conflicts of interest statement
The authors have no conflicts of interest relevant tothis article.

Acknowledgements
This study was supported in part by KAKENHI (No.
26350662) from Japan Society for the Promotion of
Science (JSPS).

References[1] Deouell LY, Sacher Y, Soroker N. Assessment of spatialattention after brain damage with a dynamic reaction time
test. J Int Neuropsychol Soc. 2005; 11: 697−707.
[2] Ponsford J, Kinsella G. The use of a rating scale of attentional behaviour. Neuropsychol Rehabil. 1991; 1: 241−
57.
[3] Whyte J, Hart T, Bode RK, Malec JF. The Moss Attention
Rating Scale for traumatic brain injury: initial psychometric assessment. Arch Phys Med Rehabil. 2003; 84:268−76.
[4] Whyte J, Hart T, Ellis CA, Chervoneva I. The Moss

Attention Rating Scale for traumatic brain injury: further
explorations of reliability and sensitivity to change. Arch
Phys Med Rehabil. 2008; 89: 966−73.
[5] Tseng PH, Cameron IG, Pari G, Reynolds JN, Munoz
DP, Itti L. High-throughput classification of clinical populations from natural viewing eye movements. J Neurol.
2012; 260: 275−84.
[6] Koch C, Ullman S. Shifts in selective visual attention:
towards the underlying neural circuitry. Hum Neurobiol.
1985; 4: 219−27.
[7] Kanaya K, Ohyanagi T, Sasaki T, Sengoku Y. A new
method for assessing patients’ inattention by using reaction time tasks. Japanese Occupational Therapy Research.
2010; 29: 207−14 (in Japanese).
[8] Viviani P, Aymoz C. Colour, form, and movement are notperceived simultaneously. Vision Res. 2001; 41: 2909−
18.
[9] Ohyanagi T, Sengoku Y. A solution for measuring accurate reaction time to visual stimuli realized with a programmable microcontroller. Behav Res Methods. 2010;
42: 242−53.
[10] Sugimoto S, Okuma O, Koyama T, Sakuma H, Komi­
yama J, Ozawa I, et al. Relationship between a simplified
version of the trail making test and the Japanese versionof the trail making test. Journal of the Japanese Physical
Therapy Association. 2014; 29: 357−60 (in Japanese).
[11] Gualtieri CT, Johnson LG. A computerized test battery
sensitive to mild and severe brain injury. Medscape J
Med. 2008; 10: 90.
[12] Sun P, Ueno K, Waggoner RA, Gardner JL, Tanaka K,
Cheng K. A temporal frequency-dependent functionalarchitecture in human V1 revealed by high-resolution
fMRI. Nat Neurosci. 2007; 10: 1404−6.
[13] Akbas E, Eckstein MP. Object detection through searchwith a foveated visual system. PLoS Comput Biol. 2017;13: e1005743.
[14] Ruff DA, Cohen MR. Attention increases spike countcorrelations between visual cortical areas. J Neurosci.
2016; 36: 7523−34.