■ORIGINAL ARTICLE

Quantifying the effectof home visit occupational therapy
on the quality of life of elderly individuals
Miyuki Imanishi1, Hisao Tomohisa2, Kazuo Higaki3
1

Research Institute of Rehabilitation Sciences, Osaka Prefectural University, Osaka, Japan
Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan3
Department of Community Health, Osaka Prefectural University, Osaka, Japan
2

Abstract:
Purpose: Japan is now the world’s first ‘super-ageing’ society. We analysed the effect of occupational therapy (OT) sessions in addressing issues related to the elderly population, in comparison with other services.
Methods: We studied 136 elderly patients receiving at-home care. Seventy-four patients received weekly OT and 62
did not. We assessed quality of life (QOL) and its trajectory over 1 year using the Philadelphia Geriatric Center Morale
Scale (PGC) to quantify changes in QOL and the Function Independence Measure (FIM) to measure changes in activities of daily living.
Results: Patient progress fell within five different trajectories, which was influenced by psychosocial factors. OT correlated with significantly greater improvement in PGC and FIM scores than other home care services.
Conclusion: There is a significant benefit associated with OT and is expected to become increasingly more important in
the growing elderly population. Tailoring of OT will be required to benefit those trajectory groups that showed unsatisfactory outcomes.
Keywords: home-visit occupational therapy, quality of life, elderly individuals(Asian J Occup Ther 13: 1−6, 2017)

1. Introduction
Japan is in the middle of a unique and unprecedented demographic change; the percentage of citizens 65
years and older has now risen to 23% of the total population [1] and will increase to 33% by 2030 [2]. Thishas been attributed to the tendency toward a lower total
fertility rate as rural populations dwindle when younger
generations move to cities, where large families are
impractical due to limited space, high cost of living andinadequate childcare opportunities for working mothers.
Another component is the increasing longevity of theelderly population and the growing tendency of theirchildren to live away from them [3].
Received: 3 July 2015, Accepted: 1 September 2016
Corresponding to: Miyuki Imanishi, Research Institute of Rehabilitation Sciences, Osaka Prefectural University, Habikino 3-7-30,
Habikino-shi, Osaka, Japane-mail: miyuki726@kcn.jp©2017 Japanese Association of Occupational Therapists

The relative isolation and potential vulnerabilitiesof the elderly age group were brought to the nation’s
attention by the Great East Japan earthquake, followed
by a tsunami, on 11 March 2011. Elderly patients wereover-represented in the number of citizens requiring
emergency care and shelter [4].
To address problems facing ageing societies, theJapanese government has adopted measures to reduce
medical expenses among the elderly, including theestablishment of a long-term care insurance system andthe revision of medical fees. This has been accompanied
by an emphasis on in-home care, with a shift ‘from careby family’ to ‘care by society’ [5, 2, 6]
This shift has, in turn, focused attention on the issueof quality of life (QOL) among those receiving in-homecare. Kawai [7] points out that the social norms of asuper-ageing society tend to regard the elderly as asocial problem that needs to be addressed, but it is questionable whether the elderly can live happily knowingthat they are considered a social problem. Washida [8]asserts that humans cannot live without recognizing

2

IN-HOME HEALTH CARE AND QOL IN ELDERLY

meaning in their lives. This in turn requires that weshould strive to organize and administer occupational
therapies that prevent elderly people from losing meaning in their lives and help them maintain or improve
QOL.
Studies to date on the QOL of the elderly have been
conducted from various viewpoints. Lawton [9] defined
QOL in this population as ‘subjective well-being’ andcreated the Philadelphia Geriatric Center Morale Scale(PGC) (see Appendix) in 1972 to measure QOL among
the elderly. The PGC is still used worldwide. In anotherstudy, Liang and Bollen [10] described factors affecting
QOL in the elderly, including sex, race, marital status,
health condition, employment situation, socioeconomic
status and social activities. Koyano [11] asserted thatbeing in good health and maintaining close relationships
with others helps improve QOL. These studies primarily
targeted healthy elderly people and did not specificallyinvestigate elderly persons receiving occupational
therapy (OT). Nevertheless, their findings serve as abenchmark for future consideration of geriatric QOL.
Analyzing the differences in QOL between elderly persons receiving home care with or without OT may help
therapists to tailor OT and improve patient QOL.
To assess these differences in home care, we conducted a prospective analysis of subjects who started touse home care services with and without OT over 1 year.

2. Materials and Methods
2.1. Design
The study was conducted under a prospective
cohort design based on age-related physical function and
QOL score in 200 patients aged 65 to 84 years who had
begun to use home care services.
2.2. Study Participants and Activities
The study lasted from May 2013 to May 2014 andincluded patients from 12 visit care stations in three prefectures (Kyoto, Osaka and Nara Prefectures) in central
Japan. Participants in the OT cohort were scheduled tocommence receiving home care visits that consisted ofweekly 1 h visits by an occupational therapist or nurse,
who engaged the patient in exercise therapy [activities
of daily living (ADL) practice], OT (cooking, gardening, crafts, music activities, going out-of-doors, practicein operating mobile, etc.), proposals of leisure activities
or volunteer activities, counselling and home exercise
guidance.
Participants in the non-OT cohort received 1−5
weekly home visits totalling 60−300 min by a nurse or
healthcare professional who assisted the patient withcleaning, laundry, shopping, bathing, eating and medication management.
Setting
All 12 care stations provide home visit care service.
In five locations, professional caregivers help with ADL,
bathing, housework, shopping and conversation. The
patients served by these five care stations were eligible
for the study as part of the non-OT cohort. In the otherseven locations, nurses or occupational therapists provide
medical services including blood pressure measurement,
physical therapy, family therapy, OT and prescription
management. The patients served by these seven carestations were eligible for the study as part of the OT
cohort.
2.3. Inclusion/exclusion criteria
Inclusion criteria included intact cognitive function
and communication skills, and a stable general condition
that allowed participation. Patients scoring less than
24 points on the Mini-Mental State Examination were
excluded.
2.4. Data collection
Physical function and QOL scores were investigated in the patients’ homes at intervals of 90 ± 10 days
using the Functional Independence Measure (FIM) and
the PGC Morale Scale. The PGC Morale Scale, used tomeasure QOL, comprises 17 questions (see Appendix).
A normal score is 11.97 ± 3.57, derived from a population of healthy community-dwelling elderly people
in Japan. The main outcome of this study was the PGCMorale Scale score.
Patient ADL was assessed using the FIM. The
FIM evaluates movement and cognitive function in 18
items and 7 steps and is mainly used at rehabilitation
clinic sites, both in Japan and abroad. The FIM score
was the secondary outcome of this study. Both tests
were administered by specialists, such as occupational
therapists. The questionnaire for the PGC Morale Scale
was completed by the participant with or without help
from a family member or friend. Higher scores in the
FIM and PGC imply higher QOL and ADL function.
When the PGC or FIM could not be administered due
to hospitalization or other interruption, or if all items ineither evaluation were not completed, we judged that thedata were missing and the patient was excluded fromanalysis.
2.5. Demographics
Clinical data and patient background information
were collected by creating a personal questionnaire that
included age, sex, illness name, course of treatment,
level of care required, family structure, employment

Asian J Occup Ther 13: 1−6, 2017

history, education history, hobbies and any participationin religious activities.
2.6. Statistical Analyses
The regularity of data distribution was validated
using the Shapiro–Wilk test. Comparisons of factors ofboth the OT and non-OT cohorts were analysed using
the Mann–Whitney U test. Correlation analysis between
two variables in the PGC and FIM was analysed using
the Spearman’s ρ (rank correlation coefficient), with thesignificance of correlation coefficients also examined.
Cross-group QOL trends were identified using hierarchical cluster analysis. The significance of probabilities wascalculated using Fisher’s exact probability test, with significance set at p < 0.05. Power analyses and statistical
calculations were conducted using specialized software(G*Power ver. 3.1®, Heinrich Heine University; Düsseldorf, Germany). All other analyses were performed
using social science software (SPSS ver. 22.0®, IBM;
Armonk NY, USA).
2.7. Consent and Ethical Approval
All patients who participated in this study gave
informed consent in writing. This study received formal
ethical approval from Osaka Prefecture University Research Ethics Committee (2012-OT-17).

3. Results
3.1. Reasons for recruitment and exclusion
Therapy for 100 patients by occupational therapists
as well as care for the 100 non-OT patients by nurses
and caregivers was initiated out of the 12 home visit stations. Twenty-six patients receiving OT and 38 patients
receiving non-OT care could not continue their homehealthcare over the study year due to placement in anursing home, moving to a distant family home, deathor other reasons (53%, 17%, 14%, 9% and 7%, respectively). The remaining 136 patients (74 in the OT cohort
and 62 in the non-OT cohort) were analysed as survey
participants.
3.2 Participant Characteristics
Mean age (years), years of schooling, FIM scoreand PGC score of the 200 patients was 78.13 ± 5.1,
10.95 ± 2.3, 84.73 ± 20.4 and 9.09 ± 2.6, respectively, atthe time of initiation of the survey. Other information we
acquired included degree of nursing care needed, nameof injuries and diseases, therapeutic course, occupational
history, hobbies, religious observance participation andfamily configuration (Table 1). On comparison of baseline information between the OT and non-OT cohorts,
significant differences between the two cohorts were

Imanishi M et al.

3seen in mean FIM score, with a score of 81 for the OT
cohort and 92 for the non-OT cohort ( p = 0.024) andthe presence or absence of a hobby (64% for OT, 47%
for non-OT; p = 0.023). No other significant differences
between the cohorts were observed.
3.3. Mean FIM and PGC scores in the OT and non-OT
cohorts after 1 year
Table 2 shows mean changes in FIM and PGCscores at the end of the year of the survey. PGC and FIM
scores increased in the OT cohort. The change in mean
PGC scores in the non-OT cohort was not significant,while FIM scores decreased significantly over the year.
3.4. Trajectories of QOL
Cluster analysis of data over the four visits revealed
different trajectories of the subjects’ QOL ratings. Welabelled these QOL trajectories as follows: A. Improving, B. Worsening, C. Stable Satisfactory, D. Stable
Unsatisfactory and E. Slightly Improving. These areillustrated in Fig. 1.
Members of the OT cohort were overrepresented
in the favourable trajectories A, C and E ( p < 0.00) andmembers of the non-OT cohort were overrepresented in
the unfavourable trajectories B and D (Fig. 2).
3.5. Factors affecting QOL trajectory
The general characteristics of those following
Trajectory A (Improving QOL) were that they started
home healthcare immediately after discharge from
hospital; they had worked in technical occupations andthey tended to have hobbies and participated in religious
activities. No specific trend was seen in family structure.
A high percentage (93%) received OT.
The general characteristics of those following Trajectory B (Worsening QOL) were that home healthcare
became necessary while they were receiving medicalcare. Their occupational histories were in sales, business, or transportation and communication. They tended
to have no hobbies. No significant differences in religious activities or family configuration were seen. Most
Trajectory B patients (63%) were in the non-OT cohort.
The general characteristics of those following
trajectory C (Stable Satisfactory QOL) were that homehealthcare became necessary while they were receiving
routine outpatient care. Their work histories were inforestry and fishery occupations. They had hobbies andparticipated in religious activities. Their family configuration was mostly three-generation households, with
40% in the non-OT cohort.
The general characteristics of those who followed
Trajectory D (Stable Unsatisfactory QOL) were thatthey had occupational histories in manufacturing and4IN-HOME HEALTH CARE AND QOL IN ELDERLY

Table 1. Patient characteristics.

NumberAgeYears of education
FIM score
PGCs core

OT cohort

Non-OT cohortP100
80.0 ± 7.0
12.0 ± 3.0
81.0 ± 35.0
8.0 ± 3.0

100
80.0 ± 9.0
12.0 ± 3.0
92.0 ± 26.8
10.0 ± 4.0

0.969
0.810
0.024
0.206

Sex

Women
Men

60
40

61
39

1.000

Level of care required

1
2
3
4
5

19
30
20
23
8

21
30
24
20
5

0.857

Classification of disease

Musculoskeletal system
Nervous system
Heart or lung disease
TraumaSystemic disease
Immune disease

18
32
10
17
12
11

13
32
15
16
13
11

0.870

Course of treatment

Discharge→Home care
Visit→Home care

52
48

44
56

0.322

Profession

Office work
Selling
Professional or technical
Service
Agriculture, forestry or fisheries
Production or labour work
Transportation or communication
Others

7
12
18
1
26
16
2
18

7
7
16
3
22
19
7
19

0.588

Hobby

Yes
None

64
36

47
53

0.023

Faith

Yes
None

64
36

55
45

0.249

Family structure

Alone
CoupleTwo-family
Three household

26
36
19
19

33
41
13
13

0.342

• t-test was used for age, years of education, FIM and PGC• Fisher’s exact test was used for sex, level of care required, classification of disease, course of treatment, profession,
hobby, faith, or family structure
Level of care required is according to the Japan’s long-term care insurance system, in which 1 = minimal carerequirement category and 5 = maximal care requirement category. Although the length of convalescence varied,these were categorised into groups by three-month periods, based on the time service provision began.

Table 2. Effect size of OT.

OT cohort
Non-OT cohort

Mean 1-yearchange in
PGCpMean 1-yearchange in
FIM score

p

1.92
−0.16

0.001
0.617

5.07
−6.07

0.001
0.001

OT = occupational therapy

labour services. They tended not to have hobbies anddid not participate in religious activities. Their family
configuration was mostly two-generation households,
and 43% were in the non-OT cohort.
The general characteristics of those who followed
Trajectory E (Slightly Improving) were that they started
home healthcare immediately after discharge from thehospital. Their occupational history was in the service
sector. They lived alone and showed no specific trends
in hobbies or religious activities. A total of 38% were in
the OT cohort.

Imanishi M et al.

Asian J Occup Ther 13: 1−6, 2017

Fig. 1. The five trajectories.
A. Improving QOL (full square), B. Worsening QOL(empty circle), C. Stable Satisfactory QOL (fullcircle), D. Stable Unsatisfactory QOL (triangle), and
E. Slightly Improving QOL (empty square).
PGC score = Philadelphia Geriatric Center Morale
Scale score.

5

service that significantly improved QOL. Patients receiving OT who were involved in religious participationand hobbies showed the most improvement. The importance of hobbies has been noted by others [12]; this isan easy feature to implement and may be combined with
OT. Religious participation cannot be mandated, but anincreased presence of clergy where the elderly congregate should certainly be encouraged. All three of thesefactors could be implemented wherever there is group
participation, such as in community centres. Nevertheless, it is important to emphasize that the greatest need
is found among those who live alone and are isolated.
Another problem that needs to be addressed is the issueof help with ADL. Mandated bathing and meal times,
arranged according to the health centre personnel’sschedule, may promote passivity and lower the patient’s
feelings of independence. This will have to be addressedin creative ways. By becoming familiar with the different trajectories of the different groups, OT and also ADL
personnel may be able to tailor their services to the patients’ needs, working together to improve independence
and QOL.
Several limitations of the study warrant mention.
First, our study was confined to a part of the Kansai district, and the experiences and QOL of Japanese in otherareas may differ. Second, the nature of our study’s inclusion criteria almost guaranteed small subject numbers
regardless of location. Finally, we did not investigate
how OT should be tailored to meet the needs of patients
who face different trajectories.

Conclusions
Fig. 2. Proportion of OT and non-OT cohorts in the five
trajectories.

Kruskal–Wallis testing identified six factors that
correlated with trajectory, namely therapeutic course,
specifically the receipt of home care services immediately after discharge, and patient need for both home careservice and medical care from their general practitioner;
occupational history; hobbies; religious participation;family configuration and OT.

4. Discussion
Clients navigating the challenges of ageing face
many difficulties, not all of which can be changed, suchas family structure. In this study, of the several services
offered to patients in their homes, including nursing,help with ADL and OT, we found that OT was the only

The fact that receivers of OT were under-represented in the lower QOL cohorts is encouraging; it implies
that the kind of OT provided currently has a positiveeffect on elderly individuals. Further work on the implementation of hobby activity, possibly in the context
of OT, may be fruitful. This was a small study, but withinteresting findings. We hope it will encourage larger
studies of OT in the rapidly expanding elderly population of Japan.

References[1] Cabinet Office, Government of Japan: Heisei 24 aged

society white paper [last accessed 2015 June 1] Available
from http://www8.cao.go.jp/kourei/whitepaper/w-2014/
zenbun/pdf/1s1s_5.pdf, 2015.6.1.
[2] Campbell JC, Ikegami N. Long-term health insurance
comes to Japan. Health Affairs. 2000; 19: 26−39. Doi:
10.1377/hlthaff.19.3.26.
[3] Oe M. Problems and implications of Japan’s ageing

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IN-HOME HEALTH CARE AND QOL IN ELDERLY

society for future urban developments. Policy and Governance Working Paper Series. The 21st Century Center of
Excellence Program. Graduate School of Medicine andGovernance, Keio University, Japan. Delivered March
2006.
[4] Yamada S, Hanagama M, Kobayashi S, Satou H, Tokuda
S, Niu K, et al. The impact of the 2011 Great East Japan
Earthquake on hospitalization for respiratory disease
in a rapidly ageing society: A retrospective descriptive
and cross-sectional study at the disaster base hospital in
Ishinomaki. BMJ Open. 2013; 3: e000865. Doi: 10.1136/
bmjopen-2012-000865.
[5] Muramatsu N, Akiyama H. Japan: Super-ageing society
preparing for the future. The Gerontologist. 2011; 51:425−32. Doi: 10.1093/geront/GNR067.
[6] Tsutsui T, Muramatsu N. Japan’s universal long term caresystem reform of 2005: Containing costs and realizing avision. Journal of the American Geriatrics Society. 2007;
55: 1458−63. Doi: 10.1111/j.1532-5415.2007.01281.x.
[7] Kawai H. “Oiru” tohadouiukotoka, 24th edition. Tokyo:
Kodansha, (in Japanese). 2011.
[8] Washida K. Oinokuuhaku, 3rd edition, Tokyo: Koubundou, [in Japanese]. 2003.
[9] Lawton MP. The Philadelphia Geriatric Center Morale
Scale: A revision. Journal of Gerontology. 1975; 30:85−9.
[10] Liang J, Bollen KA. Sex differences in the structure of
the Philadelphia Geriatric Center Morale Scale. Journalof Gerontology. 1985; 42: 468−77.
[11] Koyano W. Studies in Japanese social gerontology. Journal of the National Institute of Public Health. 2004; 53:
204−8.
[12] Iwasa H, Yoshida Y, Suzuki T, Kim H, Yoshida H. Leisure activities and cognitive function in elderly community-dwelling individuals in Japan: A 5-year prospective
cohort study. Journal of Psychosomatic Research. 2012;
72: 159−64. Doi: 10.1016/j.jpsychores.2011.10.002.

APPENDIX
Contents of the PGC-MS instrument
Answers are given as yes or no and scored as one
point for yes and zero points for no, for a maximum of
17 points.
1. Things keep getting worse as I get older.
2. I have as much pep as I had last year.
3. I feel lonely.
4. Little things bother me more this year.
5. I see enough of my friends and relatives.
6. As you get older, you are less useful.
7. I sometimes worry so much that I can`t sleep.
8. As I get older, things are (better/worse) than I
thought they would be.
9. I sometimes feel that life isn’t worth living.
10. I am as happy now as I was when I was younger.
11. I have a lot to be sad about.
12. I am afraid of a lot of things.
13. I get mad more than I used to.
14. Life is hard for me much of the time.
15. I am not satisfied with my daily life.
16. I take things hard.
17. I get upset easily.

■ORIGINAL ARTICLE

Effectiveness of an Occupation-Based Home-Visit
Program for Clients with Dementia and Caregivers:
A Pilot Study
Seiji Nishida1, Satoshi Kondo1, Masayuki Takagi1, Timothy Buthod1,
Yoko Yamanishi1, Chikako Koyama1, Kenji Kamijo2
1
2

Department of Occupational Therapy, Prefectural University of Hiroshima
Department of Rehabilitation Sciences, Nishi Kyushu University

Abstract: Several studies have been implemented on home-visit occupational therapy based on activities or occupations for clients with dementia and their caregivers, but all have been conducted abroad; none have taken place in Japan.
Therefore, we performed a pilot study of the effectiveness of an occupation-based home-visit program for clients withdementia and their caregivers using single cohort design. The results of our analysis of participants’ (n = 9) data indicated that the home-visit program could improve the behavioral and psychological symptoms of dementia, particularly
apathy, among clients with dementia, as well as caregivers’ needs or what caregivers expected of clients. Additionally,
the program tended to decrease caregivers’ care burden. The implications of the study are discussed in light of further
research on this program.
Keywords: Dementia, occupational therapy, occupation-based, home-visit(Asian J Occup Ther 13: 7−12, 2017)

1. Introduction
In Japan, the prevalence of dementia in 2012 wasestimated at 4.62 million people. Furthermore, whilein 2012 nearly 15% of people aged 65 years or older
had dementia, this rate is expected to increase to 20%
by 2025 [1]. In response, the Japanese government [2]created a dementia policy in 2012 called the “Orange
Plan.” In line with this policy, the government has
recently been promoting the creation of a society where
people can live in pleasant and familiar surroundings foras long as possible, even when they are suffering fromdementia. Within this background, occupational therapists are expected to play a part in implementing thisgovernment policy. However, we cannot yet assert basedon empirical evidence that occupational therapists offerhome-visit services for clients with dementia and their
Received: 13 June 2015, Accepted: 3 September 2016
Corresponding to: Seiji Nishida, Department of Occupational Therapy,
Prefectural University of Hiroshima, 1-1 Gakuen-cho, Mihara-city,
Hiroshima, Japane-mail: s-nisida@pu-hiroshima.ac.jp©2017 Japanese Association of Occupational Therapists

caregivers of sufficient quality in Japan. This is in contrast to the Netherlands and United States (US), where
there are a number of studies on home-visit occupational
therapy based on activities or occupations. Therefore,
we believe that it is necessary to develop effective
home-visit occupation-based therapy services for clientswith dementia and their caregivers and disseminate themacross Japan.
According to the Canadian Association of Occupational Therapists [3], an occupation is defined as “groupsof activities and tasks of everyday life, named, organized and given value and meaning by individuals and aculture.” Although the term “occupation-based” can beconsidered to refer to engaging in a given occupation [4],we consider it to include both focusing on an occupation(i.e., talking and sharing occupations with clients andtheir caregivers) and engaging in it.
The purpose of the present study was to develop ahome-visit occupation-based program and determine its
effectiveness. Our hypothesis was that a program that
promotes clients’ ability to engage with occupations
and primary caregivers’ ability to supervise clients canimprove the behavioral and psychological symptoms
of dementia (BPSD) among clients and decrease care

8

EFFECTIVENESS OF AN OCCUPATION-BASED HOME-VISIT PROGRAM

burden and satisfy the needs of primary caregivers.
1.1 Literature Review
In the Netherlands, Graff and colleagues developed
a home-visit occupational therapy program for clientswith mild to moderate dementia and their primary
caregivers and examined its effectiveness in a casestudy [5] and single cohort study [6]. Moreover, Graffand colleagues [7, 8] went on to examine the program’s
effectiveness via a randomized controlled trial (Dutch
study). The program comprised 10 one-hour occupational therapy sessions over five weeks, and included
the use of devices to compensate for clients’ cognitive
decline as well as cognitive behavioral interventions for
caregivers that aimed at improving coping behavior andsupervision of clients. At six weeks, clients in the intervention group exhibited significantly improved activities
of daily living (ADLs), quality of life (QOL), healthstatus, and depressive mood in comparison with clientsin the control group. Furthermore, primary caregivers in
the intervention group exhibited significantly improved
QOL, health status, depressive mood, and confidence incontrol over their lives in comparison with those in thecontrol group. This program was called the Community
Occupational Therapy in Dementia Program (COTiD).
Graff et al. [9] further assessed the cost-effectivenessof the COTiD alongside the single-blind randomized
controlled trial, and found that the program was more
successful and cost-effective in comparison to the usual
care.
However, Voigt-Radloff et al. [10] reported that the
COTiD did not work more effectively than a comprehensive one-session occupational therapy consultation
within German routine healthcare (German study).
Possible reasons for this were because Voigt-Radloff
et al. could not arrange for a seminar on intervention
repetition for interventionists, the interventionists had
less treatment experience with their experimental intervention than did those in the Dutch study, and clients
started off with higher ADLs in the German study thanin the Dutch study.
Van’t Leven et al. [11] reported that the COTiD
was not sufficiently used by occupational therapists who
had learned it in a COTiD guideline course at Radboud
University. They ascribed this to difficulties in actually
implementing the rather complicated treatment, andthat therapists had less competence in treating clients athome according to the guidelines. They concluded that
improvements in occupational therapists’ knowledge
and self-confidence would be needed in order to appropriately implement the COTiD guidelines.
In the USA, Gitlin et al. [12, 13] developed the
Tailored Activity Program (TAP) and examined its

effectiveness. Participants included clients with mild tosevere dementia, whose score range on the Mini-Mental
State Examination (MMSE) was 0 to 27. In the TAP,
occupational therapists visited participants six times
and telephoned twice in four months. Furthermore, they
developed activities in accordance with clients’ abilities, and offered interventions that attempted to reduceclients’ environmental demands. The eight-session occupational therapy intervention also involved providing
instructions to caregivers on the use of the developed
activities. The results indicated that the BPSD for clientsin the intervention group, especially shadowing andagitation, improved, as did mastery and self-efficacy
for caregivers. Later, Gitlin et al. [14] examined theeffectiveness of a program called Care of Persons with
Dementia in their Environments (COPE), which aimed
to decrease environmental stress and enhance caregivers’
skills (engaging clients in activities, simplifying tasks,etc.). The COPE comprised all of the TAP sessions aswell as two additional sessions—one home visit andone telephone call—administered by nursing staff thatinvolved advising caregivers on identifying pain andhelping clients drink water. Overall, the result indicatedthat clients showed improved independence in ADLs
and engagement with meaningful activities. Moreover,caregivers showed improved well-being and enhanced
confidence in using activities.

2. Method
2.1 Participants
The research sites were two cities in Hiroshima andSaga prefectures, Japan. From February 2012 to March
2014, we recruited 11 clients from two comprehensive
community centers in these cities. Clients were eligible
for participation if they were aged over 60; were exhibiting symptoms of dementia; could have a meal underobservation by a caregiver, were living in the community; and had a family caregiver who cared for them atleast three times per week, and who were motivated tocare for the clients but had some concerns about it. In
contrast, clients were ineligible if they had severe BPSD
or a diagnosis of schizophrenia or bipolar disorder.
2.2 Intervention
The program comprised eight one-hour sessions
held over eight weeks. In the first two sessions, an occupational therapist identified each client’s meaningfulactivities (i.e., his/her occupations). To this end, theoccupational therapist assessed clients’ lifestyle, occupational history, and interests, as well as the caregivers’
needs (i.e., what caregivers expected clients to do inorder to promote the client’s health), by interviewing

Nishida S et al.

Asian J Occup Ther 13: 7−12, 20179both clients and caregivers. During that interview, weused the Canadian Occupational Performance Measure(COPM) to grasp clients’ meaningful activities and caregivers’ needs. The occupational therapist also evaluatedthe clients’ BPSD and caregivers’ care burden.
In the next five sessions, clients and primary caregivers implemented the previously identified meaningfulactivities via occupational therapists’ support. Additionally, they explored other meaningful activities that
promoted clients’ health. Through demonstrations by theoccupational therapists, caregivers learned how to utilize
effective supervision, communication strategies, andskills to facilitate the clients’ occupational performance.
The facilitating skills included the use of reminder
cards, verbal or visual cueing, simplifying activities,
and simple one-step directions. The communication
strategies included using short instructions, focusing
clients’ attention and encouraging them with praise, andexpressing gratitude towards clients. In the last session,
the occupational therapists reevaluated clients’ BPSD
and caregivers’ care burden and needs (according to the
COPM).

additional outcome measure for primary caregivers was
occupational needs, as assessed with the scale of performance and satisfaction in the COPM; the score for thisscale ranges from 1 to 10, with a higher score indicating
better performance and satisfaction.
We collected information on the age and sex of bothclient and caregiver at baseline. We also assessed theseverity of clients’ dementia using the Clinical Dementia
Rating scale (CDR), which has a score range of 0 to 3
(0 = no cognitive impairment, 0.5 = very mild dementia,
1 = mild dementia, 2 = moderate dementia, 3 = severe
dementia). Furthermore, we recorded the relationshipbetween the client and caregiver.

2.3 Interventionists
All interventions were implemented by several occupational therapists with some experience working in
the field of dementia. Initially, the purpose and methodof this study were explained to them, after which they
were trained how to conduct narrative interviews,
evaluations, and interventions by accompanying thefirst author over at least eight sessions of the program.
Then, they began implementing the interventions bythemselves. In the first two sessions, they had to report
the results of all assessments and evaluations to thefirst author, who also provided advice regarding theirintervention plans and methods. After the third session,interventionists had to continue reporting the contents ofeach session and plans for the next to the first author.

2.6 Ethical Considerations
All participants signed a consent form before datacollection. Furthermore, all participation was voluntarily
and participants were free to quit at any time.

2.4 Outcome Measures
We assessed clients and caregivers in the first two
sessions to provide baseline data, and then performeda reassessment in the last session (eight weeks after
the start of the program). If the program was extended
beyond eight weeks, we still performed the reassessment in the last session. Our primary outcome measure
for clients was BPSD, which was assessed with the
Neuropsychiatric Inventory (NPI). The score for this
instrument ranges from 0 to 120 (with a lower scoreindicating less BPSD). One of the main outcomes forprimary caregivers was care burden as assessed with the
Zarit Burden Interview, which has a score range from 0
to 88 (with a lower score denoting less care burden). An

2.5 Data Analysis
To determine the effect of the program, we used the
Wilcoxon signed-rank test to assess changes in the primary outcome measures (NPI, Zarit Burden Interview,
and COPM at eight weeks) over the intervention period.
The statistical analysis was performed with IBM SPSS
Statistics 22.0 (IBM Corp., Armonk, NY), with a significance level set at p < .05.

3. Results
Of the 11 participants, two dropped out (onebecame ill, one withdrew) after baseline data were collected. As a result, a total of nine participants completed
the program and had their outcome measures reassessedat eight weeks. The baseline characteristics of participants are shown in Table 1. Clients’ mean age was 79.2
years old, the ratio of the sexes was 5/4 (male/female),and the mean CDR score was 1.3. Furthermore, clients’
Table 1. Baseline Characteristics of Clients and Caregivers
Characteristics
Age, M (SD)ClientPrimary caregiver
Sex (M/F)
ClientPrimary caregiver
Relation of caregiver
SpouseBiological child
Others
CDR score, M (SD)ClientParticipants (n = 9)79.2 (10.0)
62.5 (14.6)
5/4
1/8
4
3
2
1.3 (0.5)

Note. CDR, Clinical Dementia Rating scale

10

EFFECTIVENESS OF AN OCCUPATION-BASED HOME-VISIT PROGRAM

dementia severity ranged from mild to moderate (CDR
range = 1−2). Regarding dementia type, Alzheimer’s
disease was the most common. Note that while participants with Alzheimer’s disease took donepezil ormemantine throughout the program, their drugs were
not changed at all during the study period. Additionally,none of the participants had taken psychotropic drugs
aside from these two during the program. Clients’ mostcommon relation to their caregiver was partner.
On average, the number of home visits was 8.9(range = 8−13). Each client’s occupational history, intervention contents, and caregivers’ needs are shown in
Table 2. The meaningful activities used in the intervention included reminiscence, singing, listening to music,
organizing photos, making memory books, carving,golf, mah-jongg, cooking, cherry-blossom viewing,
gardening, walking, and knitting. Almost all of these
activities were related to clients’ occupational histories.
Furthermore, caregivers’ needs included that the client
be more active in daily life, find enjoyable activities,
interact with other people outdoors, spend an enjoyable

time with others, get dressed smoothly, consume a moderate amount of food at each meal, and excrete without
failure.
The medians and interquartile ranges of the outcome measures at baseline and eight weeks are shownin Table 3. Notably, the total NPI score, which reflected
Table 3. Median and Interquartile Ranges of Outcomes Measures atBaseline and Eight Weeks
Items

Median (IQR)
Baselinep

Eight weeks

NPI
Total
14.0 (12.0, 25.0)
Apathy8.0 ( 6.0, 12.0)
Zarit Burden Interview 39.0 (32.0, 62.0)
COPM
Performance score
2.6 ( 2.1, 3.7)
Satisfaction score
2.5 ( 2.3, 3.0)

7.0 ( 2.0, 12.5)
4.0 ( 1.0, 5.0)
33.0 (15.5, 61.0)

0.01
0.01
0.09

6.0 ( 5.6, 8.0)
7.4 ( 5.5, 8.5)

0.01
0.01

Note. Wilcoxon signed-rank test; IQR, interquartile range, NPI,
Neuropsychiatric Inventory; COPM, Canadian Occupational
Performance Measure

Table 2. Clients’ Occupational History, Intervention Contents, and Caregivers’ Needs for Clients
a

Name

Sex

Age

Occupational history

Contents of intervention

A

M

71

Company executive, golf,
karaoke, mah-jongg,
calligraphy

Reminiscence with client’s photo albums, organizing photos, mah-jongg, karaoke, advising on
the client's care, and providing information on
brain-activating rehabilitation to caregiver

Incorporating enjoyable activities into
the client’s daily life, obtaining information to prevent the progression ofdementia

B

F

71

Schoolteacher, karaoke

Reminiscence, singing, advising caregiver onclient care

Finding enjoyable activities, getting
dressed smoothly, feeling well in daily
life, going to the toilet independently at
night

C

M

82

Office worker, experienceof war, karaoke, movies,
gardening

Reminiscence with client’s photos, gardening,
advising caregiver on how to cope with BPSD

More activity in daily life, obtaining
knowledge of dementia

D

F

81

Office worker, housewife, Reminiscence, singing, cooking, cherryknitting, listening to music blossom viewing, discussing bathing methods

More activity in daily life, interactingwith others, taking a bath more often

E

F

83

Factory worker, housewife

Reminiscence, cooking, gardening

More activity in daily life, to knowdementia

F

M

90

Office worker, travel,
taking photos, reading

Reminiscence with the client’s photos, taking awalk and photos, putting a remind-card on thewall at the toilet

More activity in daily life, excreting
without failure, taking a moderateamount of food

G

M

71

Office worker, sing, golf

Making a model of a ship, singing, participatingin manufacturing classes in the community,
practicing in the use of an easy-access remotecontrol device

Interacting with others, finding moreenjoyable activities, operating remotecontrol device for the TV

H

F

97

Self-owned business,housewife, knitting

Reminiscence, knitting, handicraft, advisingcaregiver on how to care for and communicate
with client

Interacting with others outdoors, finding
activities client is able to do, excreting
without failure

I

M

67

Electrician, golf, fishing

Reminiscence, making a memory book, pattinggolf, carving, advising on the client’s care, andgiving caregiver information on brain-activating
rehabilitation

Playing client's favorite sports, making
opportunities to spend an enjoyable
time with others, giving satisfactorycare to client

Note. a Caregivers’ needs refers to what caregivers expected the clients to do in order to promote the client’s health.

Caregivers’ needs

Asian J Occup Ther 13: 7−12, 2017

severity of BPSD, significantly decreased at eightweeks (z = −2.5, p < .05); additionally, the apathy itemof the NPI also significantly decreased (z = −2.5, p <.05). Caregivers’ scores on the Zarit Burden Interview
showed a decreasing trend, but did not exhibit a significant difference (z = −1.7, p > .05). However, caregivers’
performance (z = −2.5, p < .05) and satisfaction scores(z = −2.5, p < .05) on the COPM significantly increased.

4. Discussion
We created an occupation-based home-visit program for clients with dementia and their caregivers andexamined its effectiveness in a pilot study. The results
indicated that the program, which promoted engaging clients with occupations and instructing primary
caregivers to supervise clients, could improve clients’
BPSD, particularly apathy, and satisfy caregivers’ needs.
One possible reason why this program improved clients’
apathy was that the contents of the intervention included
reminiscence. Because reminiscence reminds clients ofpast enjoyable events and stimulates their emotions, they
are more likely to become lively and thereby reducing
feelings of apathy. Another reason may be that clients
could perform interesting or familiar activities without
failure with caregivers’ supervision. The program did
not appear able to decrease the primary caregivers’ careburden, although the change was in the right direction.
In other words, our findings appear to support the hypothesis that a program promoting clients’ engagementwith occupations and instructing primary caregivers tosupervise clients can improve clients’ BPSD and satisfy
caregivers’ needs. However, it must be noted that the
hypothesis may only be supported for clients with mild
to moderate dementia and whose caregiver is motivatedto provide care.
The results concerning clients’ BPSD are consistent
with those of previous studies. Graff et al. [8] reported
that the COPE was effective for improving BPSD, especially depressive mood, among clients with dementia as
well as the depressive mood among caregivers. Similarly, Gitlin et al. [12] reported that the TAP was effectivein improving the BPSD of clients with dementia, especially agitation and argumentation. Taken together, weposit that an occupation-based program for clients withdementia and their caregivers in the community may
be effective in improving depressive mood or apathy
among clients with mild to moderate dementia, and in
improving agitation or argumentation among clientswith severe dementia.
Caregivers’ needs in this study referred to having
clients engage in meaningful activities that the caregiver
expected the clients to do in order to promote clients’Nishida S et al.

11health. In the present study, clients engaged and performed meaningful activities in collaboration with theircaregivers and occupational therapists, and caregivers
learned how to supervise clients. According to a previous study [7], learning how to supervise clients could
enhance caregivers’ confidence in controlling clients’
activities as well as clients’ ability to perform meaningful activities or ADLs. Thus, we propose that a reason
for the increased performance and satisfaction scores on
the COPM in this study was that the caregivers obtained
greater confidence in controlling clients’ meaningful activities and daily life, and that clients’ ability to perform
meaningful activities improved with caregivers’ ability
to supervise clients.
As previously described, an occupation can be
defined as “groups of activities and tasks of everyday
life, named, organized and given value and meaning
by individuals and a culture” [3]. Therefore, any meaningful activity can be regarded as an occupation. In the
COPM, the therapist asks the client about the activities
that he or she needs, wants, or is expected to perform inorder to identify that client’s occupations [15]. Thus, we
regarded meaningful activities as not only interesting
activities that the client needs or wants to perform, butalso activities that he or she is expected to perform by
the caregiver. Particularly, it is important to ask caregivers what they expect the client to do in order to promote
the client’s health because the client with dementia
often has difficulty in expressing their own desires andconcerns. Thus, one advantage of our program might bethat clients with dementia can obtain greater confidence
and liveliness by engaging in interesting, familiar, andexpected activities.
On the other hand, our results did not support a portion of the hypothesis: that is, the program did not resultin a significant decrease in care burden among primary
caregivers. A possible reason for this is that two of the
caregivers’ situations influenced the result. Specifically,of the nine caregivers, one slightly abused and neglected
his client, which made us unable to collaborate withhim. Furthermore, one went into temporary retirementfrom her job in order to devote care to her spouse (i.e.,the client) during the program, which led the caregiverto decrease her social contact. Looking at them individually, it is clear that their Zarit Burden Interview scores
actually increased over the eight weeks.
The limitations of this study include the small
number of participants and not setting up a control
group. Additionally, participants were recruited fromonly two communities and we did not analyze the influence of type of dementia. Therefore, this study appears
to offer relatively little evidence, and it may be difficult
to generalize the results. However, it should be noted

12

EFFECTIVENESS OF AN OCCUPATION-BASED HOME-VISIT PROGRAM

that some of the clients’ BPSD showed a significant
decrease and some of the caregivers’ needs were significantly satisfied. Thus, the research implications include
setting participant criteria such that caregivers cancollaborate with occupational therapists to ensure thatclients can engage in suitable meaningful activities, andto establish a control group.

5. Summary and Conclusions
Overall, the result of this study partially supported
our hypothesis—namely, a program that aims to help
clients engage with occupations and instruct primary
caregivers in client supervision can improve clients’
BPSD as well as satisfy the needs of caregivers. However, our results did not support the part of the hypothesis
concerning caregivers’ care burden. This program canpossibly serve as one of the tools to promote the Orange
Plan [2] and can contribute to building a society where
people can live in pleasant and familiar surroundings foras long as possible, even when they are suffering fromdementia.
Acknowledgements: We thank all participants and interventionists for their contributions. This research was
implemented receiving scientific research funding fromthe Japan Science and Technology Agency from 2012 to2014.

References[1] Ministry of Health, Labour and Welfare. A comprehensive strategy for the promotion of dementia measures: Towards a community friendly to the elderly with dementia“A new orange plan” [online]. Ministry of Health, Labourand Welfare [cited]. Available from: http://www.mhlw.
go.jp/file/04-Houdouhappyou-12304500-RoukenkyokuNinchishougyakutaiboushitaisakusuishinshitsu/02_1.pdf[2] Ministry of Health, Labour and Welfare. 5-year Plan for
promotion of measures against dementia “Orange Plan”[online]. Ministry of Health, Labour and Welfare [cited
2015 April 1]. Available from: http://www.mhlw.go.jp/stf/
houdou/2r9852000002j8dh-att/2r9852000002j8ey.pdf[3] Law M, Steinwender S, Leclair L. Occupation, health andwell-being. Can J Occup Ther. 1998; 65: 81−91.
[4] Fisher AG. Occupation-centred, occupation-based, occupation-focused: Same, same or different? Scand J Occup
Ther. 2013; 20(3): 162−73. doi:10.3109/11038128.2012.
754492[5] Graff MJL, Vernooij-Dassen MJM, Zajec J, Olde-Rikkert
MGM, Hoefnagels WHL, Dekker J. How can occupational therapy improve the daily performance and communication of an older patient with dementia and his primary
caregiver? Dementia. 2006; 5(6): 503−32.

[6] Graff MJL, Vernooij-Dassen MJM, Hoefnagels WHL,
Dekker J, Witte de LP. Occupational therapy at home forolder individuals with mild to moderate cognitive impairments and their primary caregivers: A pilot study. OTJR
(Thorofare N J). 2003; 23(4): 155−64.
[7] Graff MJL, Vernooij-Dassen MJM, Thijssen M, Dekker
J, Hoefnagels WHL, Olde-Rikkert, MGM. Community
based occupational therapy for patients with dementia
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BE[8] Graff MJL, Vernooij-Dassen MJM, Thijssen M, Dekker J,
Hoefnagels WHL, Olde-Rikkert MGM. Effects of community occupational therapy on quality of life, mood, andhealth status in dementia patients and their caregivers: a
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Sci. 2007; 62(9): 1002−9.
[9] Graff MJL, Adang EMM, Vernooij-Dassen MJM, Dekker
J, Jönsson L, Thijssen M, et al. Community occupational
therapy for older patients with dementia and their caregivers: Cost effectiveness study. BMJ. 2008; 336(7636):
134−8. doi:10.1136/bmj.39408.481898.BE[10] Voigt-Radloff S, Graff M, Leonhart R, Schornstein K,
Jessen F, Bohlken J, et al. A multicentre RCT on community occupational therapy in Alzheimer’s disease: 10
sessions are not better than one consultation. BMJ Open.
2011. doi:10.1136/bmjopen-2011-000096[11] Van’t Leven N, Graff MJL, Kaijen M, De Swart BJM,
Olde-Rikkert MGM, Vernooij-Dassen, MJM. Barriers toand facilitators for the use of an evidence-based occupational therapy guideline for older people with dementia
and their carers. Int J Geriatr Psychiatry. 2012; 27(7):742−8. doi:10.1002/gps.2782[12] Gitlin LN, Winter L, Burke J, Chernett N, Dennis MP,
Hauck WW. Tailored activities to manage neuropsychiatric behaviors in persons with dementia and reduce
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Psychiatry. 2008; 16(3): 229−39. doi:10.1097/JGP.0b013e
318160da72[13] Gitlin LN, Winter L, VauseEarland T, Adel Herge E,
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■ORIGINAL ARTICLE

Analysis of reaching movements in stroke patientsusing average variability of electromyogram value
Tatsunori Sawada1, Fuminari Kaneko2, Toshiyuki Aoyama3, Masahiro Ogawa4,
Tsuneji Murakami5
1

Department of Occupational Therapy, School of Health Sciences, Tokyo University of Technology, Tokyo, Japan
Second division of physical therapy, School of health science, Sapporo Medical University, Sapporo, Japan
3
Division of physical therapy, Ibaraki Prefectural University of Health Science, Ibaraki, Japan
4
Graduate school of medicine, Kyoto University, Kyoto, Japan
5
Kure Kyosai Hospital, Hiroshima, Japan
2

Abstract: The hypothesis in this study was tested by conducting EMG experiments comparing the variability in muscle
activity during repetitive reaching movements in hemiplegic patients and healthy subjects. The present study investigated the characteristics of reaching movements in hemiplegic patients using the variability in average electromyogram(EMG) value. We studied 21 right-handed stroke patients with left-sided hemiparesis and 14 right-handed healthy
control subjects. Post-stroke patients (hemiplegic group) and normal subjects (control group) repeated a reaching movement 10 times. The variability in average EMG value of each muscle was defined as the average standard deviation of
the average rectified values (nARV-SDave). During the reaching movements, the nARV-SDave values was significantly
higher in the hemiparesis group than in the control group for the biceps and triceps brachii (P < 0.05). In the hemiparesis group, significant negative correlations between the variability in nARV-SDave values and the Fugl-Meyer assessment scores were observed in all muscle types (rs = −0.46 to −0.76; P < 0.05, P < 0.01). This study identified a direct
relationship between the variability in muscle activity and the severity of motor function deficit in post-stroke patients.
The selective impact on the biceps and triceps were related to the nature of the reaching task.
Keywords: stroke, upper extremity, reaching movement, electromyography, hemiplagia(Asian J Occup Ther 13: 13−21, 2017)

Introduction
A stroke is a medical emergency because a severe
reduction or interruption of blood flow to the brain
causes the cell death within minutes. The most common
complication following a stroke is a transient or permanent impairment of upper extremity functions, limiting
the patients’ autonomy [1]. As many daily activities involve reaching for an object, it is important for physicaland occupational therapists to understand the kinematicand kinetic characteristics of reaching movements inpost-stroke patients.
Received: 17 October 2016, Accepted: 21 February 2017
Corresponding to: Tatsunori Sawada, Department of Occupational
Therapy, School of Health Sciences, Tokyo University of Technology,
5-23-22, Nishikamata, Ohta-ku, Tokyo, 144-8535, Japane-mail address: sawadatn@stf.teu.ac.jp©2017 Japanese Association of Occupational Therapists

Several kinematic studies revealed that reaching
movements in stroke patients are characterized byenhanced variability, prolonged movements, and alower range of motion in the shoulder and elbow joints,
compared with healthy subjects or the non-affected side[2−7]. The higher movement variability suggests thatstroke patients are not able to stably perform reaching
movements when asked to repeat them several times.
In other words, stroke patients assume kinematicallyunstable reaching patterns, and the trajectory varies
during repetitive reaching movements. Electromyography (EMG) studies identified muscle activation abnormalities in stroke patients, such as prolonged agonist
bursts associated with reduced speed during elbow
flexion and extension [8], simultaneous co-contractionof agonist and antagonist muscles [9−13], and abnormal
muscle tone [14]. Muscle synergy and spasticity instroke patients generate specific movement patterns[15, 16]. Most studies characterized the patients using

14

ANALYSIS OF REACH USING EMG

integral EMG data and the ratio of agonist/antagonist
muscle contraction, which provided useful information
on muscle combination, synergy, and spasticity. These
approaches identified the relation of the muscle groups
affected by a stroke during typical synergy patterns (e.g.,
co-contraction) [15, 16], but the characteristics of specific muscles remain unclear. It is important to clarify
this point to enable physical and occupational therapists
to target specific muscles when treating post-stroke patients for unstable reaching movements.
The aim of this kinetic study was to analyze thecharacteristics of reaching movements in stroke patients. This hypothesis was tested by conducting EMG
experiments comparing the variability in muscle activity
during repetitive reaching movements in hemiplegicpatients and healthy subjects. We hypothesized thatspecific muscles contribute to the variability in reaching
movements, and that their activity correlates with theseverity of motor dysfunction.

Methods
Subjects
The subjects were patients treated at Rehabilitation
Hospital (Saitama, Japan) for a stroke. Those includedin the study (hemiplegic group) met the following criteria: (1) no serious cognitive deficit; (2) a Mini-Mental
State Examination (MMSE) score > 24; (3) no marked
contracture affecting performance during a reachingtask; (4) the absence of paralysis that would preventthe subjects from completing a reaching task; and (5)right arm dominance. The patients with a lesion locatedin the cerebellum or brainstem were excluded because
the symptoms produced by such lesions are atypicalin comparison with those in other areas. Subjects wererecruited in a rehabilitation hospital.
We studied 21 right-handed stroke patients with
left-sided hemiparesis (hemiparesis group, mean age:
57.0 ± 0.8 years, 19 men, two women) and 14 righthanded healthy control subjects (control group, mean
age: 53.7 ± 10.7, seven men, seven women). All subjects
gave their written informed consent. The protocol wasin accordance with the Declaration of Helsinki andapproved by the Ethics Committee. Table 1 presents
demographic data for participants.
Experimental Procedure
The experimental design is described in Fig. 1.
Each subject was seated on a chair in front of a table,with the trunk immobilized by a set of straps. On theside affected by the stroke, the hand and forearm were
immobilized using a splint device. An acrylic board wasplaced on the table underneath the arm and was coated

Table 1. Demographic data of all subjects and clinical score of thehemiplegic subjects.
ID

Age

Sex

Durationof disease(Month)

MMSE

FM

H1
H2
H3
H4
H5
H6
H7
H8
H9
H10
H11
H12
H13
H14
H15
H16
H17
H18
H19
H20
H21

47
57
57
48
35
64
67
63
70
63
43
59
51
62
43
67
70
56
49
61
65

M
M
M
M
M
M
F
M
M
M
M
M
M
M
M
M
M
M
M
M
F

12
13
15
5
4
10
3
5
4
4
4
3
2
7
3
5
4
6
4
4
3

30
30
30
30
30
25
25
30
25
27
30
30
29
30
27
30
30
30
28
25
30

13
25
23
34
34
25
15
29
10
5
21
12
36
22
6
30
5
19
27
10
33

C1
C2
C3
C4
C5
C6
C7
C8
C9
C10
C11
C12
C13
C14

42
57
56
33
34
57
63
68
61
51
52
61
64
53

F
M
F
M
M
F
F
M
M
M
F
F
M
F

−
−
−
−
−
−
−
−
−
−
−
−
−
−

−
−
−
−
−
−
−
−
−
−
−
−
−
−

−
−
−
−
−
−
−
−
−
−
−
−
−
−

Mean ± SD

55.7 ± 10.2

5.7 ± 3.6 28.6 ± 2.0 20.7 ± 10.2

H: Hemiparesis group, C: Control group, M: Man, F: Female, MMSE:
Mini-Mental-State Examination, FM: Fugl-Meyer Assessment of Sensorimotor Recovery After Stroke Score

with silicon spray to decrease friction between the board
and the splint. Each reaching task were initiated from astarting point (30° of abduction, 10° of shoulder extension, and 100° of elbow flexion) to a target point (30° of
elbow flexion on the sagittal-horizontal axis). A circular
tag was placed at the start and target points. The data
were collected using laser sensors (LV21-A, Keyence
Corp., Japan) located at the start and target points on theother side of the table.
Each task consisted of the subject attempting tomove from the start point to the target point, and back tothe start point. The length of each task was determinedAsian J Occup Ther 13: 13−21, 2017

Fig. 1. Illustration of the experimental setup: (A) horizontal
plane view, (B) sagittal plane view.

by the signal received by the laser sensor positioned at
the start point (Laser 1). The subject was confirmed toreach the target point by a signal from the laser sensor atthat point (Laser 2). During the reaching movement, thesubjects began to move their forearm slightly before thestarting point, pass over the target point, pull back theirforearm and pass over the starting point. At the starting
and target point, the subjects were instructed to makethe pass-over distance less than a few centimeters.
Previous studies on healthy subjects analyzed reaching tasks using a ballistic movement [4, 5]. However,daily life seldom requires one to reach for something
quickly. Therefore, our subjects were asked to performthe reaching task at a comfortable speed that they determined during preliminary trials. They repeated thereaching task 10 times with a few minutes of rest after
each task. This task was not heavy, but we decided thelength of the muscle recovery period was about 2 minutes by subject’s subjectively opinions in our preliminary tests.
EMG Recordings and Analysis
Surface EMG recordings from the left upper extremity were obtained using active electrodes (DE-2.1,
Delsys Inc., USA). The six muscles targeted were thepectoralis major, the anterior, middle, and posteriordeltoid, as well as the brachii muscles of the biceps andtriceps. The electrodes were placed at the center of thebelly of each muscle. Before attaching the electrodes,
the skin surface was abraded with Nuprep Skin Prep Gel(Weaver and Company, USA), and rubbed with alcohol.

Sawada T et al.

15

The position of the electrodes was verified by the examination of the EMG activity on a computer monitor
during preliminary tasks [17].
The sampling frequency of the EMG signals was1000 Hz. An EMG amplifier (Bagnoli2, Delsys Inc.,
USA) was used to record the EMG activity. The signals
were digitized using a NR-2000 (Keyence Corp., Japan)
and recorded on a computer. The signals from laser sensors were recorded to measure the analysis period.
The data were analyzed using the method describedby Kaneko [18]. The EMG signals were filtered offline(bandwidth ranging from 10 to 500 Hz) using the Butterworth filter to calculate the average rectified value (ARV)
using LabView version 7.1 (National Instruments Corp.,
USA; Fig. 2). For experiments comparing the strokegroup to the control group, the ARV and analysis period
needed to be normalized. We could not adapt the usual
normalization method (e.g., Maximal Voluntary Contraction). Therefore, the ARV was normalized using the
maximum ARV value of all 10 reaching tasks and theanalysis periods. The EMG signals of each task were interpolated by spline transformation using MATLAB version 7.0.1 (MathWorks Inc., USA). Then, the number ofrepresenting data was fixed as 1000 points. Because all
subjects took more than 1 second to complete the task,
the method of interpolation for all trials was downsampling. The amplitude of the ARV and the time were normalized in this manner (normalized ARV; nARV). The
standard deviation of the nARV was calculated at eachpoint for a total of 10 tasks (nARV standard deviation;nARV-SD). The variability of the average EMG of eachmuscle was defined as the average nARV-SD (nARVSDave) for the 10 normalized reaching periods recorded
sequentially.
Clinical Evaluation
The motor function of the affected arm was evaluated using the Fugl-Meyer assessment method of sensorimotor recovery after the stroke test [19]. The scores
ranged from 0 (severe deficit) to 66 (no detectable deficit). In this study, we used a variant of the Fugl-Meyer
test (FM) designed for upper extremity functions.
Statistical Analysis
The unpaired t-test was used to compare the control
group and hemiplegic group for the nARV-SDave valuesof each muscle. Spearman rank-order correlation wasused to analyze the relationship between nARV-SDave
values and FM score for each muscle. SPSS 22.0 wasused for statistical analysis. The significance level of all
statistical comparisons was set at p < 0.05.

16

ANALYSIS OF REACH USING EMG

Fig. 2. Electromyogram (EMG) raw data recorded from the shoulder and elbow muscles of a normal subject (ID number C1)
during each reaching task (A). Curved line indicates the normalized average rectified value (nARV) (B).

Results
Typical Subjects
Typical nARV curves are presented for one subjectof the control group (Fig. 3) and the hemiplegic group(Fig. 4). The superimposed nARV curves were processedfrom the raw EMG data recorded during each of the 10
reaching tasks to show the variability in EMG values(Figs. 3A and 4A). The nARV-SD calculated from eachnARV are presented in Fig. 3B and 4B. FM scores foreach subject are presented in Table 1. The nARV curvesof the typical control subject (Fig. 3) were less variable
than those of the typical hemiplegic subject (Fig. 4).

Comparison of nARV-SDave between the hemiplegic andcontrol groups
The two groups were compared for the meannARV-SDave values of the six muscles. Significant differences in nARV-SDave between the two groups wereidentified by two-way ANOVA. The multiple range tests
indicated that the nARV-SDave values of the biceps andtriceps brachii were significantly higher in the hemiplegic group than in the control group (Fig. 5, P < 0.05). In
contrast, no significant difference was observed between
the groups for the other four muscles tested.

Asian J Occup Ther 13: 13−21, 2017

Sawada T et al.

17

Fig. 3. Normalized average rectified value (nARV) for a typical subject of the normal group (ID number C2). (A) Superimposed
nARV. (B) Averaged curve of the nARV (nARVave) with the standard deviation (nARV-SD) shown as the grey area.

Correlation between nARV-SDave and FM scores
The hemiparesis group was further evaluated for the
relationship between nARV-SDave and FM scores foreach muscle group (Fig. 6). Strong negative correlations
were observed in all muscles.

Discussion
We used EMG recordings to distinguish the muscle
activities during kinematically unstable repetitive reaching tasks. It has been emphasized that EMG is the mostappropriate method to measure motor function, because
it has high clinical significance [9−13, 15, 16, 20]. Integral EMG (IEMG) [14] and co-contraction ratio (CCR)[16] have been suggested to determine the co-contraction

ratio between muscles. In recent years, partially linear
decomposition methods, such principal component
analysis (PCA), linear independent component analysis(ICA) [21, 22], and nonnegative matrix factorization(NMF) [23], are often used to investigate the relation
between cortical activation (electroencephalography)
and movement (EMG). They are useful to detect inter­actions between the central nervous system (CNS) andmuscles. Whereas these new methods are useful tostudy muscle–muscle (e.g., co-contraction and synergy)
or CNS–muscle interactions, these studies could notcompare the variability in activities of each muscle type
during repetitive reaching task. Therefore, the selective
increase in variability in brachii muscle activity during
repetitive reaching movements, identified in the present

18

ANALYSIS OF REACH USING EMG

Fig. 4. Normalized average rectified value (nARV) for a typical subject of the stroke group (ID number H1). (A) Superimposed
nARV values. (B) Averaged curve of the nARV (nARVave) with the standard deviation (nARV-SD) shown as the grey area.

Fig. 5. Identification of the arm muscles responsible forreaching movement variability in post-stroke patients.

study, has high clinical significance.
The strong negative correlations between thenARV-SDave of all six muscle types and the FM scoreof the post-stroke patients clearly indicate that a severe
deficit in motor function is associated with highly
unstable muscle activities during repetitive reaching
movements. Previous studies showed that the characteristics of reaching movements in stroke combine unstabletrajectory and velocity [2−7]. These characteristics indicate that the continuous and smooth movement strategy
used during reaching activities is lost in post-stroke
patients [2]. The present study suggests that the variability in muscle activity may explain the unstable movement reported in previous kinematic studies [2]. Our
results support the notion that the variability in muscle
activity relates to unstable movement.

Asian J Occup Ther 13: 13−21, 2017

Sawada T et al.

19

Fig. 6. Relationship between the nARV-SDave values and FM scores of each muscle in the hemiplegic subjects.

It should be emphasized that measurements ofmuscle activity using EMG have a high clinical significance from the viewpoint of variability. Because motor
impairment in the upper extremity is the most frequent
stroke complication, therapists make considerable efforts to target abnormal muscle activities. Furthermore,
the present study proposes a promising method to objectively assess hemiplegic upper extremities to avoid unreliable assessments, such as the FM score, as pointed out
by [16] Despite these facts, such subjective assessment
methods are the most widely used in clinical settings [19,25]. Although these clinical assessments are very usefulto roughly estimate motor disorders, they cannot clarify
multiple muscle activities in detail. Consequently, thereliable EMG measurements presented herein clarify thecharacteristics of variability in muscle activity in poststroke patients.
The selective impact of a stroke on the activities of
biceps and triceps brachii is intriguing. Previous studies
used reaching tasks that involved pointing a forward

spatial target [4, 5]. Because these tasks required lifting
the upper extremity, the deltoid played a major role tohold the arm up against gravity. However, our study adopted a reaching task requiring the subjects to slide theirforearm on a table with reduced friction. Therefore, thesubjects could complete the task even if they had serious
upper extremity paresis limiting their ability to raise
their arm against gravity. During our task, the prime
mover muscles were likely the biceps and triceps brachii, rather than the deltoid. A previous study comparedmuscle activation patterns during reaching and retrieval
movements with and without gravity compensation, andthe data showed that the level of muscle activity was
lower with gravity compensation [26]. These results are
consistent with our reasoning that the sliding task would
predominantly engage the bicep and tricep muscles.
The comparable deltoid and pectoralis major activities of the hemiplegic and control groups suggest that
unstable muscle activity might exist in control subjects
during repetitive reaching movements. These findings

20

ANALYSIS OF REACH USING EMG

may be related to Bernstein’s problem, whereby morethan one motor signal can lead to the same trajectory ofa given motor system and identical motor signals canlead to different movements under non-identical initialconditions or in the presence of variations in the eternal
force field [27, 28]. The hypothesis supporting the concept of degrees of freedom to motor control is that the
principal problem faced by the central nervous systemis the large number of joints and muscles in the humanbody and the infinite combinations of muscle action [27,29]. In stroke subjects, kinematic variability may be
due to unstable muscle activity during a single reaching
movement. In the post-stroke subjects, the trajectory
was fluctuating during repetitive reaching movements
owing to variability in muscle activity. In control subjects, kinematic variability may be due to difficulties in
reproducing exactly repeated muscle activities. Althoughmuscle activity remains stable during each reaching
movement, the combination of muscle activity is notconstant between repetitions. Normally, coordination
between muscle types (synergy) decreases the kinematic
variability even if the variability in muscle activity increases, a mechanism lost in hemiplegic subjects.

Conclusion
We report the existence of variability in muscle
activity during repetitive reaching movements in hemiparesis subjects. A significant negative correlation wasestablished between the variability in muscle activity
and the clinical score. The use of EMG analysis may
be useful to clinically assess the variability in muscle
activity.
Conflicts of Interest
The author declares no conflict of interest.

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■REVIEW

Influence of interaction among the elderly throughamusement on their physiological function:
One-month introduction at a day care service centerfor the elderly
Nami Kawabata1, Hideki Miyaguchi2, Masafumi Kunishige3, Chinami Ishizuki2,
Yasuhiro Ito4, Toshihide Harada5, Tadayuki Iida5
1

Department of Rehabilitation/Occupational Therapist, Faculty of Health Sciences, Hiroshima Cosmopolitan University,
Hiroshima, Japan2
Department of Human Behavior Science of Occupational Therapy, Health Sciences Major, Graduate School of Biomedical &Health Sciences, Hiroshima University, Hiroshima, Japan
3
Division of Occupational Therapy, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
4
Health Sciences, Fujita Health University, Aichi, Japan
5
Department of Physical Therapy, Faculty of Health and Welfare, Prefectural University of Hiroshima, Hiroshima, Japan

Abstract: Objective: Amusement was introduced for one month and interaction among the elderly and its influenceon their physiological function and sleep were investigated. Methods: The subjects were 9 elderly females (age: 89.0
± 4.7 years old) who periodically visited a day care service center for the elderly. The survey was performed between
October 2015 and December 2015. For the amusement, Blackjack was introduced. The survey period was comprised of
3 amusement introduction periods: pre-amusement, and one week and one month after amusement introduction. In eachperiod, the heart rate (HR), sympathetic nerve activity (CSI), and parasympathetic nerve activity (CVI) were measured
during amusement, and the difference in the salivary amylase level between before and after amusement was determined. The sleep efficiency and sleeping hours were measured at night of the days with amusement. Repeated measures
one-way ANOVA was performed regarding the survey period as a factor and HR, CSI, CVI, sleep efficiency, sleeping
hours, and difference in the amylase level as dependent variables. Results: Significant amusement-induced changes
were noted in the CVI and salivary amylase level. These were significantly lower at one month after amusement introduction than those in pre-amusement. Conclusion: Amusement-induced laughing and regret or interaction through theamusement influenced their autonomic nerve system and they may have felt comfortable.
Keywords: amusement, sympathetic nerve activity, parasympathetic nerve activity, salivary amylase(Asian J Occup Ther 13: 23−30, 2017)

Introduction
The 65-year-old or older population exceeded 30
million with rapid aging in Japan. It is predicted to peakwith about 39 million in 2042 and the 75-year-old orolder population will continuously increase thereafter.
The Ministry of Health, Labour and Welfare promotes
Received: 31 May 2016, Accepted: 31 March 2017
Corresponding to: Tadayuki Iida, Department of Physical Therapy,
Faculty of Health and Welfare, Prefectural University of Hiroshima,
1-1 Gakuen-cho, Mihara City, Hiroshima Pref. 723-0053, Japane-mail: iida@pu-hiroshima.ac.jp©2017 Japanese Association of Occupational Therapists

construction of the Integrated Community Care Systemtargeting 2025 [1], and how to prevent a need-fornursing care state in the elderly is an urgent issue.
Regarding the prevention of nursing care, improvementof sociality of the elderly, such as an increase in conversation with emotional changes by interaction throughconversation employing the life review/reminiscencetherapy, and subsequent improvement of nighttime
sleeping hours have been reported [2−4]. In addition,
prevention of nursing through amusement devices has
recently been attracting attention, and improvement of
the motor function by using amusement devices has
been reported [5]. Matsuguma et al. performed researchand development of a game machine for standing up-

24

INTERACTION AMONG THE ELDERLY THROUGH AMUSEMENT

sitting down training, and investigated the influence ofthe entertainment value of the game on the positivenessof patients/users and improvement of persistence. Specifically, fatigue strength was significantly decreased byvoluntary training with the game on subjective evaluation, and the subjects tended to consider that ‘I want to
do it again’ and ‘it was fun’, showing a positive attitude[6]. It was suggested that ‘pleasant stimulations’, suchas ‘enjoying’ and ‘having fun’, which are entertainment
values of amusement, increase motivation, positiveness,
and activeness, influencing improvement of the motor
function. Regarding communication through the game,they reported that new communication between patients and rehabilitation staff and among patients wereconstructed [6, 7]. It was suggested as described abovethat amusement increases motivation and positiveness,promotes activeness, and produces new communication[6, 7]. However, no study on the physiological function
demonstrating ‘pleasant stimulation’ by interaction
through amusement has been performed, or the effect of
this ‘pleasant stimulation’ on sleep.
In preceding studies on mental stress, analysisof the endocrine system or heart rate variability wasused as a physiological index of stress analysis [8, 9].
Yamaguchi et al. focused on salivary amylase as a newindex of sympathetic nerve activity. They clarified thatsalivary amylase may serve as a stress index responding
more rapidly than cortisol, and unpleasant stimulation
elevates salivary amylase activity and inversely, pleasantstimulation decreases it, showing a possibility to distinguish comfort and discomfort based on salivary amylase[10, 11].
Shimizu et al. investigated ‘laughing stimulus’induced changes in physiological indices, and suggested that stress was reduced by laughing based on thesalivary amylase level, and sympathetic nerve activity
was enhanced while being stimulated with laughing,followed by enhancement of parasympathetic nerve
activity, and returning to the resting state [12]. Takada etal. performed intervention of the elderly with ‘pleasantconversation’, and observed that it was appropriate
for intervention of the elderly because its physical andmental burdens were small, and fulfillment of the mind
and the effect of relaxation were observed after the conversation [13]. However, all these were transient effectsof short-time intervention, and the effect of long-term
intervention was not investigated. A long-term effect isnecessary from the viewpoint of preventing needs fornursing. In addition, these studies used the low frequency (LF) component of spectral analysis of heartbeat R-R
interval, which is an index of parasympathetic nerve
enhancement, and LF/high frequency (HF) component,
which is an index of sympathetic nerve enhancement,

as indices of autonomic nerve activity [12, 13]. However, to estimate autonomic nerve activity by spectral
analysis, it is essential to have uniform respiration to a
specific depth during measurement of cardiac cycle data[14], and Sawada pointed out that spectral analysis of
the R-R interval of heartbeats is not appropriate to tracereflections of sympathetic nerve activity of the heart[15]. In such a background, Toichi et al. found a method
to evaluate cardiac autonomic nerve activity based onheartbeat R-R interval data using the Lorentz plot. They
stated that this method is capable of evaluating sympathetic and parasympathetic nerve activities individually,
which has been difficult using spectral analysis, and its
usefulness has been reported [16].
Thus, we intervene in interactions among the elderly
through one-month amusement, and investigated timecourse changes in the autonomic nerve activity calculated using the Lorenz plot and salivary amylase level andthe influence on sleep.

Materials and Methods
Subjects
The subjects were elderly females (age: 89.0 ± 4.7
years old) who periodically visited a day care service
center for the elderly in Japan. The level of care needed
was between Support Need 2 and Long-Term Care 2.
Regarding ADL, the Barthel Index (BI) [17] was 87.2
± 11.2, requiring support/assistance to some extent,
but the grade of independence was high (Table 1). The
cognitive function was evaluated using the Mini-Mental
State Examination (MMSE) [18]. The score was 26.8
± 2.6, and it was lower than 23 in 2 subjects, but theirscores correspond to mild on the severity judgment [19].

Table 1. Basic attributes of the subjectsnGenderFemale9Support Need 2
Long-Term Care 1
Long-Term Care 2

3
4
2

90−100
70−85

5
4

≤ 23
27−24
28−29

2
2
5

≤4
5−10

6
3

Age (years)
Level of care needed

BI (point)

MMSE (point)

K6 Scales (point)

mean

SD

89

(4.7)

87.2

(11.2)

26.8

(2.6)

4.3

(3.8)

Kawabata N et al.

Asian J Occup Ther 13: 23−30, 2017

For evaluation of mental stress, the Japanese version of
the Kessler Psychological Distress Scale (K6) [20] wasused. Reliability and validity of social survey using K6
have been evaluated in Japan. The score range of K6 is0−24, and mental stress increases as the score increases.
A recent study proposed a cut-off value of 10 or higher
for mood/anxiety disorder in the Japanese version [21],in which the score of the subjects was 4.3 ± 3.8 including 2 subjects with a score of 10, but no marked
change in the cognitive function, words, or behavior
suggesting serious depression was noted throughout
the survey period (Tables 1 and 2). Of 15 subjects towhom the study content was explained beforehand andconsent was obtained, 9 subjects in whom saliva could
be collected and the sleep condition could be measured
were included in analysis. This study was conductedwith the approval of the Research Ethics of Hiroshima
University (approval number: E-318), conforming to the
Declaration of Helsinki.
Survey items
The survey was performed from October 2015 to
December 2015. The survey period was comprised of
3 amusement introduction periods: before amusement
introduction (pre-amusement), and one week and one
month after amusement introduction. In each period,
the heart rate (HR) and autonomic nerve activity were
measured, saliva was collected, and the sleep condition
was measured.
Amusement
Blackjack was introduced. Staff of the day careservice center for the elderly served as a dealer, and thesubjects were players. In Blackjack, the dealer and players match games. The basic rule is that players collectcards so as to make the total score close to but smaller
than 21 and greater than that of the dealer. Regarding
the card score, ‘A’ was scored 1 or 11 (whichever con-25

Fig. 1. Cards labeled with an only a letter or number.

venient), and ‘2−10’ cards were scored as their numbers,
respectively. Since numbers printed in the designs of
trump cards are small, reading and calculating the numbers are difficult. Thus, the card designs were removed
and only numbers were printed (Fig. 1). To increase
activeness, cards were spread and the players picked up
cards for the game (Fig. 2b), the dealer did not distributecards (Fig. 2a).
Measurement of heart rate and autonomic nerve activity
HR and changes in the autonomic nervous systemon heart rate variability analysis were measured frombefore amusement to after amusement using a wearable
heartbeat sensor, WHS-1 (UNION TOOL Co.) directly
applied to the chest with a Blue Sensor (METS Inc.)
electrode pad. The amusement time was 13:30−14:30,
and data were collected during this period in all amusement introduction periods. Based on the R-R interval
data measured in 60-minute electrocardiography, HR(number of beats/min) and the indices of sympathetic(CSI: cardiac sympathetic index) and parasympathetic(CVI: cardiac vagal index) nerve activities were calculated using the Lorenz plot analysis program [22]. In
this Lorentz plot, the measured values of continuousheartbeat R-R intervals were presented as I1, I2, …, In .

Table 2. Association between the amusement introduction period and heart rate, autonomic nervous system, sleep condition, Kessler Psychological Distress Scale (K6 Scales) (n=9)
Pre-amusement

HR (/min)CSI
CVI
Sleep efficiency (%)
Sleeping hours (min)MMSE (point)
K6 Scales (point)

One week after amusement introduction

One month after amusement introduction

Mean

SD

Mean

SD

Mean

SD

75.3
1.3
6.0*a
90
420.2
26.8
4.3

(6.1)
(0.2)
(0.5)
(6.1)
(80.4)
(2.6)
(3.8)

73
1.3
5.9
92.7
421.4
25.4
3.6

(3.3)
(0.4)
(1.0)
(3.4)
(118.6)
(1.9)
(3.9)

79
1
5.4*a
91.4
470.6
27.0
4.1

(7.9)
(0.1)
(0.5)
(4.9)
(70.7)(2.3)(4.8)

p value: repeated measures one-way ANOVA*a: pre vs 1month, p = 0.004 by Bonferroni

p-value
0.052
0.208
0.059
0.262
0.134
0.148
0.712

26

INTERACTION AMONG THE ELDERLY THROUGH AMUSEMENT

a: Distribution of cards by the dealer

b: Withdrawal of cards by players

Fig. 2. Card distribution method in the amusement.

Heartbeat R-R intervals of Ik were plotted on the horizontal axis and those of Ik + 1 were plotted on the vertical axis, and the plots are distributed in an oval patternwith straight line Ik = Ik + 1 as a longitudinal axis. The
major axis component L (horizontal to the line Ik = Ik +1) and minor axis component (vertical to the line Ik = Ik
+ 1) were calculated, and the L/T ratio was regarded as
the CSI value and the area value of L and T, log (L × T),
was regarded as the CVI value [16]. An increase anddecrease in the CSI value indicate promotion and suppression of sympathetic nerve activity, respectively. An
increase and decrease in the CVI value indicate promotion and suppression of parasympathetic nerve activity,
respectively.
Measurement of change in the salivary amylase level
Saliva was collected between 11:30 and 12:00
before lunch and between 14:45 and 15:00 after amusement. To collect saliva samples for measurement, thesubjects held a swab in their mouth for 3 minutes (amaximum of 5 minutes) using Salimetrics Oral Swab(Salimetrics LLC). Saliva was separated from theswabs by centrifugation at 3,500 rpm for 15 minutes
and frozen. For the measurement, the BG5 PNP method(corresponding to JCCLS) was used. The salivary
amylase level before amusement was subtracted fromthat after amusement in all periods, and changes were
determined. There are several amylase measurement
methods, such as enzyme and blue starch methods. The
standard value is different among the measurement
methods and individual variation is large [23]. Sincechanges in individuals were investigated in this study,
the change was determined by subtracting the amylase
level after the amusement from that before the amusement.

Measurement of sleep condition
The sleep condition was measured at night on the
day the subject performed amusement. They wore Actiwatch Spectrum Plus (Philips Respironics GK) on theirwrist from 15:00 to pick-up time on the following morning. Body movement and ambient light were subjected
to quantitative analysis using Actiware, and the sleep
efficiency (%) and sleeping hours (min) were calculated.
DATA ANALYSIS
The means and standard deviations of HR, CSI,
CVI, sleep efficiency, sleeping hours, and change in
the amylase level in the amusement introduction period(pre-amusement and one week and one month after
amusement introduction) were determined. Repeatedmeasures one-way ANOVA was performed regarding theperiod as one factor and HR, CSI, CVI, sleep efficiency,
sleeping hours, and difference in the amylase level as
dependent variables. For multiple comparison, the Bonferroni method was used. The normality of HR, CSI,
CVI, sleep efficiency, sleeping hours, and the change in
the amylase level were confirmed using histograms andthe Kolmogolov-Smirnov test ( p = 0.200). Statisticalanalysis was performed using EZR Ver 1.32 [24] setting
the significance level at p < 0.05.

Results
Significant differences among the amusement introduction periods were observed in CVI (Table 2, repeatedmeasures one-way ANOVA): The value at pre-amusement was 6.0 and that at one month after amusement
introduction was 5.4, showing a significant decrease.
The heart rate, CSI, sleep efficiency, and sleeping hours
were not significantly different. The change in the salivary amylase level was significantly different among theamusement introduction periods (Fig. 3, repeated mea­

Kawabata N et al.

Asian J Occup Ther 13: 23−30, 201727

Fig. 3. Association between the amusement introduction period and change in thesalivary amylase level.
Change in salivary amylase level = after amusement salivary amylase level- before amusement salivary amylase level Mean (SD)
Repeated measures one-way ANOVA: p = 0.010*: pre vs 1month, p = 0.035 by Bonferroni

sures one-way ANOVA). The values at pre-amusement
and one month after amusement introduction were
130,634 and −111,627 U/L, respectively, showing asignificant decrease at one month.

Discussion
The amusement introduction period and CVI
showed a significant association, and CVI was significantly lower at one month after amusement introduction
than that at pre-amusement (Table 2). The results of thisstudy were consistent with those of previous reports[12, 13, 25], but these studies investigated the effectof short-time intervention, whereas our study introduced amusement and followed the subjects for a long
period, which initially clarified the association between
amusement and parasympathetic nerve activity. Regarding sympathetic nerve activity, no association withthe amusement introduction period was noted. In theamusement, Blackjack, the cards were shuffled by the
subjects before the game, the cards were distributed, andthe number of chips was determined from the distributed
card. The subjects calculated the sum of the 1st and 2nd
cards in their head to decide on pulling the 3rd card.
These processes may include many stress stimulations
required for active processing. Cardiovascular responseto stress stimulation includes active and passive copings [26]. Positive coping means actively confronting
stimulation, such as competition in mental arithmetic
and reaction time, i.e., active challenge and competition
in response to stimulation that one can deal with. In

passive coping, one cannot move, remaining in a passive attitude against stress stimulation and continue to
pay attention and surveillance [15]. Sympathetic nerve
activity is promoted and parasympathetic nerve activity
is suppressed in a situation requiring active coping
whereas sympathetic nerve activity is suppressed andparasympathetic nerve activity is promoted in a situation
requiring passive coping [26]. Therefore, active coping
during the amusement may have suppressed parasympathetic nerve activity, resulting in a low CVI value.
On the other hand, it has been reported that ‘laughing
stimuli’ of comic dialogues stimulate and enhance both
sympathetic and parasympathetic nerve activities, andthe mean parasympathetic nerve activity level was
inhibited while being stimulated [25], in which the subjects did not constantly receive ‘laughing stimuli’ andchanges also appeared in movements, such as instantaneous ‘laughing’, ‘laughing aloud’, ‘laughing with body
movement back and forth’, and ‘laughing holding one’s
sides’ [25]. It was also reported that sympathetic nerve
activity was significantly enhanced and parasympathetic
nerve activity was significantly suppressed in subjects
who felt a funny video as ‘funny’, compared with thosein subjects who did not perceive the video as funny[27]. In addition, it has been suggested that ‘laughing
stimulus’-induced enhancement of sympathetic nerve
activity occurred while being stimulated with laughing,followed by enhancement of parasympathetic nerve activity and returning to a resting state [12]. In our study,
instantaneous stimuli, such as laughing and regret, andresting, such as waiting for one’s turn and conversation,

28

INTERACTION AMONG THE ELDERLY THROUGH AMUSEMENT

were repeated in the interactions during the amusement,suggesting that enhancement and suppression of sympathetic and parasympathetic nerve activities repeated. No
significant association was observed between the amusement introduction period and sympathetic nerve activity.
Averaging the total time performing the amusement may
have influenced this. Considering that analysis averaging the entire range with stimulation investigates only apart of the characteristics in studies on ‘laughter stimulation’, Kobayashi tried to investigate time-series data
to qualitatively analyze the characteristics of responseto ‘laughter stimulation’ in individual data [25]. We may
also have been able to closely analyze changes in sympathetic and parasympathetic nerve activities during theamusement by time-series analysis, such as ‘immediately
after initiation of the amusement’ and ‘10 minutes after
initiation of the amusement’.
Our study did not aim at evaluation of the amusement-induced autonomous nervous activity during
a short period, but one-month intervention with theamusement may have suppressed parasympathetic
nerve activity by promoting active coping behavior, andinteraction through the amusement may have suppressed
excess sympathetic nerve activity.
Significant differences were noted in the change
in the salivary amylase level among the amusement
introduction periods, and it was significantly lower
at one month after amusement introduction than thatat pre-amusement (Fig. 3). The interaction during theamusement may have given comfortable stimuli [10, 11,28], and reduced the salivary amylase level. There are 2
control mechanisms reducing the salivary amylase level:
The sympathetic nervous-adrenal medullary system(SAM system) inhibits norepinephrine release from theadrenal medulla through suppressing sympathetic nerve
activity, and another system suppresses sympathetic
nerve activity and directly acts on the nerve to inhibit
enzyme secretion from the salivary glands, suggestingthat one of these mechanisms induced the low amylase
level [28]. Shimizu et al. reported that the salivary amylase level was significantly decreased by intervention
with ‘laughing stimuli’, showing stress reduction bylaughing: Laughing induced mental changes, such as reduction of negative emotion and feeling better, and these
psychological changes were involved in the reduction of
the salivary amylase activity level [12]. Based on thesereports, the significant decrease in the change in the salivary amylase level during the amusement introduction
period suggests that the subjects felt amusement-induced
laughing and regret and interaction through the amusement comfortable.
Regarding the sleep efficiency and sleeping hours,
no significant association with the amusement introduc-tion period was noted, but the mean sleeping hours increased by about 50 minutes at one month after amusement introduction compared with that at pre-amusement(Table 2). The awake time in the bed becomes longer inthe elderly [29, 30], and the sleep efficiency decreases[30]. Regarding treatment of insomnia in the elderly,
it has been reported that dozing of elderly subjects at
a nursing home can be prevented by setting a specificsocial activity [31], and an individual social activity
program for residents with dementia at a nursing home
improved the sleep efficiency and reduced nocturnal
awakening [32]. Since the subjects of our study wereusers of day care services for the elderly, their sleep efficiency was originally high and the sleeping hours werelong based on the sleep data, which may have resulted in
the absence of significant association of sleep efficiency
and sleeping hours with the amusement introduction(Table 2). However, the sleeping hours extended while
maintaining sleep efficiency, suggesting that the interactions through the amusement positively influenced their
sleep conditions at night.
Generalization of these study results may beproblematic because the frequency of using a day careservice center for the elderly varied among the elderly
female subjects, but the internal validity of the results
may have been high because they mostly stayed at homewhen they did not use the services. This study followed
the subjects for one month and clarified the associations
between the amusement introduction and parasympathetic nerve activity and salivary amylase.

Conclusion
Based on the physiological indices: heart rate, heart
rate variability analysis, and salivary amylase, it wassuggested that amusement-induced laughing and regret
or interaction through the amusement influenced theautonomic nerve system and they felt comfortable.
Acknowledgment: We are grateful to the study participants and staff of a day care service center for theelderly, Saiwai. We also thank the staff of Prova Groupfor their support with the amusement devices and instruction in their use.

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■ORIGINAL ARTICLE

Gaze Analysis During Toilet Activity in Elderly People
Yuichi Ishiura, Keizou Numata, Kazuo Higaki
Department of Occupational Therapy, School of Health Care Science, Himeji Dokkyo University

Abstract: Background: Toilet activity is performed every day with a physiological phenomenon so called “excretion”,
which is highly necessary. In this study, we used Eye Mark Recorder, a gaze analyzer, to analyze eye movement ofelderly people during toilet activities. In addition, we compared the results with those obtained from a preceding study
regarding toilet activities in young people.
Result: The toilet activity was divided into three phases: until they sit down, while they are sitting on the bowl, anduntil they leave the room. Until they sat down and until they left the room, they were looking at the entire environment
in the toilet. While they were sitting on the bowl, however, they were mostly looking forward. A similar tendency wasobserved in young people as well. Furthermore, retention time, degree of dependence on the lower gaze, rate of recognition, as well as an association between the time required for movement and the degree of dependence on the lower
gaze were investigated. The elderly people were far more likely to gaze toward the floor compared to the young people.
Conclusions: The results showed which areas the subjects had to look at during 3 toilet-activity phases in order to understand the spatial relation. In toilet activities of the elderly, the rate of gaze toward the floor increased probably due
to aging, posture and decreased balancing ability. We will need to further investigate associations between the subjects’age, posture, balancing ability and the gaze during the toilet activities.
Keywords: gaze analysis, toilet activity, eye mark recorder(Asian J Occup Ther 13: 31−40, 2017)

Introduction
When someone makes decisions somehow in daily
activities, there is an eye movement in advance [1]. It
has also been reported that eye movement occurs 0.6
seconds before the activity [2], suggesting that there is a
close relationship between activities of daily living andvisual functions. Wilmut [3] stated that visual information is essential for controlling the limbs, and Crowdy
et al. [4] reported on effects of visual control in patientswith cerebellar symptoms or unilateral spatial neglect.
Hence, we consider that the ability of activity of dailyliving would be increased or improved by analyzing andunderstanding the gaze observed before various movements.
The preceding studies regarding visual functions
Received: 10 January 2017, Accepted: 29 May 2017
Corresponding to: Yuichi Ishiura, Department of Occupational Therapy, School of Health Care Science, Himeji Dokkyo University, 2-1,
Kamioono 7-chome, Himeji-shi, Hyogo 670-8524, Japane-mail: ishiura@gm.himeji-du.ac.jp©2017 Japanese Association of Occupational Therapists

and daily activities include a study by Ehara et al. [5]on gaze behaviors in cooking activities, a study by Nito
et al. [6] on association between visual and upper limb
movements while eating with spoons and chopsticks,
and a study by Suzuki et al. [7] on visual input during
dressing activity in hemiplegia patients. In addition,
Land et al. [2, 8, 9] reported studies regarding eye
movement when making tea or measurement of eye
movement when swinging a baseball bat to hit a ball.
However, there is no report available on measurement ofgaze in toilet activities.
Toilet activity is performed every day with a physiological phenomenon so called “excretion”, which ishighly necessary [10]. Suehiro et al. [10] reported that inaddition to somatic, vestibular and auditory sensations,visual sensation also plays a significant role in toilet
activity. Furthermore, Kimura et al. [11] stated that it
is crucial to visually confirm toilet activity throughout
the course from the time of taking them to the toilet
until the end. In the preceding study [12], we analyzed
gaze of young people during toilet activities. The results
revealed that, their gaze was mainly in forward direction
in both men and women although there was a slight dif-

32

GAZE ANALYSIS DURING TOILET ACTIVITY

ference between them in terms of duration of gaze. We
will need to further compare the data obtained from theelderly with those from young people.
For the gaze of the elderly while walking, Itoh et al.
[13] reported that they had been mostly looking at thefloor or around the feet and frequently gazing toward thefloor. In addition, their duration of gaze to watch theirsteps was longer than that of young people. Itoh et al.
[14] also reported that the elderly had relied on the central vision while walking and that their eye-movement
range had been broader and stayed lower. These suggestthat eye movement of the elderly during toilet activities
would be toward the lower direction compared to that of
the young people.
The objectives of this study were to reveal the gazeof the elderly during toilet activities and to investigate if
there would be any differences between men and womenor any features according to sex. The data obtained were
further compared with those of young people measured
in the preceding study and investigated to find out if
there were any differences between the elderly andyoung people or features according to their age.

MethodSubjects
The subjects included 35 healthy elderly adults(hereinafter, the elderly; 17 men and 18 women, themean age 68.8 ± 5.7 years old, using a nearby day-carenursing service center) who had no problem with eye
moving in activities of daily living and had submitted
oral and written informed consent. We excluded subjects
who have problems with visual field or visual eyesight,
subjects who could not understand instructions formotions, or subjects whose eye marks could not be detected.
Measuring device
In this study, we used a hat-shaped gaze analyzer,
Eye Mark Recorder (Pupil Centre Corneal Reflection;
EMR-8B, nac Image Technology), to measure gazeof elderly people. The device consists of a head unit,
controller, Calibration cable, etc. (Fig. 1) and is able
to output visual field images with eye mark signals on
them. The visual field images were recorded using a digital cassette recorder (GV-HD700, SONY). In addition,
the gaze measurements were performed on both eyes.
The horizontal angle of the visual field camera lens was
115°. The sampling frequency was 60 Hz.
Method of measurement
The measurements were performed in a toilet roomof about 1.62 m2 in a nearby day-care nursing service

Fig. 1. Eye Mark Recorder System.
① Head Unit
④ AC adapter② Calibration cable ⑤ Digital cassette recorder③ Controller

center (Fig. 2). The subjects became familiar with thetoilet environment and activities before wearing the
Eye Mark Recorder in order to avoid the effects of experiences as much as possible. Then they wore the EyeMark Recorder, and calibration was performed at the
point 1m away from the toilet door. We observed theirvarious gazes when they are at the toilet door and when
they are sitting on the toilet bowl, and examined if there
is any shift of eye marks. After calibration, subjects
stood up from a chair and waited in front of the door.
We recorded their gaze throughout the whole process of
opening the door with a starting signal, simulating the
movement of putting down the trousers, sitting down on
the toilet bowl, sitting still for 5 seconds, and leaving
the room. After recording, we analyzed the gaze with
EMR-dFactory Ver.1.2 (nac Image Technology).
Analysis method
The gaze was defined as a line connecting a gazepoint and the central fovea of retina, and retention time
was defined as the duration of time they are looking at
the gaze point. We also defined the condition “one gazedat the point” as a situation where an eye mark stayed
within the range of 9 degrees from a point for more than
200 msec. Upon analysis, toilet activity was divided into
three phases: until they sit down, while they were sitting
on the bowl, and until they leave the room, according to
the excretion activity model proposed by Yada et al. [15]In each phase, (1) we extracted the gaze points in orderto reveal where they were looking at, (2) calculated therate of retention time in order to find where they werelooking at the most (gaze duration/time required for
activity × 100), and (3) calculated the sum of retention
time for the gaze on the floor in each phase, using theIshiura Y et al.

Asian J Occup Ther 13: 31−40, 201733

Results
Table 1 shows the time required subject’s motionin each phase. The results of gaze points of the elderly
subjects in each phase and the rate of retention time areshown in Fig. 3 and Table 2. Together, the data of young
people [12] is shown in Table 2.

Fig. 2. Appearance of toilet room.

rate of retention time obtained in (2), as the degree of
dependence on the lower gaze, (4) calculated the rate ofrecognition (number of subjects gazed/the total numberof subjects × 100), on the basis of the study conductedby Katsura et al. [16], in order to find out what were
the gaze points looked at by many people as they werecrucial for activities, and (5) revealed the association
between the time required for activities and the degreeof dependence on the lower gaze.
In statistical analysis, Mann-Whitney U test wasused in comparisons between elderly men and womenfor the rate of retention time and the degree of dependence on the lower gaze, as there had been non-normality included in the data. Meanwhile, χ2 test was used incomparison for the rate of recognition. The association
between the time required for activities in each phaseor for a series of those in all 3 phases and the degree of
dependence on the lower gaze was analyzed using theSpearman’s rank correlation coefficient. The significancelevel was set to be < 0.05. After the tests, we investigated the difference between the elderly and young people
from results obtained from the elderly men and womenand those of young people.
This study was conducted with approval fromthe bioethics committee of Himeji Dokkyo University(No.12-04) and the ethical review board of Osaka Prefecture University (2012-OT01).

(1) Gaze points
For men, 17 points until they sat down, 7 points
while they were sitting on the bowl, and 18 points until
they left the room were extracted. For women, 17 points
until they sat down, 8 points while they were sitting
on the bowl, and 16 points until they left room wereextracted. In men, light switch was not extracted fromthe phase while they were sitting on the bowl, and in
women, the left wall next to the door and the left front
wall were not extracted from the phase until they left theroom.
The gaze points were very similar to those of young
people [12] in each phase, although there were someminor differences. The subjects were likely to lookaround the entire toilet environment until they sat down
or until they left the room. While they were sitting on
the bowel, they tended to look forward most of the time.
(2) Rate of retention time
Until they sat down, the rate of retention time wassignificantly higher in women than in men for the rightwall next to the door (U = 91.0, p = 0.04). While until
they left the room, the rate of retention time was significantly higher in men than in women for outside the door.
In elderly people, the rate of retention time on thefloor was higher compared to that of young people until
they sit down and until they left the room. In young
people, however, the rate was higher for the wall andtoilet bowl, etc. compared to the elderly.
(3) Degree of dependence on the lower gaze in eachphase
The degrees of dependence on the lower gaze ineach phase for both elderly and young people [12] areshown in Table 2. In the elderly people, no significant
difference was observed between men and women for
Table 1. The time required subject’s motion in each phase.

Elderly men
Elderly womenall subjects
Unit: second

Until they
sit down

While sitting
on the bowl

Until theyleave the room

21.8
17.2
19.5

5
5
5

33.2
27.6
30.3

34

GAZE ANALYSIS DURING TOILET ACTIVITY

Fig. 3. Extracted gaze points.
① Door
② Door handle③ Right wall next to the door
④ Left wall next to the door

⑤ Light switch⑥ Outside the door
⑦ Lock
⑧ Left wallthe 3 phases and for the series of activities.
The degree of dependence on the lower gaze washigher in the elderly compared to the young people forthe series of activities until they sat down and until theyleft the room.
(4) Rate of recognition in each phase
The rates of recognition in each phase for bothelderly and young people [12] are shown in Table 3. For
the elderly, no significant difference was observed in all
3 phases. For the young people, significant difference
was observed in the flush lever (χ2 = 0.02, p = 0.02).
When compared between the elderly and young
people, the rate of recognition for the floor was lower
in the young people than in the elderly. However, it
was higher for the handrail, wall, and the flush leverin the young people compared to the elderly. It wasalso revealed that the young people were more likely
to obtain information from various gaze points. Whilesitting on the bowl, there were some minor differences
for the lock, left wall, floor and the toilet roll; the rates
varied among individuals. As in the phase until they sat
down, the rate of recognition was high for the floor in
the elderly in the phase until they left the room.
(5) Association between the time required in each phaseand the degree of dependence on the lower gaze
The association between the time required in each

⑨ Handrail⑩ Floor⑪ Toilet bowl
⑫ Front wall

⑬ Right wall
⑭ Toilet roll
⑮ Right front wall
⑯ Left front wall

⑰ Flush lever⑱ Otherphase and the degree of dependence on the lower gazefor both elderly and young people [12] are shown in
Table 4. There was no association between the timerequired in each phase and the degree of dependence
on the lower gaze in the entire elderly people or only inmen or in women.
For the phase until they sat down, the association
between the time and the degree of dependence on thelower gaze varied among men in young people. However, for the other phases, there was no difference between
the young people and the elderly.

Discussion(1) Gaze points
It was revealed that the extracted gaze points were
almost the same between the elderly men/women andyoung people. According to the report made by Miya­hira et al. [17] there seemed to be a possibility thatgaze points were different between men and women
during toilet activities. However, the results of this study
suggested that in toilet activities there was hardly any
or no difference in gaze points according to sex or age.
Further investigation will be required with increased
number of subjects.
For phases until they sat down and until they left
the room, activities included physical movement of
excretion activity model proposed by Yada et al. [15],Ishiura Y et al.

Asian J Occup Ther 13: 31−40, 2017

Table 2. Gaze points and rates of retention time.
Elderly men(Young men)

Elderly women(Young women)

33.9 (25.9)
1.8 (1.4)
3.7 (4.0)
0.04 (0)4.3 (4.3)
3.3 (5.9)
0.6 (1.0)
7.5 (6.6)
0.3 (0.6)
10.1 (6.3※)
12.0 (14.4)
3.8 (2.5)
13.1 (18.2)
1.5 (1.2)
3.9 (7.1)
0 (0.1)0 (0)0.3 (0.5)

31.9 (30.6)
0.7 (1.7)
5.7 (4.4)
0.1 (0)5.6 (4.1)
3.7 (4.6)
0.7 (1.1)
6.2 (8.0)
0.4 (0.6)
8.1 (2.5※)
10.0 (13.9)
3.9 (4.0)
16.2 (17.0)
1.6 (1.4)
5.1 (5.6)
0 (0.3)0.1 (0.2)
0.01 (0)129.5, p = 0.44
120.5, p = 0.26
91.0, p = 0.04
153.0, p = 1.00
113.5, p = 0.19
132.5, p = 0.50
132.0, p = 0.40
130.5, p = 0.46
146.5, p = 0.81
106.0, p = 0.12
120.0, p = 0.28
128.0, p = 0.41
115.0, p = 0.21
145.0, p = 0.79
148.5, p = 0.88
153.0, p = 1.00
144.0, p = 0.54
142.5, p = 0.48

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

6.3
0.8
3.5
0.0
2.2
3.4
0.9
3.0
0.6
4.1
2.6
2.2
5.0
1.4
3.0
0.1
0.0
0.0

89.0 (88.4)
1.7 (3.6)0 (0)1.6 (1.6)
0.8 (2.1)
0 (0.7)
2.4 (1.6)
0.8 (0.3)
3.6 (1.8)
0 (0)70.7 (85.8)
1.1 (3.8)
0.1 (0)0.1 (1.3)
3.2 (0.6)
0 (3.3)10.4 (2.3)
5.7 (0)7.8 (2.7)
0 (0.1)112.0, p = 0.17
128.0, p = 0.24
144.5, p = 0.33
143.5, p = 0.61
129.0, p = 0.19
153.0, p = 1.00
153.0, p = 1.00
153.0, p = 1.00
153.0, p = 1.00
153.0, p = 1.00

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

10.0
2.2
0.0
0.0
0.0
0.0
0.6
0.0
0.6
0.0

33.0 (29.8)
0.4 (0.8)
0.3 (2.0)
0.1 (0)2.8 (2.7)
12.7 (13.7)
0.7 (0.6)
6.0 (2.8)
0.1 (0.2)
7.6 (2.3)
8.6 (10.0)
3.1 (5.4)
11.9 (14.7)
8.1 (8.3)
2.7 (3.4)
0.1 (0.8)  2.1 (2.5※)
0.01 (0)35.8 (32.5)
0.7 (1.5)
1.6 (2.8)0 (0)3.5 (2.9)
8.1 (11.3)
0.5 (0.7)
5.5 (3.1)
0.1 (0.1)
4.4 (1.6)
9.2 (11.3)
4.8 (5.3)
14.0 (13.8)
7.0 (6.9)
3.4 (4.3)
0 (0.1)
1.6 (1.7※)
0.01 (0)130.0, p = 0.46
101.5, p = 0.09
94.5, p = 0.053
144.0, p = 0.78
118.0, p = 0.26
85.5, p = 0.03
137.0, p = 0.61
145.5, p = 0.81
143.5, p = 0.76
103.0, p = 0.10
147.0, p = 0.86
103.5, p = 0.10
126.5, p = 0.39
139.0, p = 0.66
130.0, p = 0.46
144.0, p = 0.78
117.0, p = 0.25
152.5, p = 0.99

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

6.5
0.9
2.1
0.0
1.9
3.9
0.3
2.9
0.0
1.2
3.7
2.8
3.9
2.8
1.6
0.0
1.3
0.0

Mann-Whitney U test

Quartile deviation

Until they sit down
Door
Door handle
Right wall next to the door
Left wall next to the door
Light switch
Outside the door
Lock
Left wall
Handrail
Floor
Toilet bowl
Front wall
Right wall
Toilet roll
Right front wall
Left front wall
Flush lever
Other
While sitting on the bowl
Door
Door handle
Light switch
Lock
Left wall
Floor
Right wall
Toilet roll
Right front wall
Left front wall
Until they leave the room
Door
Door handle
Right wall next to the door
Left wall next to the door
Light switch
Outside the door
Lock
Left wall
Handrail
Floor
Toilet bowl
Front wall
Right wall
Toilet roll
Right front wall
Left front wall
Flush lever
Other

Unit: %, *: p < 0.05, n.s: not significant
Number in ( ) are data of young people. Excerpt from reference 12.
※ Significant difference was observed between young men and young women.

35

36

GAZE ANALYSIS DURING TOILET ACTIVITY

Table 3. Rates of recognition in each phase.
Elderly men(Young men)

Elderly women(Young women)

100 (100)
41.2 (20.0)
58.8 (65.0)0 (0)94.1 (85.0)
76.5 (75.0)
11.8 (20.0)
88.2 (85.0)0 (10.0)
88.2 (65.0)
100 (100)64.7 (40.0)
100 (90.0)
41.2 (15.0)
82.4 (85.0)0 (0)5.9 (0)5.9 (0)100 (100)27.8 (19.4)
83.3 (67.7)
5.6 (0)88.9 (83.9)
72.2 (71.0)
16.7 (22.6)
77.8 (96.8)
5.6 (9.7)
83.3 (38.7)
100 (100)
66.7 (64.5)
94.4 (100)33.3 (32.3)
72.2 (71.0)
0 (6.5)5.6 (3.2)
0 (3.2)

1.0, p = 1.0
0.70, p = 0.40
0.15, p = 0.15
1.0, p = 1.0
1.0, p = 1.0
0.01, p = 0.92
1.0, p = 1.0
0.66, p = 0.66
1.0, p = 1.0
1.0, p = 1.0
1.0, p = 1.0
0.05, p = 0.81
1.0, p = 1.0
0.73, p = 0.73
0.69, p = 0.69
1.0, p = 1.0
1.0, p = 1.0
0.49, p = 0.49

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

100 (100)
5.9 (15.0)
11.8 (10.0)
5.9 (10.0)0 (10.0)
5.9 (10.0)
5.9 (0)23.5 (13.7)

94.4 (96.8)
16.7 (16.1)
11.1 (3.2)
5.6 (3.2)
0 (3.2)27.8 (6.5)
11.1 (0)22.2 (16.1)

1.0, p = 1.0
0.60, p = 0.60
1.0, p = 1.0
1.0, p = 1.0
1.0, p = 1.0
0.18, p = 0.18
1.0, p = 1.0
0.10, p = 0.76

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

100 (100)17.6 (30.0)
23.5 (50.0)
5.9 (0)94.1 (80.0)
100 (100)
23.5 (20.0)
94.1 (55.0)
0 (5.0)88.2 (40.0)
100 (95.0)
70.6 (90.0)
100 (100)
94.1 (95.0)
88.2 (75.0)
5.9 (20.0)
88.2 (85.0※)

100 (100)
33.3 (41.9)
50 (45.2)0 (0)100 (71.0)
88.9 (93.5)
22.2 (16.1)
88.9 (51.6)
0 (0)77.8 (38.7)
100 (100)
83.3 (83.9)
94.4 (96.8)
88.9 (90.3)
66.7 (80.6)
0 (3.2)72.2 (51.6※)

1.0, p = 1.0
0.44, p = 0.44
1.61, p = 0.20
0.49, p = 0.49
0.49, p = 0.49
0.49, p = 0.49
0.10, p = 0.76
1.0, p = 1.0
1.0, p = 1.0
0.66, p = 0.66
1.0, p = 1.0
0.44, p = 0.44
1.0, p = 1.0
1.0, p = 1.0
0.23, p = 0.23
0.49, p = 0.49
0.40, p = 0.40

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

χ2 testUntil they sit down
Door
Door hadle
Right wall next to the door
Left wall next to the door
Light switch
Outside the door
Lock
Left wall
Handrail
Floor
Toilet bowl
Front wall
Right wall
Toilet roll
Right front wall
Left front wall
Flush lever
Other
While sitting on the bowl
Door
Door hadle
Lock
Left wall
Floor
Right wall
Toilet roll
Right front wall
Until they leave the room
Door
Door hadle
Right wall next to the door
Left wall next to the door
Light switch
Outside the door
Lock
Left wall
Handrail
Floor
Toilet bowl
Front wall
Right wall
Toilet roll
Right front wall
Left front wall
Flush leverunit: %, *: p < 0.05, n.s: not significant
Number in ( ) are data of young people. Excerpt from reference 12.
※ Significant difference was observed between young men and young women.

Ishiura Y et al.

Asian J Occup Ther 13: 31−40, 201737

Table 4. Association between the time required in each phase and degree of dependence on lower gaze.

Until they sit down
Until they leave the room
A series of activities

Elderly men(Young men)

Elderly women(Young women)

All elderly people(All young people)−0.21, p = 0.15 n.s(−0.45, p = 0.05※)−0.33, p = 0.20 n.s(0.19, p = 0.42 n.s)
−0.23, p = 0.39 n.s(−0.42, p = 0.06 n.s)

0.24, p = 0.35 n.s(−0.07, p = 0.71 n.s)
0.17, p = 0.51 n.s(0.19, p = 0.32 n.s)
0.43, p = 0.08 n.s(−0.02, p = 0.92 n.s)

0.20, p = 0.25 n.s(−0.20, p = 0.15 n.s)
0.01, p = 0.96 n.s(0.16, p = 0.26 n.s)
0.24, p = 0.17 n.s(−0.16, p = 0.27 n.s)

Values represent Spearman correlation coefficients (rs)*: p < 0.05, n.s: not significant
Number in ( ) are data of young people. Excerpt from reference 12.
※ Significant difference was observed between young men and young women.

suggesting that they had to look at a variety of gazepoints in order to understand the spatial relation. On thecontrary, while they were sitting on the bowl, there was
hardly any physical movement, suggesting that they
were able to understand the spatial relation with a few
gaze points. It was also revealed that this method of
understanding the spatial relation was an essential strategy regardless of age. We considered that we may needto practice toilet activities and toilet induction, taking
the gaze points in each phase into consideration.
Further investigations will be necessary in the
future for each phase in order to assess whether or not
postures or activity efficiency would differ between
activities looking at the gaze points and those not looking at the gaze points. In addition, we will also need toinvestigate the differences for gaze points between thesimulated activities performed in this study and actual
activities.
(2) Rate of retention time
Significant differences were observed between
men’s and women’s gaze points. Women tended togaze toward the right wall next to the door until theysat down and for the gaze toward outside the door until
they left the room. Generally, women are said to havelower visual cognitive function than men. We think thatthe men’s gaze was directed to something else insteadof staying long at the right wall near the entrance.
Because, before they sat down, the men perceived thetoilet environment faster than the women. Likewise, we
think that the proportion of retention time outside thedoor increased because, before they left the room, themen finished the cognition inside the toilet early andtheir attention was directed to the outside. These rates
of retention time were considered to be a feature of sex
difference in toilet activities. We expect the cognitive
process for grasping the toilet environment to be revealed by considering the rates of retention time and thegaze movement in future researchers.
As a feature until they sat down, both the elderly
people and the young people had higher rates of retention time in the order of the door, the right wall, thetoilet bowl, and the floor. As a feature while sitting on
the bowl, the rates of retention time at the front was
high. As a feature until they left the door, the rates ofretention time at the sink levers and the toilet roll werehigher than those until they sat down. Moreover, in theelderly, the rate of retention time was high for the gaze
toward the floor in both phases until they sat down anduntil they left room compared to the young people.
The rate of retention time for the gaze toward the wall,
however, decreased as that for the floor increased. These
results appeared characteristic to the gaze during toilet
activity in the elderly. It was also suggested that themethods of collecting information to understand thespatial relation might be different between the elderly
and young people. We need to reveal how they obtain
information by analyzing the details of eye movement
during activities.
It is also necessary to assess the elderly with diseases, as the subjects included in this study were healthyelderly adults, and investigate whether or not the rateof retention time for the gaze toward the floor would be
different. The association between the retention time andthe conduct of activities should be revealed as well.
(3) Degree of dependence on the lower gaze in eachphase
For the degree of dependence on the lower gaze,
there was no significant difference observed in eachphase between elderly men and women. In the phases
until they sat down and until they left the room, it was
higher in the elderly than in the young people. It wasconsidered necessary to investigate changes in the
degree of dependence on the lower gaze according toeach age group.

38

GAZE ANALYSIS DURING TOILET ACTIVITY

Itoh et al. [13] and Kuroiwa et al. [18] stated thatthe gaze of young people when they were walking
tended to be forward while that of elderly people tended
to be lower. It was also revealed in this study that thegaze of the elderly was lower than that of young people.
Moreover, it has been reported that balancing abilityof the elderly was associated with visual sensation,
contrast sensitivity, and stereoscopic vision [19, 20] andthat their ability of maintaining the posture decreased
remarkably under the condition where their visual field
had been reduced [21]. The more they become dependent on the lower gaze, the more their visual field would
be reduced and their ability of maintaining the postureduring toilet activity might be affected as well, resulting
in onset of falls. We may be able to prevent these falls,
leading them to the safe toilet activities, by investigating
whether or not if there is a difference in the degree of
dependence on the lower gaze between the subjects withthe history of falls and those without.
(4) Rate of recognition in each phase
Until they sat down, the recognition rate was highfor the gaze toward the floor in the elderly comparedto the young people. However, in young people, it washigh for the handrail, wall and flush lever compared tothe elderly. These indicate that young people were attempting to obtain information from more various gazepoints compared to the elderly. Meanwhile, Itoh et al.
[13] reported that, for the elderly people, gaze while
walking included eye movement to collect information
using visual data as feedforward and activities to observe their own feet movements; the recognition rate forthe gaze toward the floor was high in the elderly probably as they attempted to collect information and observe
their own feet movements. We need to investigate how
the toilet activity of the elderly will be affected if theirgaze toward the floor is restricted.
The recognition rates for the toilet bowl, right andleft walls, and the light switch were high in both elderly
and young people. These points may be important forthem to gaze at in order to understand the spatial relation. The recognition rate for the light switch was highprobably because it required them to do operation.
The recognition rate for the handrail was low
in both elderly and young people. It may depend on
frequency of use in their daily lives; it is necessary tofurther investigate the association between subjects
with diseases or subjects whose balancing ability havedecreased and the recognition rate for the handrail.
While sitting on the bowl, there was no differencein the recognition rate between the elderly and young
people. The higher rates were reported for gaze points
around the door located in front of them. However, gazepoints with high recognition rates had varied according
to subjects; we need to consider that their gaze while
sitting on the bowl could be different among individuals.
Further investigations will be necessary to find out how
the recognition rate is affected by making the duration
longer for sitting on the toilet bowl.
In the phase until they left the room, higher tendencies were observed for elderly people to gaze at the lightswitch, the left wall, the floor, and the flush lever compared to young people. The recognition rate was highfor the left wall in elderly men and women; informationfrom the left wall might have been more important in
the elderly compared to the young people. We need toinvestigate whether or not a similar tendency would
be observed in a different toilet environment. For thefloor, the cognition rate was higher in the elderly thanin the young people, probably for the same reason as
in the phase until they sat down. The cognition rate forthe flush lever was significantly higher in men than inwomen. This may be associated with how often the flush
lever is being used by men and women. Women use theflush lever more often than men; they might have beenable to obtain information not with the direct gaze butwith the indirect vision. We should further investigate
how experiences would affect gaze.
(5) Association between the time required in each phaseand the degree of dependence on the lower gaze
Itoh et al. [13] evaluated correlation between thewalking speed and the gaze direction toward the floor
and around the feet, and reported that significant correlation was observed in the young people but not in
the elderly. Furthermore, they also reported that rates ofgaze direction toward the floor and around the feet in theelderly might be associated with factors of aging effects
such as visual functions which young people do not haveor aging effects of physical functions other than walking
speed or feet movements. In the preceding study [12], anegative correlation (r = −0.45) was observed between
time and the degree of dependence on the lower gaze inyoung men, while in the elderly, no significant correlation was observed. These results correspond to thosereported by Ito et al. It was therefore suggested that thedegree of dependence on the lower gaze had been affected not by duration of activities but by other factors suchas age, posture and balancing ability. We should further
investigate how the differences in posture or balancing
ability would affect gaze in the future.

Conclusions
In this study, we analyzed gaze of elderly people
during toilet activities and investigated characteristics
according to their age or sex. The results were further

Asian J Occup Ther 13: 31−40, 2017

compared with data obtained from young people in thepreceding study. The gaze points were almost the samefor the elderly and young people. It was considered thatthey might need to look at the entire toilet environment
until they sit down or until they leave the room, andwhile they are sitting on the bowl, they may need to lookforward in order to understand the spatial relation. Furthermore, comparisons were made between the elderly
and young people for rates of retention time, degrees
of dependence on the lower gaze, recognition rates,
as well as associations between time required in eachphase and the degree of dependence on the lower gaze.
According to the results, the rate of retention time washigh for the gaze toward the floor. This was probably
due to their age, posture and decreased balancing ability
rather than duration of the movement. In the future, weshould investigate a method of intervention for subjects
to safely perform toilet activities by revealing how activities would change if gaze points were limited during
the toilet activity, how toilet environment change would
affect gaze, and relationship between balancing ability
and gaze.

Limitation
The Eye Mark Recorder used in the gaze analysis
had a wire cable. This might have affected the toilet
activity. Some activities such as putting up and down
the trousers, wiping the buttocks, and flushing the toilet
were simulations. The results need to be compared withthose obtained for gaze in actual activities. Duration ofsitting on the toilet bowl had been assessed in advanceand determined. However, it may vary according to thesubjects; we should also investigate how gaze would be
affected if the duration was longer.
Acknowledgements: We appreciate all participants inthis study for their cooperation and staff members of“Akatonbo”, the day service rehabilitation center, forletting us use their toilet for the measurement purpose.
We also would like to appreciate Professor Norikazu
KONISHI from Himeji Dokkyo University, Departmentof Occupational Therapy, School of Health Care Sciences for his guidance in preparation of this article.

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■ORIGINAL ARTICLE

Relationship between Fear of Falling, Physical Activity,and Health-Related Quality of Lifein Elderly Daycare Service Users
Tomonori Nomura
Department of Occupational Therapy, Faculty of Medical technology, Niigata University of Health and Welfare

Abstract: Background: Physical activity (PA) has been found to affect the fear of falling (FOF). Although objective
measures can improve the accuracy of measurement compared with subjective measures, previous studies have primarily used self-report measures to assess PA. The relationship between FOF, PA, and health-related quality of life (HRQOL)
in elderly people who need long-term care has therefore not been sufficiently clarified.
Purpose: The purpose of this study was to investigate the relationship between FOF, PA, and HRQOL in elderly daycare service users.
Methods: The participants were 39 frail elderly people living at home who regularly used daycare facilities (13 men,
26 women; mean age, 75.1±6.7 years). A cross-sectional study design was used. FOF was assessed using the Japaneseversion of the Falls Efficacy Scale (FES), PA was measured using a triaxial accelerometer, and HRQOL was assessedusing the Japanese version of the Short Form-8 Health Survey. Based on median FES scores, participants were divided
into two groups, High FES and Low FES, and then the PA and HRQOL values were compared.
Results: Patients in the Low FES group had significantly less PA ( p = 0.019) and lower physical component scores inregard to HRQOL ( p = 0.006).
Conclusions: The results of this study suggest the presence of a relationship between low FES scores in elderly daycare
service users and less PA and low physical component scores in regard to HRQOL.
Keywords: elderly, fear of falling, physical activity, health-related QOL, accelerometers(Asian J Occup Ther 13: 41−46, 2017)

Introduction
Bone fractures and trauma due to falling are someof the factors that reduce independence in activities
of daily living (ADL) in the elderly. One issue is thefear of falling (FOF). Research on fall prevention has
progressed, and FOF is reported to be related to physicalfunctioning [1−2], social relationships [3], and healthrelated quality of life (HRQOL) [4]. Therefore, FOF isconsidered a more significant issue than falling itself[5−6]. FOF can lead to activity avoidance [7], which has
been reported to occur in 35% to 55% of elderly people
worldwide [8−11]; in Japan, this is reported in 50% toReceived: 5 January 2017, Accepted: 29 May 2017
Corresponding to: Tomonori Nomura, Department of Occupational
Therapy, Faculty of Medical technology, Niigata University of Healthand Welfare, Shimami 1398, kita-ku, Niigata, 950-3198, Japane-mail: nomura@nuhw.ac.jp©2017 Japanese Association of Occupational Therapists

60% of elderly people [12−13]. FOF is also reported
to lead to restricted activity in 13% to 50% of elderly
people [14−16].
Previous studies on factors related to FOF havereported a relationship between walking speed [17],scores on the timed up-and-go test [18−19], muscle
strength [20], and balance in the standing position [21].
In addition to physical function, physical activity (PA)has also been found to influence FOF [22]. However,most of these studies used self-report measures to assess
PA. The accuracy of subjective assessment of the elderly
may be affected by a decline in cognitive function due
to aging. Therefore, in research on PA in the elderly, theuse of objective rather than subjective measures can improve the accuracy of the measurements. PA research on
elderly people using accelerometers found that FOF was
related to total daily activity [23]. We previously reported a relationship between low-intensity activity and FOF
in elderly daycare service users [24]. These results may
be related to low PA and FOF. However, the relationship

42

FEAR OF FALLING AND PHYSICAL ACTIVITY AND HEALTH RELATED QOL IN ELDERLY

between FOF, PA, and HRQOL in elderly people whoneed long-term care has not been sufficiently clarified.
The purpose of this study was to investigate therelationship between FOF, PA, and HRQOL in elderly
daycare service users. Accelerometers were used tomeasure PA in an attempt to base the findings on objective data. While elderly daycare service users generally
demonstrate low PA, most studies have used self-reportmeasures to assess PA. Therefore, the use of objective
rather than subjective measures, incorporating physicalfunction and ADL, may enhance the potential of elderly
daycare service users to meet the recommended daily
PA level. The findings of this study are expected to contribute to the development of effective intervention programs designed to decrease FOF and improve HRQOL
in the elderly.

on the Japanese edition of the Falls Efficacy Scale (FES).
The FES is a well-known FOF scale in Japan [13]. The
FES is composed of 10 items, with responses chosenfrom the following, as specified in the Japanese edition:‘1: not confident’, ‘2: lacking some confidence’, ‘3:
confident’, or ‘4: very confident’ (Table 2). Regarding
physical measurements, the timed up-and-go (TUG) test
was used to assess mobility [26]. In the TUG test, participants are timed on how long it takes to stand up from

Table 2. Falls Efficacy Scale score distribution.
Items

1 Take a tub bath

1: Not confident
2: Lacking some confidence
3: Confident
4: Very confident

2 Reach into cabinets or closets

1: Not confident
2: Lacking some confidence
3: Confident
4: Very confident

3 Prepare a simple meal

1: Not confident
2: Lacking some confidence
3: Confident
4: Very confident

4 Walk around house

1: Not confident
2: Lacking some confidence
3: Confident
4: Very confident

5 Get in/out of bed

1: Not confident
2: Lacking some confidence
3: Confident
4: Very confident

6 Answer telephone

1: Not confident
2: Lacking some confidence
3: Confident
4: Very confident

7 Stand/sit

1: Not confident
2: Lacking some confidence
3: Confident
4: Very confident

8 Get dressed and undressed

1: Not confident
2: Lacking some confidence
3: Confident
4: Very confident

9 Simple cleaning

1: Not confident
2: Lacking some confidence
3: Confident
4: Very confident

10 Simple shopping

1: Not confident
2: Lacking some confidence
3: Confident
4: Very confident

Methods
1. Participants
The study participants were 39 frail elderly people(13 men, 26 women; mean age, 75.0 ± 6.7 years; age
range, 60−85 years) living at home who regularly used
daycare facilities no more than twice a week. All participants were able to walk independently. Participants who
had dementia were excluded. A mental status questionnaire [25] indicated whether cognitive function was in
the normal range (Table 1). The research plans and procedures for obtaining consent from the participants wereapproved by the ethics committee of Niigata University
of Health and Welfare. Written informed consent was
obtained from all participants.
2. Tasks and Procedures
The study design was cross-sectional, and interviews and physical measurements were performed. Interviews were held to investigate the use of an assistive
device, history of falling in the previous year, and score
Table 1. Participants’ demographics.
n = 39Age (year)
Body Mass Index (kg/m2)
Mental Status Questionnaire (point; 0−10)
Main diagnoses
Cerebrovascular disease
Fracture
Osteoarthritis of the knee
Low back pain
OthersUse of an assistive device
Fall history within 1 year
Mean± SD, Median [range]

75.0 ± 6.7
24.2 ± 4.2
10 [8−10]
15 (38.5%)
8 (20.5%)
6 (15.4%)
8 (20.5%)
2 ( 5.1%)
26 (66.6%)
11 (28.2%)

Asian J Occup Ther 13: 41−46, 2017an armchair, walk 3 m, return, and sit back down on thechair. To evaluate ADL and instrumental ADL, scores on
the Barthel Index [27] and the Frenchay Activities Index
were used [28−29]. HRQOL assessment was performed
using the Japanese version of the Short Form-8 (SF-8)
Health Survey. The SF-8 is composed of multiple question items that measure eight health concepts [30]. Twosummary scores of the SF-8, the Physical Component
Summary (PCS) and the Mental Component Summary(MCS), were used.
An individual’s PA was measured using a small(74.5 × 13.4 × 34.0 mm) and lightweight (36.0 g) triaxial accelerometer (Actimarker; Panasonic, Osaka, Japan)
with epoch length set at 12 s [31]. This device collects
data on triaxial acceleration at 20 Hz; a standard deviation of 12 s is defined as the mean value of acceleration.
All participants were requested to wear the device for 7
to 10 consecutive days, from the time of getting out of
bed in the morning until going to bed at night, except
during bathing activities. The device was fastened to thepants above the iliac spine. After wearing the device,
the participants returned it to the researchers, who thendownloaded the data using the device software. Data
from the day of using the daycare facility were excluded, and were only used if there were more than 5 days intotal for which the device had been worn for more than
10 h throughout the day [32]. From the PA data gatheredby the accelerometers, metabolic equivalents (METs)
were used to represent PA levels. METs are calculatedusing a linear regression formula produced by the relationship between the mean value of acceleration and
the METs measured with a respiratory gas metabolic
system. The mean daily METs value was used.
3. Data analysis
The participants were divided into two groups
based on median FES scores: a High FES and a Low
FES group. The outcome measures between the twogroups were then compared using the chi-square test,
t-test and Mann–Whitney U test. The significance level
was set at 5%. Statistical analyses of the data were performed using SPSS (version 15.0; IBM Japan, Tokyo,
Japan).

Results
The participants’ demographic characteristics areshown in Table 1. Overall, 26 (66.6%) participants
reported use of an assistive device, and 11 (28.2%) reported a fall within the previous year. The data analyzed
in this study are shown in Table 3. The median ADL andphysical function scores were as follows: Barthel Indexscore, 95 points (range, 80−100 points); median Fren-

Nomura T

43

Table 3. The main outcome measures of the study subjects (n = 39).
The main outcome measures

Median [range]

Barthel Index (point; 0−100)
Frenchay Activities Index (point; 0−45)
Timed Up and Go (sec.)
Fall Efficacy Scale (point; 0−40)
SF-8 PCS
SF-8 MCS

95 [80−100]
18 [3−26]
16.3 [7−64.5]
31 [20−39]
45 [32.6−53.5]
46.1 [34.1−60.6]

PCS: Physical component summary, MCS: Mental component summary

chay Activities Index, 18 points (range, 3−26 points);
and the TUG test, 16.3 s (range, 7−64.5 s). FOF, which
was assessed based on FES scores, had a median valueof 31 points (range, 20−39 points). Regarding HRQOL
measured using the SF-8, the median PCS score was 45(range, 32.6−53.5), and the median MCS score was 46.1
(range, 34.1−60.6).
The relationship between the High and Low FES
groups’ scores and outcome measures are shown in
Table 4. The participants were divided into two groups
based on median FES scores: 20 participants in the HighFES group and 19 participants in the Low FES group.
According to the results of comparing the High and Low
FES groups, a significant difference was observed in PA( p = 0.019) and PCS on the SF-8 ( p = 0.006). No significant difference was observed in other factors.

Discussion
This study was to investigate the relationshipbetween FOF, PA, and HRQOL in elderly daycare
service users. The results of the present study suggestthat low FES scores are associated with low levels of
PA and poor HRQOL in elderly daycare service users.
In this study, the FES was used for assessing FOF, but
the cutoff value of this scale is not clear. Therefore, theparticipants were classified into two groups based on the
median of FES scores, there was no significant difference in sex, age, cognitive function, and ADL in the twogroups. Therefore, there was little significant difference
between the participants in the two groups.
Murphy et al. [33] reported that a “sedentary lifestyle” affects FOF in the elderly. Too much sitting mightalso be considered a behavioral health hazard [34]. Reidet al. [35] examined patterns of television watchingamong the elderly over a survey period of 12 years andtheir associations with performance-based measures ofphysical function, and found that patterns of sedentary
behavior were associated with weak lower-extremity
muscle strength. For the frail elderly, it is necessary to
improve PA in order to prevent a decline in physical44

FEAR OF FALLING AND PHYSICAL ACTIVITY AND HEALTH RELATED QOL IN ELDERLY

Table4. Relationships between Fall Efficacy Scale and outcome measures.

Gender (women)
Age (year)
Body Mass Index (kg/m2)
Mental status questionnaire (point; 0−10)
Use of an assistive device
Fall history within 1 year
Barthel Index (point; 0−100)
Frenchay Activities Index (point; 0−45)
Timed Up and Go (time)
Physical activity (METs)
SF-8 PCS
SF-8 MCS

Low FES Group(n = 19)High FES Group(n = 20)

p value

12 (63.2%)
75.7 ± 6.6
23.8 ± 5.3
10 [8−10]
13 (68.4%)
7 (36.8%)
95 [80−100]
19 [3−26]
19.5 [7−32.4]
1.37 [1.27−1.62]
40.0 [32.6−49.2]
44.0 [34.1−60.6]

13 (65.0%)
74.6 ± 6.9
24.5 ± 3.5
10 [8−10]
13 (65.0%)
4 (20.0%)
97.5 [80−100]
17.5 [4−22]
15.1 [8−64.5]
1.54 [1.30−1.77]
45.0 [36.2−53.5]
51.9 [35−59.7]

0.584
0.615
0.494
0.229
0.545
0.209
0.615
0.460
0.116
0.019
0.006
0.056

FES: Fall Efficacy Scale
PCS: Physical component summary, MCS: Mental component summary
Low FES Group: 20−31 point, High FES Group: 32−39 pointn (%), Mean ± SD, Median [range]
Chi-squared test, t-test, Mann–Whitney U test

function. The Sedentary Behavior Research Network[36] suggests that sedentary behavior should be formallydefined as “any waking behavior characterized by anenergy expenditure ≤ 1.5 METs while in a sitting or
reclining posture”. In the present study, accelerometers
were used to measure PA in an attempt to base the findings on objective data. The median PA level in the Low
FES group was 1.37 METs, which indicated sedentary
behavior. Daily repetition of this low-level PA is thought
to have led to a reduction of self-efficacy in ADL. In
addition, a meta-analytic review by Schepens et al. [22]reported that prospective studies found a strong relationship between FOF and PA. Participants in the present
study, many of whom were frail elderly people with low
PA, used daycare services. Their main going out activity
was to attend their daycare facilities; they seldom participate in outdoor activities independently. It is therefore
possible that their low-intensity lifestyle could reduce
their self-efficacy for various activities. Ensuring meaningful activities for such persons and increasing their PA
may contribute to improving their self-efficacy in ADL.
The participants of the present study were able towalk independently, although 66.6% used an assistive
device. Kondo et al. [37] reported that the use of anassistive device was related to a low FOF. In the present
study, no such relationship was found. The use of assistive devices is affected by a decline in physical function,and thus this sample included many participants withlow mobility. Friedman et al. [5] reported that falls werean independent predictor of developing FOF. However,no relationship with fall history was found. FOF is
associated with a decline in physical performance and a
gradual decline in HRQOL [3]. Numerous studies havereported that elderly people with low dynamic balanceor mobility have a high FOF [17−18, 38]. However, theresults of the present study showed no relationship between FOF and physical performance. In contrast to thepresent study, the participants in previous studies tended
to be healthy elderly people, not frail elderly peopleusing daycare services. Higuchi et al. [39] reported that
the TUG test is not related to FOF in elderly people withlow functioning in need of long-term care. However,few studies on this issue have been conducted, and it istherefore necessary to examine the relationship between
physical performance and FOF in the low-functioning
frail elderly. In the present study, physical HRQOL wasfound to be declining. It is therefore necessary to breakaway from this vicious lifestyle cycle and encourage theelderly to rebuild their lifestyle to improve their PA.
The primary limitation of this research is that it wasa cross-sectional study, and thus the causal relationships
remain unclear. For future research, a longitudinal study
is needed.

Summary and conclusions
The aim of this study was to investigate the relationship between FOF, PA, and HRQOL in elderly
daycare service users. The findings showed that participants in the Low FES group had lower PA and physicalcomponent scores in regard to HRQOL. These results
suggest a relationship between lower FES scores inelderly daycare service users and lower PA and physicalcomponent scores in regard to HRQOL.

Asian J Occup Ther 13: 41−46, 2017

Conflicts of interest
The author has no conflicts of interest to declare.
Acknowledgments: This work was supported by aGrant-in-Aid for Advanced Research from the Niigata
University of Health and Welfare, 2013.

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■ORIGINAL ARTICLE

Development of a Video-Based Hazard Detection Task:
Preliminary Study in Younger Drivers
Tsutomu Sasaki1, Kyouhei Yamada1, Takao Kojima2, Kunihiro Kanaya3,
Tomoko Abe4, Yuka Hirao5
1

Division of Occupational Therapy, Department of Rehabilitation, Faculty of Health Science,
Hokkaido Chitose College of Rehabilitation, Chitose, Japan2
Department of Rehabilitation, Shuyukai Hospital, Sapporo, Japan3
Department of Rehabilitation Medicine, Sasson-Sugata Clinic, Otaru, Japan
4
Department of Rehabilitation, Fujimi Kogen Hospital, Nagano, Japan
5
Department of Rehabilitation, Saiseikai Suita Hospital, Osaka, Japan

Abstract: We are developing tasks on a laptop computer to enable cheaper and easier driving assessments at medical
institutions. The aim of this preliminary study is to characterize the performance of young drivers in the developed
tasks. The participants were 42 young licensed drivers who performed a video-based hazard detection task and a visual searching task (Trail Making Test). In the hazard detection task, they were instructed to touch the hazardous eventson the computer screen that was likely to become involved in a traffic conflict during a driving video. Results showedthat the video included 11 hazards and young drivers detected hazardous events during a particular period of time. For
the visual searching tasks, our computer-based TMT had proper cognitive load, which was not found in existing paper-based TMT. Further investigations recruiting subjects from other age groups should be necessary to validate ourdriving assessment programs.
Keywords: driving, assessment, hazard detection, young drivers(Asian J Occup Ther 13: 47−54, 2017)

Introduction
Automobiles are an essential means of transportation for modern daily living [1]．Difficulty with driving
automobiles due to a disability is known to significantly
reduce quality of life [2−4]. In Japan, the Road Traffic
Law was revised in 2002 to stipulate that many medical
conditions constituted relative grounds for disqualification. In light of this change, occupational therapists
now have more opportunity, and greater responsibility,
to perform driving assessments for patients with stroke
and brain injury. Typically, the determination of fitness
to drive after a brain damage is made by a public safety
Received: 3 August 2016, Accepted: 19 January 2017
Corresponding to: Tsutomu Sasaki, Division of Occupational Therapy,
Department of Rehabilitation, Faculty of Health Science, Hokkaido
Chitose College of Rehabilitation, 2-10, Satomi, Chitose, Hokkaido,066-0055, Japan (former affiliation: Division of Occupational Therapy,
School of Health Sciences, Faculty of Medicine, Shinshu University)e-mail: t-sasaki@chitose-reha.ac.jp©2017 Japanese Association of Occupational Therapists

commission based on an off-road evaluation performed
at a medical institution and an on-road evaluation
carried out at a driving school. As public safety commissions defer to the judgments of medical institutions, specifically doctors’ diagnoses, these medical institutions
must provide appropriate evaluations and assistance.
In particular, although adaptive driving devices can beused to compensate for a decline in driving ability due
to motor disability, it is not easy to compensate similarly
for cognitive disability, and an appropriate assessmentof this type of disability is therefore required [5].
The off-road evaluations currently carried out inmedical institutions mainly consist of neuropsychological tests performed by occupational therapists. The tests
most often used for driving assessments include visual
searching tasks [6−8], reaction time tasks [9−11], visuospatial recognition tasks [12−14], the useful field ofview test [15−16], and the Stroke Drivers Screening Assessment (SDSA) [17−20]; however, as these are static
tests, they are all far removed from the actual experienceof driving. We believe that dynamic tasks using moving

48

HAZARD DETECTION

images are more appropriate for driving assessments.
In fact, assessments using driving simulators have beenshown to be highly valid as driving assessments [21−23],
but these are too expensive and require too large an
installation site to be of practical use.
We have, therefore, used actual driving footage todevelop a hazard detection task on a laptop computer.
We also developed a visual searching task capable of assessing visual searching ability, which is regarded as themost important element in driving [24]. The objective of
the present study was to evaluate the characteristics ofyoung holders of driver’s licenses in the performance of
these two tasks.

Methods
Participants
The participants were 42 young driver’s license
holders (15 male and 27 female; mean age 21.7 ± 2.4
years, range 19−33 years). None had any history of neurological disease, ophthalmic problems, or other issues
that might affect their participation in the study. Nine
participants had obtained their driver’s license within
the previous year, 14 within the previous 1−2 years, 9
within the previous 2−3 years, 6 within the previous 3−4
years, and 4 at least 4 years previously. In terms of driving frequency, 2 participants drove every day, 3 drove
once every 2−3 days, 5 drove once a week, 21 drove
several times a year, and 11 reported driving almost
never. One participant each had either experienced accidents involving skidding on a snowy road, or reversing
into an object while parking, or colliding with an object
due to not paying attention to what was in front of them.
Both verbal and written informed consent were obtained
from all the participants. This study was approved by
the Ethics Committee of Shinshu University’s Faculty of
Medicine (approval no. 2081).
Hazard detection task
We used a dashboard camera (Venture Craft,
Paparazzi) to record actual video footage of driving
and extracted and edited segments from this recorded
footage in which hazard prediction was used to produce
a driving scenario. The maximum speed during therecording of this driving footage was approximately 40
km/h. MovieWriter2010 Pro (CORE) was used to edit
the videos. The completed driving scenario comprised
an eight-scene (four in the city center and four in residential areas) video lasting approximately two minutes.
Each of the scenes was between 15 s and 40 s long. The
four city-center segments included scenes that required
drivers to watch carefully for oncoming vehicles, buses
stopping to allow passengers to alight and board, pedes-

trians walking along the sidewalk and crossing the road,and oncoming traffic when either entering or turning
right at an intersection, turning right at the intersection.
The four residential area video segments included
scenes requiring drivers to watch out for pedestrians andcyclists unexpectedly entering their path as they drove
along narrow streets, and entered the main road. Boththe city-center and residential scenes required drivers
to drive forward, negotiate curves, stop, and to proceedslowly.
The participants had to identify scenes of predictedrisk during the two-minute driving scenario. They were
instructed to touch the touch panel on a laptop computer(Let’s Note CF-C1B，Panasonic, 12.1-inch) every timethey identified such a scene (Fig. 1). Every time they
touched the panel, the video stopped, and the onscreen
still image was captured. At this point, the authors asked
the participants about the identified elements and recorded them on an assessment monitor (Plus One, LCD10000U, Century, 10-inch). Touching the panel again
restarted the driving scenario. The participant-identified
elements, still images marked with the exact locations,and the times they touched the screen were saved on thecomputer. The hazard detection task program was developed by Nishizawa Electric Meters Manufacturing Co.,
Ltd. The results were used to evaluate the characteristicsof the locations and touch on the screen, the elements
the participants identified, the frequencies with which
they were identified, and the times at which they weredetected.
Visual searching task
The trail-making test (TMT) was used for the visual
searching task illustrations. The TMT is a test designed
to evaluate visual searching ability, and it consists of
two parts—Part A (TMT-A) and Part B (TMT-B) [25].
In TMT-A, the participants saw the numerals 1 through25 on a computer screen, and they were asked to touchthem in ascending order. In TMT-B, they were shown
the numerals 1 through 13 and the Japanese hiragana
characters あ (a) through し (shi) on the screen, andthey were asked to touch the numbers and hiragana
alternately in the order 1 → あ → 2 → い, and so on to
the end. The participants started the tasks themselves
by touching the “Start” button, and the characters 終了(shuūryō, “end”) appeared immediately after the final
target was touched. For both tasks, sounds indicating
either a correct or incorrect target were played wheneach target was touched. Even after a target had been
touched correctly, it remained on the screen. The timerequired, time to touch for each target, and the numbersof correct and incorrect answers were saved on thecomputer. The results were used to calculate the time re-Asian J Occup Ther 13: 47−54, 2017

Sasaki T et al.

49

Fig. 1. Experimental setup.

quired, the number of incorrect answers, and the cognitive load value (the time required for the TMT-B divided
by the time required for the TMT-A). The cognitive load
is an index of the difference in difficulty between the
TMT-A and TMT-B, and as the TMT-B is more difficult
than the TMT-A (Lehrner et al., 2008), the cognitive
load is > 1 if the TMT is valid. In addition to the computer-based TMT, we also administered the paper-based
TMT to examine the validity of the computer-based
TMT as a task to evaluate visual searching ability. The
order of the task conditions (computer-based TMT andpaper-based TMT) was counter balanced between subjects. The visual searching task program was developedby Nishizawa Electric Meters Manufacturing Co., Ltd.

pedestrians when turning right at an intersection (19%),
watching speed when driving down a narrow road (71%),
watching out for pedestrians on the left stepping out
unexpectedly (24%), watching out for an oncoming vehicle stopped across the center line (50%), and watchingout for a bicycle crossing against the lights (64%)．The
hazard “watching out for oncoming vehicles and traffic
lights when entering an intersection” (17%) was identified during a 5-s interval 18−23 s after the video began,and “watching out for a vehicle making a wide turn”(93%) was identified during a 14-s interval 38−52 s after
the video began, indicating that the time range during
which hazards were identified varied depending on thespecific hazard (Table 1).

Results

Visual searching task
One participant was excluded due to missing
values, and the results from 41 participants were therefore analyzed. Non-repeated measure two-way ANOVA
showed the interaction between condition (computerversus paper) and type (TMT-A versus TMT-B) (F(1,80)= 26.6, p < 0.0001). A simple main effect analysis
revealed that the time taken in computer-based TMT-A
was significantly shorter than in computer-base TMT-B(F(1,80) = 50.6, p < 0.0001), and in paper-based TMT-A(F(1,80) = 53.0, p < 0.0001) (Fig. 2). The number ofincorrect answers was found only in computer-based
TMT-B, and a significant interaction was found between
condition and type (F(1,80) = 33.1, p < 0.0001). A
simple main effect analysis revealed that the numberof incorrect answers in computer-based TMT-B was
significantly greater (F(1,80) = 16.6, p < 0.0001). As for

Hazard detection task
The mean number of participant-identified hazards
during the eight-segment, two-minute-long driving
scenario was 5.5 ± 2.3 (range 2−11) per person. After
scenes identified by < 10% of the participants (≤ 4/42)
were excluded from all the hazards identified, 11 scenes
were left. These comprised watching out for oncoming
vehicles and traffic lights when entering an intersection(17%), watching out for incoming vehicles from theleft (62%), watching out for a stopped bus preparing
to start up again (43%), watching out for an incoming
vehicle making a wide turn (93%), complying with therequirement to stop when entering a main road (38%),
watching out for oncoming traffic when turning rightat an intersection (38%), being careful not to run over

50

HAZARD DETECTION

Table 1. Results of hazard detection task.
Detection
frequency

Detection time (s)(range)Type of hazard

1

17%

20.1 ± 1.6(18−23)

Watching out for oncoming vehicles and traffic lights
when entering an intersection

2

62%

27.6 ± 1.0(26−29)Watching out for incoming vehicles from the left

343%28.9 ± 2.1(26−35)Watching out for a stopped bus preparing to start up
again

4

93%

40.7 ± 3.2(38−52)

Watching out for an incoming vehicle making a wide
turn

5

38%

47.8 ± 6.5(39−58)Complying with the requirement to stop when entering amain road

6

38%

64.9 ± 1.8(62−69)Watching out for oncoming traffic when turning right at
an intersection

7

19%

66.3 ± 1.7(64−69)Being careful not to run over pedestrians when turning
right at an intersection

871%82.5 ± 6.0(72−89)Watching speed when driving down a narrow road

HazardHazard location

Sasaki T et al.

Asian J Occup Ther 13: 47−54, 201751

Table 1. Results of hazard detection task (continued).
Detection
frequency

Detection time (s)(range)924%108.5 ± 1.0(107−110)

Watching out for pedestrians on the left stepping out
unexpectedly

10

50%

116.9 ± 0.7(116−118)

Watching for an oncoming vehicle stopped across thecenter line

11

64%

128.0 ± 1.2(124−130)

Watching out for a bicycle crossing against the lights

HazardHazard location

Fig. 2. Comparisons of time taken in visual searching task.
Non-repeated measure two-way ANOVA revealed
significant interaction between task conditions (Computer vs. Paper) and task types (TMT-A vs. TMT-B).
Analysis of simple main effect showed that time takenin the computer-based TMT-A significantly shorter
than the computer-based TMT-B, and the paperbased
TMT-A.

the cognitive lead, the computer-based TMT showed asignificant higher cognitive load than the paper-based
TMT (t(40) = 6.4, p < 0.00001) (Fig. 3).

Type of hazard

Fig. 3. Comparisons of cognitive load in the visual searchingtask.
Cognitive load of the computer-based TMT is significantly higher than the paper-based TMT.

Correlation between hazard detection task and visual
searching task
To examine the relationship between the hazard detection task and the visual searching task, we calculated
Pearson correlation coefficient (r) as a function of thenumber of detection in the hazard detection task and thetime taken in the visual searching task. Results showed

52

HAZARD DETECTION

that no significant correlation was found for the numberof detection versus the computer-based TMT-A (r = 0.10,
p > 0.1), the TMT-B (r = 0.02, p > 1.0), the paper-based
TMT-A (r = −0.06, p > 0.1), and the TMT-B (r = −0.07,
p > 1.0) (Fig. 4).

Discussion
In this study, we reported that the characteristics
of young licensed drivers in newly developed hazard
detection task, and examined the validity of the computer-based visual searching task as a measure of cognitive
lead.
Recently, the road sign recognition task has shown
correlations with on-road driving evaluations, enablingassessments of an individual’s ability to read drivingrelated situations [19, 26−27]. In this task, driving
situations are displayed as photographs or illustrations,and the participant is asked to choose the road sign
most appropriate to each situation. This task, however,
only evaluates the participant’s understanding of thesituation and his or her knowledge of road signs without
assessing their ability to predict hazards. Actual driving

Number of detection in hazard detection task

also requires the ability to deduce the situation after
having seen the road sign, the opposite process fromwhat is assessed in this test. In addition, as this test uses
photographs or illustrations, rather than video footage,
it is far removed from actual driving situations in which
visual information changes moment by moment. Nouri
and Lincoln (1992) [28] have described a task in which
participants are shown a 3-min driving video and areasked to predict hazards. That test, however, requires
participants to recall of hazards at the end of the driving
video, meaning that it does not evaluate the immediate
ability to predict risk. The hazard detection task we havedeveloped, however, assesses the ability to predict riskin real time during a driving video, meaning that it iscapable of evaluating the ability to judge situations in anenvironment similar to that of actual driving. Althoughhazard detection ability assessment using driving videos
has previously been reported [29], these assessments
were not designed to be conducted in medical institutions. To our knowledge, in Japan, there are no previous
reports on hazard detection ability assessment using
video. Furthermore, video-based assessment procedures
reflective of Japanese traffic conditions, scenery, andNumber of detection in hazard detection task

Fig. 4. Correlation between hazard detection task and visual searching task.
No significant correlation is found between number of detection in hazard detection task and time taken in visual searching task.

Sasaki T et al.

Asian J Occup Ther 13: 47−54, 2017traffic rules are necessary.
We found that when young licensed drivers completed our hazard detection task, their responses werecharacterized by variations in the frequency with which
different hazards were detected, but there was a consistent time range during which they were detected. The
fact that the detection frequency varied indicates that
there is a priority order for those hazards that should
be detected in the driving scenario. This suggests thathazard detection failure of frequently identified objects
may indicate low ability in predicting hazards. A clear
delay in hazard identification beyond the normal time
range, as found in this study, may also indicate low
hazard prediction ability. However, it should be notedthat the hazard detection task has limitations. One of themost important limitations is that this task is not capableof evaluating the ability of actual behavioral response
to avoid accidents. Therefore, the relation to the performance in on-road assessments such as road test [30]should be examined.
As for the visual searching task, the TMT is a wellknown neuropsychological test for assessing visual
searching ability, and its results are known to be correlated with on-road driving evaluations [25, 31−32].
Reports vary concerning the time required to performthe TMT tasks [12, 33−34], and no standardized data are
available, but the TMT’s most important characteristic isthat the TMT-B must have a higher cognitive load than
the TMT-A [35]. Accordingly, the TMT-B should require
more time to complete than does the TMT-A, and its
performance should result in more errors. In our study,
this was definitely the case. Unlike existing paper-based
TMT, the computer-based TMT-B required more timethan did the TMT-A, and the number of errors was
greater. The cognitive load of the TMT-B was, therefore,
greater than that of the TMT-A, demonstrating that thetasks in our TMT are valid. This task is also performed
solely by touching the screen, making it more usefulfor assessing pure visual searching ability than existing
TMTs, which also involve motor function by requiring
participants to join targets with a pencil.
Another important result of our study was that the
number of detections in the hazard detection task did
not correlate to the time required in the visual searchingtask. This would suggest that the hazard detection task
measures different ability from the visual searchingtask. Successful TMT performance requires rapid visual
processing, on the other hand, the hazard detection task
requires not only visual processing but also the ability
to predict hazardous events. As safety driving involves
a wide variety of cognitive abilities [36−38], the development of tasks in addition to those used in the present
study might enable the development of a low-cost

53

driving assessment program that does not require theinstallation of any equipment.

Conclusions
This pilot study showed that the video-based hazard
detection task included 11 hazardous events to be detected at various times, and that young drivers detectedhazardous events during a particular period of time, andalso that the computer-based TMT was valid to evaluate
visual searching ability. The results of this study, however, only illustrate the characteristics of young driver’s
licenses holders. Future research is needed to ascertain
the relevant characteristics of other age groups. Youngpeople and the elderly cause more traffic accidents thando other age groups [39], and a study of elderly licensed
drivers’ hazard detection task performance, in particular,
will be important for developing a more thorough picture of drivers and their cognitive capabilities.
Acknowledgments: This study was performed withthe support of a Grant-in-Aid for Young Scientists (B);
Grant number 24700526. We are grateful to Mr. Hideya
Momose of Nishizawa Electric Meters ManufacturingCo., Ltd., for his exceptionally valuable program development advice.

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■RAPID COMMUNICATIONS

Computed Tomography Investigationof the Effects of a Dynamic Orthosison the Metacarpophalangeal Joint
Jun Nakayama1, Mituru Horiki2, Kakuro Denno2, Kazunori Ogawa3,
Hisao Oka4, Kazuhisa Domen5
1Department of Allied Health Sciences, Kansai University of Welfare Sciences
Department of Orthopaedics Surgery, Kansai Rosai Hospital
3
Daiya Gum Industry Co.
4
Graduate School of Health Science, Okayama University
5
Department of Physical Medicine and Rehabilitation, Hyogo College of Medicine
2

Abstract: Background: Continuous stretching is an effective treatment for contractures, and its efficacy can be improved with a dynamic orthosis. Dynamic orthotic positioning is expected to achieve greater clinical results in joints
with less pretreatment stiffness and in those with a short window between injury and treatment. Here we studied theeffect of dynamic orthotic positioning on the metacarpophalangeal (MCP) joint using computed tomography (CT).
Methods: The MCP joints of 10 human index fingers were examined using CT in healthy subjects who wore flexion- or
traction-type orthoses versus those who wore no orthoses.
Results: The palmar joint distance between the traction-type and no orthosis group was not significantly different; however, the distance was shorter with the flexion-type than the traction-type orthosis ( p < 0.05). Compared to healthy subjects without orthoses, the palmar joint space decreased in patients with flexion-type orthoses ( p < 0.05) and increasedin healthy subjects with traction-type orthoses ( p < 0.05).
Conclusions: The traction-type dynamic orthosis was designed to correct flexion while achieving joint traction to enhance MCP joint area spacing and minimize damage caused by articular surface collision. Our findings show that thetraction-type dynamic orthosis causes joint space widening and may reduce the risk of articular surface collision compared with the flexion-type orthosis.
Keywords: tomography, orthotic devices, metacarpophalangeal joint, pilot projects, traction(Asian J Occup Ther 13: 55−60, 2017)

Introduction
Joint contracture, which can result from various
complications that occur after a hand injury, remains
a common orthopedic problem. After fracture, a handtherapist should avoid placing the hand in an incorrect
position and having the joints fixated for longer than
medically necessary, and they should be cautious about
inappropriate rehabilitation such as the excessive use of
Received: 6 May 2016, Accepted: 8 August 2017
Corresponding to: Jun Nakayama, Department of Allied Health Sciences, Kansai University of Welfare Sciences, 3-11-1, Asahigaoka,
Kashiharashi, Osaka 582-0026, Japane-mail: j-nakayama@tamateyama.ac.jp©2017 Japanese Association of Occupational Therapists

strong force. Contractures in the metacarpophalangeal(MCP) joint can occur after a joint trauma or burn [1].
Continuous stretching is an effective treatment forcontractures, and its efficacy can be improved with adynamic orthosis [2], a well-accepted modality used toregain joint motion in an injured hand [3]. Dynamic orthotic positioning is expected to achieve greater clinicalresults in joints with less stiffness before treatment aswell as those with a short window between injury andtreatment [4]. The dynamic flexion orthosis (hereafterreferred to as the flexion-type orthosis) [5] has been
widely used for the treatment of extension contracturesof the MCP joint. The conventional flexion-type orthosis can affect the articular surface of the joint, which
can lead to pain when the finger is held in flexion foran extended period [6]. As a result, it is difficult to56

FLEXION-TYPE ORTHOSIS VS TRACTION-TYPE ORTHOSIS

achieve range of motion improvements [5]. Decreased
finger motion reduces one’s ability to perform activities
using the hand and activities of daily living (ADLs)[7]. In contrast, traction reduces fracture fragments via
ligamentotaxis and helps prevent periarticular joint
ligament contracture. Conventional traction orthoses areoften used in the treatment of joint fractures that require
surgical invasion [8]. However, few reports state that a
dynamic orthosis can increase flexion while achieving
joint traction without increasing the risk of subsequent
surgical intervention.
If a dynamic orthosis that provided traction whilebending the MCP joint existed, patients’ conditions
could improve smoothly without pain and patients may
experience an early improvement in ADLs. However,since such a device does not exist, a flexion-type dynamic traction orthosis was developed [9] (hereafter,
traction-type orthosis). The precedent study stated that
activity difficulty was reduced by improving the rangeof motion of the MCP joint [1]. Therefore, we used a
traction-type orthosis to extend the ligament. Computed
tomography (CT) is useful in the anatomical evaluationof the MCP joint [10]. One study showed the usefulnessof the orthosis-wearing effect using CT [11]. Therefore,
the aim of this study was to evaluate the distance andarea of the joint space using CT in healthy subjects fittedwith a flexion-type, a traction-type, or no orthosis.

Methods
Study design and ethics
The study design was approved by the hospital’s
ethics committee on human research, and written informed consent was obtained from each subject.
Subjects
The MCP joints in 10 healthy human index fingers
from six men and four women (mean age, 29.4 years;
range, 24−34 years) were evaluated. The average bodymass index was 21.89 kg/m2; average height was 166.6
cm; and average weight was 66.8 kg. All of the subjects
were right-handed.
Measurements
This pilot study investigated the joint space distanceand area in the MCP joint as a function of three alternative orthotic positioning methods. CT images of thesubjects who wore a flexion-type, a traction-type, or no
orthosis were obtained, and the sagittal sections of the
MCP joint were measured. The images were obtainedwith patients in the prone position with the shoulder
joint at 180° flexion, elbow joint extended, wrist joint
at 30° of extension, and MCP joint at 40° of flexion.

For those not wearing an orthosis device, the hand was
passively positioned by the radiologist. The distance
between the central, most dorsal, and most palmar partsof the joints and the area of the joint space in the palmar
and dorsal parts of the joint were measured using digital
photography analysis as described below. The wearing
time for the orthosis was approximately 10 min, and theimages were captured thrice.
Orthotic devices
The flexion-type orthosis was manufactured ofthermoplastic Orfit (1835-7, 3 mm, no hole; OG Giken
Ltd., Okayama, Japan), and a Velcro strap and elastic
band were used. The traction-type orthosis was also
manufactured from thermoplastic Orfit (3 mm, no hole;
OG Giken Ltd.), aquaplast (1.6 mm, hole; OG Giken
Ltd.), and a Velcro strap and elastic band were used
(Fig. 1). These orthoses applied a 200-g force [12] on
the proximal phalanx bone of the index finger. No subject experienced pain while wearing either orthosis.
CT equipment
The scan conditions for CT were as follows:
number of rearrangement functions, Fc30; lines, 0.5 mm
× 64; helical pace, 53; tube voltage, 120 kV; tube electric current, 100 mA; and turnover rate, 0.5 s. The CT
equipment used was Aquilion One (Toshiba Inc., Tokyo,
Japan). Regarding the CT device, 160 lines of volume
helical scanning are possible. In addition, the CT device
allows three-dimensional image construction. The
images were taken in the sagittal plane at a 0.1-mm slice
interval and analyzed using Vitrea software (ToshibaInc.). The images were evaluated in a blinded fashion by
a radiologist.
Measurement of joint space distance in the MCP joint
The level of the sagittal plane was measured at
the middle point between the medial and lateral joint
aspects. The most palmar points were identified on theproximal phalanx base and the metacarpal head (Fig.
2(i)a). The most dorsal points were also obtained for theproximal phalanx base and metacarpal head (Fig. 2(i)b).
The central points were defined as the points halfway
between the most palmar and the most dorsal points forthe proximal phalanx base and the metacarpal head (Fig.
2(i)c). The mean joint space distance was the average
distance among three points on the proximal phalanx
and the metacarpal head, namely the most proximal
points, most distal points, and central point (Fig. 2(i)d–f).
Measurement of joint space area in the MCP joint
The level of the sagittal plane was measured at
the middle point between the medial and lateral joint

Nakayama J et al.

Asian J Occup Ther 13: 55−60, 201757

Fig. 1. The dynamic orthoses used in this studya Flexion-type orthosis. The cock-up orthosis fixes the wrist joint and metacarpal bones. The subject’s fingers are placed in a
glove, and the tip of the finger is directly pulled by the glove into flexion at the metacarpophalangeal joint.
b Traction-type orthosis. The cock-up orthosis fixes the wrist joint and metacarpal bones. The subject’s fingers are placed in arotary pipe, while the proximal phalanges are fixed by a dorsal and palmar cuff while traction is applied to enhance the joint
space and provide flexion.

aspects. The palmar area of the joint space was definedas the area between the central and most palmar partsof the joint. The dorsal area of the joint was defined as
the area between the central and most dorsal parts of thejoint (Fig. 2(ii)). A total of 20 points were marked on
the proximal phalanx base and metacarpal head. These
points were 0.1 mm apart based on the bone curvature.
The ratio of cancellous bone and the articular cavity wasmaintained at 1:1.
Statistical methods
We used Friedman’s test to confirm whether there
was a difference among the flexion-type, traction-type,and no orthosis groups. A significant difference wasobserved, so we performed the Steel-Dwass test for
multiple comparisons to confirm whether there was asignificant difference among groups. We then calculated
the P value. Statistical analyses were performed using
the SPSS Base 11.0J software package (SPSS Japan
Inc., Tokyo, Japan). P values < 0.05 were considered
statistically significant.

Results
Joint space distance of the MCP joint
There was no significant difference in the mostdorsal joint space distance between the flexion-type andtraction-type orthoses (Fig. 3). When no orthosis wasused, significant narrowing occurred compared to that of
the flexion-type and traction-type orthoses ( p = 0.03).
The central joint space increased significantly
by the traction-type orthosis compared to that withthe flexion-type orthosis ( p = 0.04) or no orthosis ( p= 0.03). In contrast, the palmar joint space decreased
significantly with the flexion-type orthosis compared tothe traction-type orthosis ( p = 0.02) or no orthosis ( p =0.04).
Joint space area of the MCP joint
The dorsal joint space area significantly increasedby the traction-type orthosis compared to that when no
orthosis was used ( p = 0.02). In contrast, the dorsal joint
space area was not significantly different between the

58

FLEXION-TYPE ORTHOSIS VS TRACTION-TYPE ORTHOSIS

Fig. 2. Method for measuring the joint space distance and area in the metacarpophalangeal joint(i) Method for measuring the joint space distance in the metacarpophalangeal joint. (a) The most palmar point is the most palmar
point of the proximal phalanx and the metacarpal head. (b) The most dorsal point is the most dorsal point of the proximal
phalanx and the metacarpal head. (c) The central point is the point halfway between points a and b. (d) The central part is theline between the two central points. (e) The most palmar part makes a parallel translation from c to the most palmar point of
the proximal phalanx; the distance to the metacarpal head was obtained. (f) The most dorsal point makes a parallel translationfrom c to the most dorsal point of the proximal phalanx.
(ii) Method for measuring the joint space area in the metacarpophalangeal joint. (a) The palmar part is the area of the joint
located between the central part and the most palmar part. (b) The dorsal part is the area of the joint located between the mostdorsal part and the most central part.

Fig. 3. Comparison of the joint space distance in the metacarpophalangeal joint
We examined 10 index fingers of healthy volunteers. (a) is the most dorsal part; and (b) and (c) are the central and the mostpalmar part. n.s; not significance, *; p < 0.05.

Asian J Occup Ther 13: 55−60, 2017

Nakayama J et al.

59

Fig. 4. Comparison of the joint space area in the metacarpophalangeal joint
We dissected 10 fingers of healthy volunteers. (a) the most dorsal part; and (b) the most palmar part. n,s; not significance,*; p < 0.05.

flexion-type orthosis and no orthosis (Fig. 4).
The palmar joint space area was significantly
increased by the traction-type orthosis compared to theflexion-type orthosis ( p = 0.04). In contrast, the palmar
joint space area decreased insignificantly by the flexiontype orthosis compared with no orthosis ( p = 0.12).
Finally, the palmar joint space area of the traction-type
orthosis was significantly greater than that of theflexion-type orthosis.

Discussion
CT is useful in the anatomical evaluation of the
MCP joint; [10] hence, we used it to measure the effectof the dynamic (traction-type) orthosis on the MCP joint
distance and area spacing. The traction-type orthosis
can add traction to the MCP joint in a variety of flexed
positions because it uses a rotary pipe. Compared to theflexion-type orthosis, the traction-type orthosis induced
joint space widening and, therefore, can reduce the riskof articular surface collision, which can cause injury.
However, compared to wearing no orthosis, wearing thetraction-type orthosis did not significantly increase thejoint space area in the most palmar part of the MCP. According to previous studies, the bony origin of the index
collateral ligament of the MCP joint lies along the dorsolateral tubercle of the metacarpal, while its insertionis along the proximal phalanx near the volar plate [13].
Generally, the collateral ligaments of the MCP joint
relax in the extended position and are tense in the coiled
position. Furthermore, when the MCP joint is flexed to40°, the radial collateral ligament and the ulnar collateral ligament are extended by 2−3 mm [13]. Therefore,
in the 40° coiled position, approximately 70% of thecollateral ligament is in a rigid state. The traction-type
orthosis creates traction from the stiff angle, whichsuggests why it was ineffective at increasing the joint
distance in the most palmar part.
MCP joint contracture is a common clinical condition [8]. The most common cause of extension contracture of the MCP joint is shortening of the collateral
ligament [8]. It is important to maintain the maximum
possible range of joint motion during the early treatmentof contractures. Treatment is difficult and requires
more time once the contracture is fully formed. Here, a
traction-type dynamic orthosis was designed to correct
flexion while achieving joint traction to enhance the
MCP joint area spacing and minimize damage caused byarticular surface collision [5, 9].
Based on the results of our study and previous
studies, a therapist considers the power of traction andmanufactures orthoses according to patients’ symptoms.
Therefore, sharp pain caused by traction-type orthosis
does not differ significantly from that caused by flexiontype orthosis [14]. However, our results show that thearticular surface was pulled using a traction-type orthosis rather than a flexion-type orthosis. This shows thatboth ligament and joint capsules were pulled using thetraction-type orthosis. Furthermore, another study reported that a significant improvement in ROM occurredwith the traction-type orthosis compared with theflexion-type orthosis after 6 weeks [9]. In addition, thetraction-type orthosis is effective for treating contractures of the MCP joint [15].
This study has a few limitations. First only healthy
subjects, not those with MCP joint contractures, were
evaluated; therefore, the data may not be extrapolated toother patients. Second, in clinical practice, an orthosis
is often worn for long periods, but this study evaluated only the immediate effects of its application. The
traction-type orthosis will most likely require several
improvements. In addition, because of the risk of irradi-

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FLEXION-TYPE ORTHOSIS VS TRACTION-TYPE ORTHOSIS

ation to the patient when using CT, it may be necessary
in future studies to devise an alternative means of evaluating the usefulness of the dynamic orthosis. To validate
the results of the current study, further long-term studies
are needed in a larger patient population. In this study,
we made our evaluations using surrogate scales without
a functional standard. Furthermore, in the future, wewish to evaluate the dynamic orthosis using functional
standards such as range of motion or sharp pain.

References[1] Choi JS, Mun JH, Lee JY, Jeon JH, Jung YJ, Seo CH,
et al. Effects of modified dynamic metacarpophalangeal
joint flexion orthoses after hand burn. Ann Rehabil Med.
2011; 35: 880−6.
[2] Flowers KR, LaStayo P. Effect of total end range time on
improving passive range of motion. J Hand Ther. 1994; 7:
150−7.
[3] Judith A. Rehabilitation of the hand. St. Louis: The C. V.
Mosby Company; 1978. p. 322−9.
[4] Celeste G. Dynamic splinting for the stiff hand after
trauma: predictors of contracture resolution. J Hand Ther.
2011; 24: 195−205.
[5] Nakayama J, Kurokawa K, Konishi A, Hamanami K, Oka
H. A trial of a revolving-type dynamic traction splint forextension contracture of the metacarpophalangeal joint.
Occupational Therapy. 2008; 27: 168−73. (in Japanese)[6] Ueba Y, Kurata H, Ono I. Basic biomechanics for orthotic
therapy of the hand. Bull Jap Soc Prosth Orthot. 1999;
15: 119−24. (in Japanese)[7] Anzarut A, Chen M, Shankowsky H, Tredget EE.
Quality-of-life and outcome predictors following massive
burn injury. Plastic Reconst Surg. 2005; 116: 791−7.

[8] Jack RH. Management of a metacarpophalangeal joint
fracture using a dynamic traction splint and early motion.
J Hand Ther. 1999; 12: 219−27.
[9] Nakayama J. Effect of rehabilitation of a revolving typedynamic traction splint for extension contracture of themetacarpophalangeal joint. J Phys Med. 2009; 20: 351−7.
(in Japanese)[10] Vanderperren K, Ghaye B, Snaps FR, Saunders JH. Evaluation of computed tomographic anatomy of the equine
metacarpophalangeal joint. Am J Vet Res. 2008; 69:
631−8.
[11] Nakayama J, Horiki M, Ogawa K, Oka H, Domen. Development of a new dynamic traction and flexion splintfor MCP joint extension contractures. Tokyo Keiogijyuku: Soc Biomech Jap; 2014. p. 249−58.
[12] Shibata K, Ikuta M, Nomura T. Relation between traction
force and cuff shape of splint on the peripheral blood flowof the digits. Occ Ther. 1986; 7: 485−6. (in Japanese)[13] Kataoka T, Moritomo H, Miyake J, Murase T, Yoshikawa
H, Sugamoto K. Change in shape and length of the collateral and accessory collateral ligaments of the metacarpophalangeal joint during flexion. J Bone Joint Surg Am.
2011; 93: 1318−25.
[14] Nakayama J, Horiki M, Denno K, Ogawa K, Oka H,
Domen. Development of a new dynamic splint for MP
joint extension contracture using a curved pneumatic artificial rubber muscle. 16th International Congress of theWorld Federation of Occupational Therapists 2014: PRE
18−26, 215.
[15] Nakayama J, Horiki M, Denno K, Ogawa K, Oka H,
Domen. Pneumatic-type dynamic traction and flexion
splint for treating patients with extension contracture of
the metacarpophalangeal joint. Prosthet Orthot Intl. 2016;
40: 142−6.

■ORIGINAL ARTICLE

Tasks and Prospects of Psychiatric Occupational
Therapy in South Korea
Yoon-Jeong Eom1, Hiroshi Yamane2, Sumie Yamada3
1

Occupational therapist, Center for Dementia, Gwanak-gu Public Health Center
Society of Human and Occupation-Life, Kyoto University
3
Human Health Science Graduate School of Medicine, Kyoto University
2

Abstract: Background: Occupational therapy (OT) in South Korea suffers from ambiguous legislation and lack ofinstitutional support.
Aim: To identify the current state and prospects of psychiatric OT in South Korea.
Methods: We introduced the concept of Japanese psychiatric OT to Korean occupational therapists (OTRs). In-depthsemi-structured interviews were conducted with participating OTRs. All interview data were analyzed using thematic
analysis and NVivo10.
Results: Interview data were divided into two themes: (1) [Current state of Psychiatric OT in South Korea] and (2)[Impressions on Psychiatric OT in Japan]. Furthermore, [Current state of Psychiatric OT in South Korea] was divided
into three nodes: (a) [clinical psychiatry], (b) [legal system], and (c) [psychiatric OT]. In addition, we identified thatpsychiatric OT in Korea had four major problems related to clinical psychiatry, the legal system, psychiatric OT, andeducation. Although the treatment structure of OT for acute phase, referred to as “parallel place,” is difficult to apply inSouth Korea, opinions on OT in Japan by practitioners were generally positive.
Conclusion: We suggest three approaches that could be used in the future in South Korea. Considering the differencesin culture and therapeutic systems between South Korea and Japan, this study proposes solutions to improve the quality
and status of psychiatric OTRs in South Korea.
Keywords: psychiatric occupational therapy, South Korea, Japan, mental health, legislation(Asian J Occup Ther 13: 61−69, 2017)

1. Introduction
Occupational therapy (OT) in Korea began withpsychiatric OT conducted by the Japanese Governor
General of Korea in 1928 [1]. It was formally introduced
after the Korean War to treat the injured and focused ontreating physical disability rather than mental illness [2].
Thereafter, the Mental Health Act was amended, and aclause regarding OT [3, 4] was created in 2008. In thefollowing year, regulations were enforced regarding the
involvement of occupational therapists (OTR) [3, 4].
However, the Mental Health Act states that psychiatricReceived: 24 October 2016, Accepted: 8 August 2017
Corresponding to: Yoon-Jeong Eom, Occupational therapist, Center
for Dementia, Gwanak-gu Public Health Center, Gwanak Ro 145,
Gwanak-gu, Seoul, South Korea
e-mail: yoonjeongeom@gmail.com©2017 Japanese Association of Occupational Therapists

OT is to be carried out by mental health specialists (i.e.,social workers, nurses, and clinical psychologists) [3, 5],which contradicts with regulations [6].
In Japan, where OT is also conducted under the national health insurance system, similar to South Korea,
the total number of OTR in 2010 was 53,080 and thenumber of psychiatric OTR was 5,565 [7], which is relatively large compared to South Korea. Japan has also
more consistent regulations regarding psychiatric OT.
With regard to psychiatric OT in South Korea, aprevious study described the issues in South Korea’s
legal system with reference to foreign countries [6]. Another study examined the current state of psychiatric OT
and its problems (shortage of personnel, limited use of
assessment tools, and lack of awareness about OT) [8].
However, the state of psychiatric OT remained relatively
unchanged even after the studies were conducted.
In order to establish psychiatric OT in South Korea,
researchers in the previous study investigated the issues

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SUGGESTIONS FOR PSYCHIATRIC OT IN KOREA

surrounding psychiatric OT in South Korea. We focusedparticularly on the changes that were made to the laws
regarding mental health in South Korea, details of OT
education, working environment of OTRs in the mental
health field, and problems in fieldwork education [9,10].
In the present study, OTRs in South Korea weredirectly interviewed and the data were analyzed. Thismethod allowed us to objectively identify the challengesof psychiatric OT in South Korea compared to previous
studies. Through our clinical and research experience inJapan, we examined plans for establishing psychiatric
OT that is most appropriate to South Korean culture andinstitution.

2. Methods
Based on the first author’s six and a half years ofexperience in Japanese psychiatric OT, we used qualitative research methods [11], including an in-depthsemi-structured interview that examined the opinions of
Korean psychiatric OTRs on the characteristic elements
and benefits of the psychiatric OT system in Japan (Table1), as well as problems in the current state of OT and
its future challenges. The names of participants were
replaced with pseudonyms to ensure anonymity. The
study was approved by the Ethics Committee of Kyoto
Table 1. Characteristics of Japanese Psychiatric Occupational Therapy<Session 2>
Interview 1. Japanese mental health system and laws related to
psychiatric OTInterview 2. The basics of psychiatric OT (focusing on evaluation,planning, effectiveness of occupation, etc.)<Session 3>
Interview 3. OT and psychiatric healthcare systems according torecovery status (i.e., acute phase, convalescence, and chronic
phase)
Interview 4. Treatment program (Introduction to the generalprogram and OT-specific treatment such as parallel place)Note. OT: Occupational therapy

University Graduate School and Faculty of Medicine.
2.1. Participants
As of 2014, there were 10,071 licensed OTRs in
South Korea [12], but only 25 worked in the field of
psychiatry [13]. Among them, recruitment emails weresent to 15 OTRs who were assumed to have been working in adult psychiatry for more than a year. A researcher visited six participants who had agreed to participate,explained the research objectives, both in writing andverbally, and received written informed consent prior
to initiation. The other nine OTRs refused to participate
because they were either on maternity leave or for otherprivate reasons. Participant characteristics are shown in
Table 2.
2.2. Data Collection
This study was carried out over three sessions (onesession per day) in order to give participants time tofully understand the contents and make appropriate decisions. The first session was a demographic interview
consisting of open-ended questions (duration: 22–58
min). In the second and third sessions, we introduced
characteristic elements of psychiatric OT in Japan (Table1), on which the participants were asked to commentand reflect. Further, they were asked questions regarding
the problems with South Korean psychiatric OT andtheir possible solutions (4–5 h per session). The interview was conducted while allowing the participants torest and relax, according to their state and needs. The
contents of the semi-structured interview are shown in
Table 3.
All interviews were conducted by the first author
and were recorded with the consent of the participant.
Observations made during the interview were noted in
the field notes, along with the time and date of the interview, description of the environment/facility, and nonverbal behaviors.
2.3. Data Analysis
We used thematic analysis [14, 15], which was
conducted over six phases: familiarization with data,
generating initial codes, searching for themes among

Table 2. Participant Characteristics
Subject

Employment
StatusEmployment
PeriodEducation

Facility

Age

Gender

1
2
3
4
5
6

Permanent
Contract
Contract
Permanent
Contract
Contract

Over 10 Years
Over 10 Years
5–10 Years
5–10 Years
1–5 Years
5–10 Years

MasterDoctoralBachelor
MasterBachelor
MasterHospital
HospitalCommunity Facility
HospitalCommunity Facility
Community Facility

50s
40s
30s
30s
20s
30s

FemaleFemaleFemaleMale
FemaleMaleEom Y-J et al.

Asian J Occup Ther 13: 61−69, 2017

codes, reviewing themes, defining and naming themes,
and producing the final report.
Furthermore, in order to improve the reliability ofdata analysis, we used NVivo10 [16], which helps formulate theories by individually coding textual data byword, phrase, sentences, and eventually creates categories [17].
All transcripts were transcribed verbatim and translated into Japanese; nuances of the language and culturalexpressions were explained in detail to all researchers.
The researchers reviewed the transcripts and field notes
multiple times, and consensus coding was performed
until all researchers agreed on the main themes and subthemes. A total of 433 pages of transcripts and coding
categories, which required no further revision, were
documented and converted into NVivo data by the firstauthor. The data were categorized into final coding categories, and during this process, the relationship between
the nodes were structured in stages. A total of 422 subnodes were divided into two nodes: (1) [Current state of

Psychiatric OT in South Korea] and (2) [Impressions on
Psychiatric OT in Japan]. In addition, [Current state of
Psychiatric OT in South Korea] node was divided into
three nodes: (a) [clinical psychiatry], (b) [legal system],and (c) [psychiatric OT]. The entire process of NVivo
analysis was carried out according to the guidelines ofNVivo10 data analysis [18, 19].

3. Results
The data obtained through NVivo10 were converted into 737 data (images, excel, and word files), whichwere discussed by the researchers. Nodes that were commonly mentioned by more than half of the participants
were determined as significant. Based on the number oftimes the participants mentioned the node (References)and the number of participants who mentioned the node(Sources), we considered meaningful data as 1) references that occurred more than ten times and 2) sourcesthat were more than four participants; these were more

Table 3. Questions in the Semi-Structured Interview<Session 2>
Interview 1
1. Impressions and questions regarding the provided book (on psychiatric OT in Japan) if the participant read it
2. Impressions and questions regarding the researcher’s explanation for Interview 1
3. Impressions and opinions related to the psychiatric heath care system and psychiatric OT laws in Japan
4. Differences and similarities in the psychiatric heath care systems and psychiatric OT laws between South Korea and Japan
5. What would be the most beneficial if applied to South Korea, and why?
6. Opinions on the best ways to apply this beneficial factor
Interview 2
1. Impressions and questions regarding the researcher’s explanation for interview 2
2. Impressions and opinions regarding Japan’s psychiatric OT system
3. Impressions and opinions regarding the evaluation method of Japan
4. Opinions on the psychiatric OT planning method in Japan
5. Impressions and questions on the YouTube video (on art and craft) created by the researcher if the participant watched it
6. Impressions and opinions on a method of treatment such as handicraft in Japan
7. On OT in South Korea (trends, evaluation, plans, and treatment methods)
8. What would be the most beneficial if applied to South Korea, and why?
9. Opinions on the best ways to apply this beneficial factor<Session 3>
Interview 3
1. Impressions and questions regarding the researcher’s explanation for interview 3
2. Impressions on the psychiatric heath care system and OT according to recovery status in Japan
3. Differences and similarities in the psychiatric heath care systems between South Korea and Japan
4. Thoughts on application in South Korea and its possibility
5. Opinions on the best ways to apply these beneficial factors
Interview 4
1. Impressions and questions regarding the researcher’s explanation for interview 4
2. Impressions and opinions on Japan’s treatment structure and treatment program
3. Impressions and opinions on Japan’s parallel place
4. Thoughts on the most beneficial factor if applied in South Korea, and why?
5. Opinions on the best ways to apply this method
Note. OT: Occupational therapy

63

64

SUGGESTIONS FOR PSYCHIATRIC OT IN KOREA

than 5% of total transcripts (Coverage) (Table 4). Table
5 presents some noteworthy statements made by the participants.
Due to limited number of psychiatric OTR in South
Korea, there is a risk of exposing the identity of participants despite ensuring anonymity. Therefore, the participants will be referred to as numbers randomly assignedby researchers in this paper (Table 5). For example, P1
denotes Participant 1.
3.1. Clinical psychiatry
In the [clinical psychiatry] node (Table 4), the lackof an understanding of OT in South Korea and the skepticism about the professionalism of OTRs was mostcommonly mentioned (Table 5A).

Furthermore, there were conflicts among healthcare professionals due to overlapping treatment, andOTRs were at a disadvantage because of to their smallorganization size (Table 5B). Moreover, health system
in South Korea lacks a systematic patient management
program after discharge, which prolongs hospitalizationand inhibits rehabilitation.
3.2. Legal system
Article 46, paragraph 2 of the legislation, which isan OT-related law, does not require an OTR to performthe treatment [3, 20]; thus, the need to employ an OTR
was low. Moreover, due to limited medical insurance
fees, it was difficult to receive support from hospitals
for arranging a suitable environment for performing OTTable 4. NVivo 10 Results
Categories
Current stateof Psychiatric
OT in Korea

Node
Clinical
Psychiatry

References

Sources

Coverage

Lack of understanding
regarding OT

17

5

3.48%

Overlapping treatment

12

3

5.07%

Non-systematic patientmanagement system

10

4

3.96%

Treatment/clinical status

155

12.89%

Problems related Problems with medical feesto psychiatricExclusion/discrimination from mental health
OT laws
specialist occupations

18

5

3.37%

21

6

2.67%

Mental health laws problems

21

4

5.01%

The shortage of OTRs

16

5

1.55%

Unclear identity of psychiatric OT

11

4

2.21%

Lack of psychiatric OT evaluation

11

6

4.88%

Problems in
education

Lack of psychiatric OT lectures

11

5

3.15%

Solutions

Need for evidence

10

6

2.72%

Need for listing OTRs as essential legal personnel

15

4

3.68%

Need for publicizing OT

11

5

3.89%

Need for a larger number of psychiatric OTRs

14

5

4.36%

Need for establishing the practice of psychiatric OT

12

3

6%

Need for development/proposal of practical programs

11

3

9.76%

10

5

4.16%

11

3

5.8%

Clinical problems

Problems with otheroccupations

Problems after discharge

Legal System

Psychiatric OT Problems inclinical practice

Impressions
on Psychiatric
OT in Japan

Reflections regarding
parallel place

Problems with application
in South Korea

Reflections on the explanation of the researcher

Laws related toworking pattern

Problems with medical
fees

Note 1. OT: Occupational therapy; OTR: Occupational therapist
Note 2. Gray background: nodes that were mentioned more than ten times or nodes that were mentioned by more than four subjects or coveragethat were more than 5%.

Eom Y-J et al.

Asian J Occup Ther 13: 61−69, 2017

(Table 5C).
Another reported major problem in the legal system was [exclusion /discrimination from mental healthspecialists] (Table 5D). This node was most frequently
mentioned and was mentioned by all participants. Legally, mental health specialists hold many rights and canperform OT according to article 46, paragraph 2 of thelegislation [3]; therefore, OTRs in clinical settings frequently encounter discrimination and have many com-65

plaints regarding this matter.
In terms of local facilities, problems in working
patterns, such as legally requiring OTRs as well as otherprofessionals to renew their contracts annually, werediscussed.
3.3. Psychiatric OT
The [psychiatric OT] node can be divided into three
categories: [problems in clinical practice], [problems inTable 5. Participants Quotes
A(Questions from other occupations) What can occupational therapists boast as their expertise within psychiatry; What are you(OTR) goodat… (P1)

B

Since there are other professions that perform overlapping duties... it’s kind of like a fight with professions (from different occupations)…
there is a subtle… competition... that exists... (P4)C

There was no support, and of course, there were financial issues, and legal issues, and the fact that we can’t hire another person (OTR).
There isn’t any funding, so there won’t be a reason to hire (an OTR). (P4)
[Occupational and recreational therapy] They’re bundled together like this. You don’t receive additional payment... you can do occupational therapy or recreational therapy… (P5)D

There are limits placed in work. In fact, since it is not included as a mental health specialist, (omitted) (OTRs) actually get excluded fromall lectures and education on counsel or treatment programs (P1).
Occupational therapists are part of miscellaneous personnel; the people who are in miscellaneous personnel are, you know, people who do
accounting? (Omitted) It’s under that category, the occupational therapists. (P6)E

There is a lack of support in discussing the matter in institutes right now. It’s because there are only a few people (OTRs) working in
psychiatry… (P3)
Since there are only a small number of OTRs, OT must focus on one thing, even though there are various things that the OT wants to do...
it’s kind of unfortunate... (P4)F

In nursing, for example, there is medical knowledge—medication management and such—which are representative of an occupation.
(omitted) (However,) when you’re asked what does an occupational therapist do well in the psychiatry field, there isn’t a single proper
response yet… that you can say... (P1)G

Regarding the therapeutic value of occupation, I think it’s largely missing from our education process. Also, it seems that graduating fromschool (majoring in occupational therapy) doesn’t imply that everybody can perform psychiatric occupational therapy (P3)
The most difficult part of working in psychiatry is that we learned very little from school (omitted) and we don’t practice (what we learned
related to arts and craft) ~(P6)H

Nurses are also involved with training for activities of daily living; there are no clear distinction for an occupational therapist (as an
occupation for performing training for activities of daily living in the law) (P4)
Occupational therapist must be placed under a personnel structure by law.(P5)I

I think more publicity for psychiatric occupational therapy is needed (omitted) for it to be invigorated—anywhere—it requires people to beinterested in that area (P2)
Lobbying activities must be made by creating data on the need for OT (P3)J

If there are more OTRs, people will say (omitted) oh, there are so many occupational therapists in psychiatry—it’s an obvious occupation (inpsychiatry) that people are in—this way, people become naturally aware of OT, right? (P1)
There are this many occupational therapists working in developed countries; but, even if you submit this evidence to the secretary generalfor healthcare policy, it won’t be recognized, so I think there needs to be more OTRs working in the psychiatric field (P6)K

Either way, one part (practice) needs to be selected quickly. If not, it appears that we might lose it all (to another occupation). (omitted)
The daily routine in hospital wards is already fully planned out with activity programs. (P3)L

It would be great if parallel place was possible… but because of the very small budget of the Ministry of Health and Welfare, and because
the health insurance is always in deficit, the current tone is decrease and reduction. So, I don’t think it will be easy. Even implementation
itself (P6)

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SUGGESTIONS FOR PSYCHIATRIC OT IN KOREA

education], and [solutions]. Among them, three nodes,[the shortage of OTRs], [unclear identity of psychiatric
OT], and [lack of psychiatric OT evaluation], were commonly mentioned under the [problems in clinical practice] node. The most frequently mentioned node was[shortage of OTRs] (Table 4), which was also mentioned
as a factor that weakened the organizing ability and as
impeding treatment variety (Table 5E).
Regarding the [unclear identity of psychiatric OT]
node, there were four OTRs who had concerns similar
to those listed in Table 5F, which was the second mostfrequently mentioned node among [problems in clinicalpractice] (see Table 4).
All the participants evaluated the psychiatric OT(Table 4) and pointed out the lack of an evaluation system appropriate to Korean culture and clinical practice,including the lack of a common evaluation tool that canbe used by psychiatric OTRs.
Moreover, in the [problems in education] node, participants mentioned lack of psychiatric education during
undergraduate studies that lead to difficulties in applying
for psychiatric OT in clinical practice (Table 5G).
Lastly, the [solutions] nodes included [need forevidence], [need for listing OTRs as essential legal personnel], [need for publicizing OT], [need for a larger
number of psychiatric OTR], [need for establishing thepractice of psychiatric OT], and [need for development/
proposal of practical programs]. Among these, [need forevidence] was proposed by all participants as a solution

Clinical
Psychiatry

to problems in clinical practice, and as a necessary step
to list OTR as an essential legal personnel. The node
[need for listing OTRs as essential legal personnel] was
the most frequently mentioned node among [solutions],
and other nodes were mostly mentioned in support ofthis node (Table 5H). Furthermore, [need for publicizing
OT] was mentioned as a challenge in Table 5I due to thelack of awareness of OT and problems in the legal system, which seem to be due to a shortage of psychiatricOTRs in South Korea (Table 5J).
In addition, in the node [need for establishing thepractice of psychiatric OT], participants believed that
the Korean psychiatric OTRs should not overlap inpractice with other professionals and should develop
treatment and therapy that are not practiced by otherspecialists (Table 5K).
Lastly, the [need for development/proposal of practical programs] node was present in more than 9% of
total transcripts, and many OTRs asked for specializedpractices and practice methods due to lack of establishedpsychiatric OT practices.
The relationship between the current state of psychiatric OT in South Korea and its solutions according
to analyses of interviews are shown in Fig. 1.
3.4. Impressions on Psychiatric OT in Japan
In the [psychiatric OT in Japan], [reflections regarding parallel place] and [reflections on the explanationof the researcher] nodes were considered meaningful.

- Problems with other occupations
Lack of understanding regarding OT
Overlapping treatment- Problems after discharge
Non-systematic patient management system- Treatment/clinical status

Problems inclinical practice- Small number of OTR- Unclear identity of psychiatric OT- Lack of psychiatric OT evaluation

Legal System- Problems with mental health laws
Laws related to work model- Problems related to laws on psychiatric OT
Problems with medical fees
Exclusion/discrimination from mental healthspecialist occupations

Problems in
education- Lack of psychiatric OT lectures

Fig. 1. The relationship between the current state of psychiatric OT in South Korea and its solutions<Solutions>- Need for alarger numberof psychiatric
OTR- Need for listing
OTR asessential legal
personnel- Need forevidence- Need for
publicizing OT- Need forestablishing thepractice of
psychiatric OT- Need fordevelopment/
proposal ofpractical
programs

Asian J Occup Ther 13: 61−69, 2017

Among these, the [reflections on the explanation of theresearcher] node included opinions, reflections, andsatisfactory ratings of the explanation by the first author(Table 2), and, based on this, any problems with the explanation method were identified.
Although these were not selected as nodes for analyses because they were neither mentioned more than 10times nor accounted for 5% of what was mentioned, theparticipants’ response to the evaluation of legislation, recovery status, and healthcare system in Japan was mostly positive. At least four participants expressed positive
comments saying that they were specific and systematic.
More than 4 participants showed positive responses to [parallel place], that is, patients could choose
their desired occupation and were able to proceed withthe treatment according to their current state. Parallel
place is a unique treatment structure in Japan, similar toParten’s parallel play or Mosey’s parallel group [21, 22],
but this treatment structure targets mainly patients in theacute phase, without increasing the level of cohesion in
the organization [23]. However, [problems with medicalfees] were pointed out as challenges in terms of application in South Korea (Table 5L). It was indicated that application in South Korea would be difficult due to lackof legal standards regarding clinics and facilities, andthe materials and tools required for OT [24], comparedto those that are present in Japan. Furthermore, it was
mentioned that with the current medical insurance fees,
it is not possible to receive funding from the hospital toequip OTRs with the materials and tools required for
OT; there were also many opinions on the need for application of elements other than parallel place in clinicalpractice.

4. Discussion
Previous research clearly indicated problems in
psychiatric OT in South Korea such as lack of education, evaluation tools, and workforce, problems in OTR
organization and the legal system, and lack of awarenessregarding OT [6, 8, 10].
By conducting an in-depth semi-structured interviews and using NVivo10, the present study objectively
identified/organized the problems and their solutions regarding psychiatric OT in South Korea. Specifically, we
identified that psychiatric OT in Korea had four major
problems (Fig. 1) related to clinical psychiatry, the legal
system, psychiatric OT, and education. In addition, we
learned that psychiatric OTRs in South Korea considered the following solutions to address these problems:
the need for evidence, need for listing OTRs as essential
legal personnel, need for publicizing OT, need for a larger number of psychiatric OTRs, need for establishing the

Eom Y-J et al.

67

practice of psychiatric OT, and need for development/
proposal of practical programs.
Furthermore, South Korean psychiatric OTRs expressed positive responses towards legislation, evaluation methods, and the recovery status/health care system
in Japan, as they described them as detailed, specific,
systematic, and clear. However, we also found that factors, such as medical fees and differences in treatment
systems, led to hesitation about parallel place.
4.1. Pandora’s box
After analyzing the data repeatedly to identify thecause of the problems, we narrowed the possible reasons
down to two: low professionalism of psychiatric OT andsocial and institutional problems in South Korea.
Contrary to what was expected, most of the factors
mentioned above as problems and their respective solutions started with one single factor, that is, low professionalism of psychiatric OT. The problems caused bysocial and institutional problems in South Korea only
included problems after discharge in the [clinical psychiatry] node and problems with mental health laws in
the [legal system] node.
Problems caused by social and institutional problems in South Korea were the same as problems facedby people in other occupations, such as psychiatricpractice. However, at the surface level, OT seemed to
struggle with problems due to factors such as legislation,
institution, society, clinical practices, and other occupations; yet a deeper evaluation revealed that they werecaused by one single factor, that is, low professionalismof psychiatric OT.
When we used the NVivo10 to categorize andanalyze data, we used the language or words used by
OTRs. While such an analysis revealed many problems
in psychiatric OT in South Korea, the suggested solutions were superficial. This was because the participants
unconsciously used projection and rationalization as defense mechanisms. Unfortunately, some defense mechanisms used by the participants made it more complicatedto identify this problem as they knew, albeit vaguely,that the cause of the problems with psychiatric OT was
related to low professionalism.
Admitting this play of defense mechanisms in theinterview process will perhaps contribute to a reflective
inquiry and serve to improve the results of the research.
4.2. Solutions for Psychiatric OT in South Korea
There are few OTRs working in psychiatry in South
Korea, and we attempted to represent their current position and circumstances and identify the solution to
improve professionalism in a small organization. There
could be three approaches that could be used in the

68

SUGGESTIONS FOR PSYCHIATRIC OT IN KOREA

future.
First, psychiatric OT could include the task of coordinating therapy programs. OTRs could hire music
therapists, horticultural therapists, and art therapists,
and manage the therapeutic plan and schedule. This
would be an efficient way to organize group programs.
However, for this, psychiatric OTRs should be legallydefined as mental health specialists so that they have theauthority to coordinate therapeutic plans. In addition,
to gain recognition as coordinators and, OTRs need todemonstrate outstanding abilities in occupation analysis
and provide evidence to justify the occupation provided
to patients. Therefore, the OT association and school
teachers should work together to research and develop
the OT education program.
Second, psychiatric OTRs could perform all thetasks and operate the programs on their own, as in Japan. However, this approach might face many obstacles.
For starters, the entire curriculum needs to be reformed,
such as extension of practice hours, for OTRs to beable to perform all the tasks. In addition, there would
be many difficulties due to coordination in terms of thescope of work with other professions, and such a change
will take time. For this reason, psychiatric OTRs in
South Korea need to explain the distinct effects of thetasks performed by them as compared to other occupations by presenting definite evidence. Further, it would
require a communication between OTRs in Japan andthe OT association in Korea to adopt this approach.
Finally, there is an approach wherein psychiatric
OT in South Korea could develop and evaluate their
specialized programs. Since this should be a programthat is not currently performed by other occupations, itwill require detailed research and a considerable amountof funding. Further, it would require guidance and approval from the Korean Association of Occupational
Therapists. As such, it is expected that psychiatric OTRs
working in clinical practices, the OT association, andschool teachers work together to facilitate research.
4.3. 
Applicability of Japan’s Psychiatric OT for theDevelopment of South Korea’s Psychiatric OT
This study was conducted as a trial with one of thestudy purposes being to examine the applicability ofJapan’s psychiatric OT, which is equipped with a better
therapy structure and system in terms of clinical practices, in the context of South Korea, as both countries sharea similar health care system. However, we encountered
several problems in the course of the study.
First, there was a difference in history and cultureof South Korea and Japan. Even though both countries
are located in Asia and have a similar national healthcare system, there was a wide gap in the contexts. After

Japan’s colonial rule in South Korea ended, the financial and health insurance system was in a bad shape. In
addition, many people were physically injured during
the Korean War, and there was an increase in acute disease treatment and physical treatment directly related todeath. Therefore, the progress of mental treatment andrehabilitation for improving quality of life received low
priority. This historical background created imbalancesin payments covered by health care insurance in South
Korea, so the problems that the country’s heath caresystem faces are fundamentally different from those ofJapan’s, which was well-established.
Second, there was a gap in OT treatment structure
between the two countries. In South Korea, one programis used to perform therapy using the same occupations.
On the contrary, Japan uses the parallel place, which isdifferent from group therapy, and provides occupations
personalized according to the needs and current statusof patients. In this regard, the anxiety of OTRs in South
Korea about parallel place was higher than expected.
To begin with, since they had never seen or experienced
this therapy structure designed for multiple patients, it
might have been difficult for them to imagine and theanxiety could have been a result of their doubts about
the structure. The operations of parallel place, which
provides various tasks tailored to the needs of a certain
person, are in fact difficult to apply to South Korea
in practical terms. In South Korea, a therapy program
gathers patients with the same needs and groups themby providing them the same tasks. For this purpose,music therapists, horticultural therapists, art therapists,and other professionals work together in this process.
Therefore, it is difficult to imagine a therapy structure
like parallel place. While it is true that problems withlegislation and institutions have a large impact, in order
to upgrade these, a therapeutic method to maximize theprofessionalism of OTRs and ensuring cost-effectiveness while hiring them is required. Therefore, instead ofdebating whether or not to apply parallel place, priority
should be on researching and developing unique group
operational and therapeutic methods and increase professionalism of OTRs in South Korea.

5. Conclusion
The present study analyzed the status and problems
in psychiatric OT in South Korea. From the perspectiveof Korean OTRs who have experience with psychiatric
OT in Japan, we examined the tasks and solutions of
psychiatric OT in South Korea. Although issues suchas the historical background between the two countries
cannot be disregarded, we hope that this study can contribute to an interdisciplinary research aiming to estab-Asian J Occup Ther 13: 61−69, 2017lish an international standard of psychiatric OT appropriate to South Korea. This would allow us to improvetreatments for those suffering from mental illness.
Acknowledgments: We would like to thank the South
Korean and Japanese OTRs as well as related organizations for their interdisciplinary cooperation and guidance in this paper. This study did not receive any external sources of funding. We would like to thank Editage(www.editage.co.kr) for English language editing, andthe researcher claims no conflicts of interests.

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■ORIGINAL ARTICLE

Relationship between Recovery and Cognitive Insight,
Neurocognition, Social Functioning, and Symptoms
in Patients with Schizophrenia:
A Cross-Sectional Study
Takeshi Shimada1, 2, Asami Takamaru2, Sayaka Komatsu2, Yu Sato2,
Tomotaka Yoshida2, Masayoshi Kobayashi1
12Graduate School of Medicine, Shinshu University, Nagano, Japan
Medical Corporation Seitaikai Mental Support Soyokaze Hospital, Nagano, Japan

Abstract: This cross-sectional study investigated the factors associated with recovery in patients with schizophrenia.
One-hundred and three patients with schizophrenia participated in this study. Measures included the Japanese versionof the Recovery Assessment Scale (RAS-J), Japanese version of the Beck Cognitive Insight Scale (BCIS-J), Wechsler
Adult Intelligence Scale-III (WAIS-III) similarities and symbol search subtests, Life Assessment Scale for the Mentally
Ill (LASMI), and Brief Psychiatric Rating Scale (BPRS). Stepwise multiple regression analyses were performed to investigate relationship between recovery and other clinical variables, including cognitive insight, neurocognition, social
functioning, and symptoms. Goal/success orientation and hope in the RAS-J was significantly associated with selfreflectiveness (β = 0.42) in the BCIS-J and self-recognition (β = 0.59) in the LASMI. Reliance on others in the RAS-J
was significantly associated with self-certainty (β = 0.49) and self-reflectiveness (β = 0.49) in the BCIS-J. Personal confidence in the RAS-J was significantly associated with self-certainty (β = 0.22) in the BCIS-J and endurance and stability (β = 0.78) in the LASMI. No domination by symptoms in the RAS-J was significantly associated with self-certainty(β = 0.69) and self-reflectiveness (β = 0.28) in the BCIS-J. Willingness to ask for help in the RAS-J was significantly
associated with self-certainty (β = 0.41) in the BCIS-J and belligerence (β = 0.59) in the BPRS. RAS-J total score wassignificantly associated with self-certainty (β = 0.20) and self-reflectiveness (β = 0.12) in the BCIS-J and endurance andstability (β = 0.69) in the LASMI. Our findings provide encouraging evidence for the relationship between recovery
and cognitive insight and contribute to developing tailored interventions to improve cognitive insight with the aim ofachieving recovery in patients with schizophrenia.
Keywords: recovery, cognitive insight, schizophrenia, self-reflectiveness, self-certainty(Asian J Occup Ther 13: 71−78, 2017)

Introduction
Schizophrenia treatment has moved beyond management of psychotic symptoms to the more ambitious,and to the patient more personally meaningful, goal of‘‘recovery”. Recovery is a widely discussed concept thatemerged in the 1980s in published accounts detailing
Received: 26 April 2017, Accepted: 11 August 2017
Corresponding to: Masayoshi Kobayashi, Department of Occupational
Therapy, Graduate School of Medicine, School of Health Science,
Shinshu University
e-mail: mkobaya@shinshu-u.ac.jp©2017 Japanese Association of Occupational Therapists

the struggles of people with severe and chronic mental
illness. These accounts described patients’ journeys torebuild their lives, defining recovery as a deeply personal, unique process of changing one’s attitudes, values,
feelings, goals, skills, and/or roles [1, 2]. Recovery
reflects a way of living a satisfying, hopeful, and contributing life, even with limitations caused by the illness,and involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic
effects of mental illness [3]. Because of the importanceof recovery in severe mental illnesses, including schizophrenia, interventions to support recovery have been
widely implemented [4, 5]. Furthermore, there havebeen attempts to develop methods of evaluating recov-

72

RELATIONSHIP BETWEEN RECOVERY AND COGNITIVE INSIGHT IN SCHIZOPHRENIA

ery in the treatment and rehabilitation of schizophrenia[6]. In a review of previous studies, Liberman et al. [7]suggested the following definition of recovery from any
serious mental illness using objectively measurable indicators: at least two consecutive years of maintenanceat or above the threshold levels, including symptom
remission, functioning in vocational or educational activities, satisfying social interpersonal relationships, andindependent self-care functioning. In addition, previous
studies have reported several factors that are associatedwith recovery, including experience of peer support[8], social support from family and friends [9, 10], andmeaningful social participation such as work [7, 11, 12].
Delusion is a characteristic psychotic symptomof schizophrenia, and was once considered to be psychologically beyond comprehension [13]. In recent
years, the cognitive behavioral approach to psychotic
symptoms has empirically clarified cognitive psychological mechanisms related to the psychotic symptoms ofschizophrenia [14]. Within this approach, a lack of clinical insight has been accepted as a hallmark feature ofschizophrenia, where insight is defined as awareness of
having a mental illness, of specific symptoms and their
attribution to the disorder, of social consequences, andof need for treatment [15−18]. An important extensionof the concept of clinical insight was proposed by Becket al. [19]. They suggested that although clinical insight
focuses on awareness of illness factors, the concept of‘‘cognitive insight” focuses on the cognitive processes
involved in correcting erroneous judgments and certainty about mistaken judgments. Beck et al. [19] distinguishes the traditional approach to clinical insight from
cognitive insight, suggesting that the latter is a form ofcognitive flexibility that encompasses the evaluation andcorrection of distorted beliefs and misinterpretations. It
has been proposed that patients with schizophrenia, particularly those with delusions, have a limited capacity
to evaluate erroneous inferences, to distance themselvesfrom and reflect on their psychotic experiences, and torespond to corrective feedback [20, 21]. In addition, it
has been found that cognitive insight is associated not
only with delusions, but also with cognitive functioning[22, 23] and has an impact on real world functioning,such as daily functioning, interpersonal relations, andwork [24, 25]. For these reasons, psychological interventions aimed to improve cognitive insight in schizophrenia have been developed [26, 27].
Promoting the recovery of patients with schizophrenia is a very important theme within mental health careprovided within occupational therapy [28−32]. However, whether the cognitive insight is associated withrecovery in patients with schizophrenia has not yet been
demonstrated. In this study, we investigated the relation-

ship between recovery and several variables, including
cognitive insight, neurocognition, social functioning,and symptoms in Japanese patients with schizophrenia
at a psychiatric hospital. We hypothesized that cognitive
insight would be associated with recovery in thesepatients. Moreover, hypotheses included that neurocognition and social functioning would be associatedwith recovery. Clarifying these relationships may haveimportant clinical implications for the development ofinterventions that promote recovery in patients withschizophrenia.

Methods
We conducted a cross-sectional study investigating
the factors associated with recovery in patients withschizophrenia at a Japanese psychiatric hospital between
October 2016 and January 2017. Ethical approval forthe study protocol was granted by the ethics board of
the Mental Support Soyokaze Hospital, Nagano, Japan.
Study participants provided written informed consent
for all study procedures.
Participants
Inclusion criteria for this study were aged 20−65
years, and a diagnosis of schizophrenia or schizoaffective disorder based on the criteria of the Structured
Clinical Interview for DSM-5 [33]. Exclusion criteria
were a diagnosis of mental retardation, alcohol or drug
disorders (abuse or dependence), or any current or pasthistory of neurological disorders, including head injury,
cerebral vascular disorders, epilepsy or dementia.
Measures
Recovery was assessed with the Japanese versionof the Recovery Assessment Scale (RAS) [34−36]. The
RAS was developed by Corrigan et al. [34, 35], and aJapanese version (RAS-J) was subsequently developedby Chiba et al. [36]. Outcomes on the RAS-J wereanalyzed using the five domains previously described,
which includes goal/success orientation and hope, reliance on others, personal confidence, no domination by
symptoms, and willingness to ask for help [36]. Each
item was scored on a 5-point Likert scale (1, strongly
disagree; 5, strongly agree), with higher scores indicating a better attitude to recovery.
Cognitive insight was assessed with the Japaneseversion of the Beck Cognitive Insight Scale (BCIS-J).
This comprises 15 items and two subscales: nine self-reflectiveness items assessing objectivity, reflection, andopenness to feedback, and six self-certainty items assessing certainty about being right and resistance to correction [19, 37]. Each item was scored using a 4-point

Shimada T et al.

Asian J Occup Ther 13: 71−78, 2017

scale (0, do not agree at all; to 3, agree completely), witha higher score of self-reflectiveness indicating greater
objectivity, and recognition of self and situation andwith a higher score of self-certainty indicating greatercertitude and confidence in one’s belief. A composite
index was calculated by subtracting the self-certainty
score from the self-reflectiveness score. Low composite
index scores indicate lower cognitive insight, reflecting
low self-reflectiveness and high self-certainty.
Neurocognition was assessed with the similarities
and symbol search subtests from the Wechsler Adult
Intelligence Scale-Third Edition (WAIS-III) [38]. Sumi­
yoshi et al. [39, 40] suggested that the combination ofthese WAIS-III subtests is the optimal and most concise
assessment of neurocognition in terms of administration
time, providing an assessment that is sensitive to overall
cognitive functioning and functional outcomes forschizophrenia.
Social functioning was assessed with the Life
Assessment Scale for the Mentally Ill (LASMI) [41].
The LASMI was developed to assess an individual’s
disabilities in daily life. It contains 40 items in five categories, including daily living, interpersonal relations,work, endurance and stability, and self-recognition, withhigher scores indicating more severe disability. In thisstudy, we used four categories: daily living, interpersonal relations, endurance and stability, and self-recognition.
Symptoms were assessed with the 18-item Brief
Psychiatric Rating Scale (BPRS) [42]. Outcomes on
the BPRS were analyzed using the 5-factor solution
described by Harvey et al. [43], which includes thefollowing subscales: positive, negative, disorganization,
belligerence, and affect. Each item was rated from 1(not present) to 7 (extremely severe), with higher scoresindicating more severe symptoms.
Statistical analyses
Descriptive statistics were used to summarize thedemographic and clinical variables. Pearson correlation
coefficients were calculated to examine the association
between RAS-J and each variable (BCIS-J, WAIS-III
similarities and symbol search, LASMI, and BPRS). To
investigate the extent of the impact of clinical variables
on recovery, stepwise multiple regression analysis was
performed to determine the factors associated withrecovery. Scores on each of the RAS-J subscales andthe RAS-J total score were dependent variables, andclinical variables that were significantly correlated withRAS-J (with p < .05 and with r > 0.3) were independent
variables. A test result was considered significant wherep < .05 for a two-sided test. Statistical analyses were
performed with JMP13.0.0 for Microsoft Windows (SAS73

Institute, Cary, NC, USA).

Results
One-hundred and three patients with schizophrenia
participated in this study. Demographic and clinical variables are summarized in Table 1 and 2. The mean ageof participants was 50.93 years (SD = 10.93), and themean antipsychotic dose (chlorpromazine equivalents)
was 750.89 mg (SD = 253.28). Of the 103 participants,
59 (57.28%) were male and 81 (78.64%) were inpatients. Mean scores for RAS-J subtests were as follows:
goal/success orientation and hope, 32.34 (SD = 5.83);
reliance on others, 14.24 (SD = 2.47); personal confidence and hope, 15.97 (SD = 3.71); no domination by
symptoms, 6.87 (SD = 1.88); willingness to ask for help,
14.07 (SD = 2.32); and the mean RAS-J total score was
83.50 (SD = 12.04). Mean scores for the BCIS-J wereas follows: self-reflectiveness, 11.09 (SD = 4.92); selfcertainty, 7.36 (SD = 2.88); and composite index score,
3.69 (SD = 3.96). Results of the Pearson correlation of
the scores for RAS-J with other variables are shown in
Table 3. There were several significant correlations (r >0.3). Goal/success orientation and hope was correlatedwith self-reflectiveness (r = 0.35) in the BCIS-J and
self-recognition (r = 0.37) in the LASMI. Reliance onothers was correlated with self-reflectiveness (r = 0.65),
self-certainty (r = 0.45), and the composite index (r =0.46) in the BCIS-J. Personal confidence was correlatedwith self-certainty (r = 0.38) in the BCIS-J, endurance
and stability (r = 0.53), and self-recognition (r = 0.31)
in the LASMI, and disorganization (r = 0.40) and belligerence (r = 0.45) in the BPRS. Not dominated by symptoms was correlated with self-reflectiveness (r = 0.47)

Table 1. Patient demographics
Age (years), mean (SD)50.93 (10.93)
Gender, n (%)
Male
59 (57.28)
Female44 (42.72)
Age of onset (years), mean (SD)23.76 (3.47)
Number of hospital stays, mean (SD)2.80 (1.22)
Total length of hospital stays (months)a, mean (SD) 21.92 (16.46)
Education (years), mean (SD)11.30 (2.38)
Experience of employment, n (%)
Yes
31 (30.10)
No72 (69.90)
Treatment setting, n (%)
Inpatient
81 (78.64)
Outpatient
22 (21.36)
Antipsychotic dose (mg/day)b, mean (SD)750.89 (253.28)a

The total length of hospital stay represented the total length of all
previous hospital stays.
b
Chlorpromazine equivalent dose.

74

RELATIONSHIP BETWEEN RECOVERY AND COGNITIVE INSIGHT IN SCHIZOPHRENIA

Table 2. Descriptive statistics of clinical variables

RAS-J
Goal/success orientation and hope
Reliance on others
Personal confidence
No domination by symptoms
Willingness to ask for help
RAS-J total
BCIS-J
Self-reflectivenessSelf-certainty
Composite index
WAIS-III
Similarities raw score
Symbol search raw score
LASMI
Daily living
Interpersonal relations
Endurance and stability
Self-recognition
BPRS
Positive
Negative
Disorganization
Belligerence
AffectBPRS total

Mean (SD)Range

32.34 (5.83)
14.24 (2.47)
15.97 (3.71)
6.87 (1.88)
14.07 (2.32)
83.50 (12.04)

21 − 43
10 − 20
9 − 254 − 1510 − 2065 − 114

11.09 (4.92)
7.36 (2.88)
3.69 (3.96)

3 − 273 − 16−4 − 16

15.39 (5.98)
21.97 (9.05)

0 − 27
8 − 3922.37 (6.87)
22.50 (7.75)
7.55 (1.34)
7.85 (2.89)

8 − 328 − 344−9
1 − 1224.16 (4.63)
12.30 (2.68)
13.89 (3.24)
12.19 (3.17)
17.84 (3.82)
80.49 (14.01)

11 − 32
6 − 196 − 196 − 189 − 2438 − 107

RAS-J, Japanese version of the Recovery Assessment Scale; BCIS-J,
Japanese version of the Beck Cognitive Insight Scale; WAIS-III,
Wechsler Adult Intelligence Scale-Third Edition; LASMI, Life Assessment Scale for the Mentally Ill; BPRS, Brief Psychiatric Rating Scale.

and self-certainty (r = 0.61) in the BCIS-J. Willingness
to ask for help was correlated with self-reflectiveness(r = 0.32) and self-certainty (r = 0.61) in the BCIS-J,and belligerence (r = 0.31) in the BPRS. RAS total was
correlated with self-reflectiveness (r = 0.48) and selfcertainty (r = 0.54) in the BCIS-J, endurance and stability (r = 0.30) in the LASMI, and belligerence (r = 0.38)
in the BPRS.
The stepwise multiple regression analysis was performed to investigate factors associated with recovery
measured by the RAS-J. However, there was evidenceof multicollinearity because the variance inflation factor
for dependent variables in a stepwise multiple regression analysis including BCIS-J self-reflectiveness, selfcertainty, and composite index scores, with RAS-J reliance on others as the dependent variable were 356.72,
126.36, and 223.47, respectively. Therefore, we conducted the analysis of factors associated with RAS-J reliance on others excluding the BCIS-J composite index.
The final models from the stepwise multiple regression
analyses are shown in Table 4. The models fit were good
(goal/success orientation and hope, F = 765.30, p =.000; reliance on others, F = 597.26, p = .000; personal
confidence, F = 1529.56, p = .000; no domination by
symptoms, F = 621.95, p = .000; willingness to ask for
help, F = 1150.42, p = .000; RAS-J total, F = 1499.79,
p = .000).
Goal/success orientation and hope in the RAS-J

Table 3. Correlations among RAS-J, BCIS-J, WAIS-III, LASMI, and BPRS
RAS-J
BCIS-J
SRSC
CI
WAIS-III
Similarities
Symbol search
LASMI
DL
IR
ES
SR
BPRS
Positive
Negative
Disorganization
Belligerence
Affect
Total

GO

RE

PE

NO

WI

Total

0.35**
0.24*
0.27**

0.65**
0.45**
0.46**

0.14
0.38**−0.12

0.47**
0.61**
0.10

0.32**
0.61**−0.07

0.48**
0.54**
0.19

−0.11
0.04

0.05
0.03

−0.11
−0.15

0.17
0.10

0.15
−0.18

−0.03
−0.04

0.03
−0.05
0.28**
0.37**−0.01−0.26**
−0.04
−0.01

0.21*
0.20*
0.53**
0.31**

0.09
−0.10
−0.00
−0.09

0.19
0.01
0.08
0.07

0.13
−0.03
0.30**
0.27**

0.27**−0.18
0.11
0.26**
−0.15
0.09

−0.06
−0.25*−0.24*
0.13−0.25*−0.16

0.29**
0.16
0.40**
0.45**−0.24*
0.25*

0.10−0.20*−0.08
0.19−0.21*
−0.04

0.17
0.17
0.27**
0.31**−0.15
0.18

0.26**−0.09
0.17
0.38**−0.26**
0.12

RAS-J, Japanese version of the Recovery Assessment Scale; GO, goal/success orientation and hope; RE, reliance on others; PE,
personal confidence; NO, no domination by symptoms; WI, willingness to ask for help; BCIS-J, Japanese version of the Beck
Cognitive Insight Scale; SR, self-reflectiveness; SC, self-certainty; CI, composite index; WAIS-III, Wechsler Adult Intelligence
Scale-Third Edition; LASMI, Life Assessment Scale for the Mentally Ill; LASMI-DL, daily living; LASMI-IR, interpersonal
relations; LASMI-ES, endurance and stability; LASMI-SR, self-recognition; BPRS, Brief Psychiatric Rating Scale.
*p < .05, **p < .01

Shimada T et al.

Asian J Occup Ther 13: 71−78, 201775

Table 4. Stepwise multiple regression analyses for relationships between recovery measured by RAS-J and clinical variables

GO
RE
PE
NO
WI
RAS-J total

SR (BCIS-J)
SR (LASMI)
SC (BCIS-J)
SR (BCIS-J)
SC (BCIS-J)
ES (LASMI)
SC (BCIS-J)
SR (BCIS-J)
SC (BCIS-J)
Belligerence (BPRS)
SC (BCIS-J)
SR (BCIS-J)
ES (LASMI)

B

SE

β

t

95% CIp

Adjusted R2

1.13
2.30
0.90
0.58
0.46
1.66
0.62
0.17
0.74
0.67
2.12
0.86
7.55

0.14
0.20
0.15
0.10
0.10
0.10
0.07
0.05
0.10
0.06
0.54
0.32
0.45

0.42
0.59
0.49
0.49
0.22
0.78
0.69
0.28
0.41
0.59
0.20
0.12
0.69

8.22
11.60
5.89
5.96
4.73
16.51
8.58
3.49
7.19
10.38
3.95
2.73
16.94

0.85 − 1.40
1.91 − 2.69
0.60 − 1.20
0.38 − 0.77
0.27 − 0.65
1.46 − 1.86
0.48 − 0.77
0.07 − 0.26
0.53 − 0.94
0.54 − 0.79
1.05 − 3.19
0.24 − 1.49
6.66 − 8.43.000**.000**.000**.000**.000**.000**.000**.000**.000**.000**.000**.007**.000**

0.94
0.92
0.97
0.93
0.96
0.98

RAS-J, Japanese version of the Recovery Assessment Scale; GO, goal/success orientation and hope; RE, reliance on others; PE,
personal confidence; NO, no domination by symptoms; WI, willingness to ask for help; BCIS-J, Japanese version of the Beck
Cognitive Insight Scale; SR, self-reflectiveness; SC, self-certainty; LASMI, Life Assessment Scale for the Mentally Ill; LASMIIR, interpersonal relations; LASMI-ES, endurance and stability; LASMI-SR, self-recognition; BPRS, Brief Psychiatric Rating
Scale; B, Partial regression coefficient; β, standardized partial regression coefficient; 95% CI, 95% confidence interval**p < .01

(adjusted R2 = 0.94) was significantly associated with
self-reflectiveness (β = 0.42, p = .000) in the BCIS-J
and self-recognition (β = 0.59, p = .000) in the LASMI.
Reliance on others in the RAS-J (adjusted R2 = 0.92)
was significantly associated with self-certainty (β = 0.49,
p = .000) and self-reflectiveness (β = 0.49, p = .000) in
the BCIS-J. Personal confidence in the RAS-J (adjusted
R2 = 0.97) was significantly associated with selfcertainty (β = 0.22, p = .000) in the BCIS-J and endurance and stability (β = 0.78, p = .000) in the LASMI.
No domination by symptoms in the RAS-J (adjusted R2= 0.92) was significantly associated with self-certainty(β = 0.69, p = .000) and self-reflectiveness (β = 0.28,
p = .000) in the BCIS-J. Willingness to ask for help
in the RAS-J (adjusted R2 = 0.96) was significantly
associated with self-certainty (β = 0.41, p = .000) in
the BCIS-J and belligerence (β = 0.59, p = .000) in
the BPRS. RAS-J total score (adjusted R2 = 0.98) was
significantly associated with self-certainty (β = 0.20, p =.000) and self-reflectiveness (β = 0.12, p = .007) in the
BCIS-J and endurance and stability (β = 0.69, p = .000)
in the LASMI.

Discussion
Participant characteristics
Participants in this study included 81 inpatients(78.64%) and 22 outpatients (21.36%), with a mean
RAS-J total of 83.50 (SD = 12.04). Although standardized scores for the RAS-J have not been elucidated, ourresults are consistent with the Japanese sample withschizophrenia reported by Chiba et al. (mean = 82.11,

SD = 15.76) [36], which included 115 inpatients (55%)
and 94 outpatients (45%). Therefore, the degree of recovery for participants in our study may be generalizable
to Japanese patients with schizophrenia. Although the
BCIS-J standardized score has also not been identified,
the mean self-reflectiveness score in our study (11.09,
SD = 4.92) was similar to that in a Japanese sample withschizophrenia reported by Uchida et al. (11.85, SD =3.30), while mean self-certainty scores in our study (7.36,
SD = 2.88) were higher than those reported in the previous study (4.27, SD = 2.13) [37]. It has been reported
that low self-reflectiveness and high self-certainty reflect
low cognitive insight, and are associated with the occurrence of delusions [44, 45]. Therefore, it is possible thatparticipants in our study had more severe delusions thanthose among general Japanese patients with schizophrenia.
Factors associated with recovery in patients with schizo­
phrenia
Results of stepwise multiple regression analysis
indicated that goal/success orientation and hope in the
RAS-J was significantly associated with self-reflectiveness in the BCIS-J and self-recognition in the LASMI.
Reliance on others in the RAS-J was significantly associated with self-certainty and self-reflectiveness in the
BCIS-J. Personal confidence in the RAS-J was significantly associated with self-certainty in the BCIS-J and
endurance and stability in the LASMI. No domination
by symptoms in the RAS-J was significantly associatedwith self-certainty and self-reflectiveness in the BCIS-J.
Willingness to ask for help in the RAS-J was signifi-

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cantly associated with self-certainty in the BCIS-J andbelligerence in the BPRS. Finally, RAS-J total score
was significantly associated with self-certainty and selfreflectiveness in the BCIS-J and endurance and stability
in the LASMI.
This is the first study to demonstrate that cognitive
insight measured with the BCIS-J is significantly associated with recovery measured with the RAS-J in patientswith schizophrenia in a Japanese psychiatric hospitalsetting. In our model, cognitive insight was the mostimportant predictive variable explaining the degree ofrecovery. These results provide encouraging evidence
for a relationship between recovery and cognitive insight, supporting the assertion that interventions aimed
to improve cognitive insight are needed for the achievement of recovery in patients with schizophrenia.
Moritz et al. [26, 27] developed metacognitive
training (MCT) as a psychological intervention for improving cognitive insight related to delusions in schizophrenia. Ishigaki [46] developed the Japanese versionof the MCT (MCT-J), and introduced it into the mental
health field in Japan. Further study is needed to examine
the impact of MCT-J in improving cognitive insight andthe effects this has on recovery of patients with schizophrenia.
Endurance and stability in the LASMI, whichassesses social adaptation, and its sustainability andstability, was associated with goal/success orientationand hope, personal confidence, and total RAS-J scores.
Goals and hopes are important components of recovery[11, 47]. This suggests that interventions aimed at improveing sustainability and stability of social adaptation
would help patients achieve these recovery domains.
Belligerence in the BPRS was associated with willingness to ask for help in the RAS-J. In fact, our findings
show that comprehensive support is important for theachievement of recovery. Therefore, not only shouldinterventions aim to improve cognitive insight but theyshould also target social adaptation.
We did not find a significant correlation between
RAS-J and the WAIS-III similarities and symbol search
subtests that reflect neurocognition. This result is notconsistent with some previous studies, which havefound associations between neurocognition and recovery in schizophrenia [22, 23, 48, 49]. This difference
may be due to differences in the measures used to assess
neurocognition, as we only used two WAIS-III subtests
reflecting overall cognitive functioning in schizophrenia[39, 40]. Therefore, it could not examine the relationshipbetween multiple aspects of cognitive functioning andrecovery measured using RAS-J in this study. To verify
the relationship between neurocognition and recovery, it
may be necessary to include a comprehensive measureof cognitive functioning, such as the MATRICS Consensus Cognitive Battery (MCCB) or Brief Assessment of
Cognition in Schizophrenia (BACS) which could assess
multiple aspects of cognitive functioning in schizophrenia.
Limitations
A number of study limitations should be noted.
First, study participants might not be representativeof all patients with schizophrenia, as this study was
conducted at a single site and the sample size was small.
Therefore, caution should be exercised in generalizing
the findings to patients with schizophrenia as a whole.
A multicenter research approach with a large sample
is required to avoid this limitation and provide greater
clarity regarding the relationship between recovery andcognitive insight. Second, participants included both
inpatients and outpatients with schizophrenia. It may benecessary to investigate factors associated with recovery
in each of these groups separately, because hospitalization may act to impede recovery [50]. Third, the longitudinal studies are required to explore the cause-andeffect association between recovery and cognitive
insight, because cross-sectional studies are limited in
the inferences that can be made about cause-and-effectassociations between recovery and the factors including
cognitive insight examined. Fourth, the RAS-J is a selfreported questionnaire and useful to assess subjective
personal recovery, but not for assessing objective recovery. Therefore, future research is needed to investigate
the relationship between objective recovery and cognitive insight in schizophrenia.

Conclusions
This study provides encouraging evidence for the
relationship between recovery and cognitive insight inschizophrenia and may contribute to developing tailoredinterventions to improve cognitive insight with the aimof achieving recovery of patients with schizophrenia.
Interventions to improve cognitive insight are rarely implemented in Japan. Therefore, future research is needed
to evaluate the effects of adding such interventions torehabilitation programs, including occupational therapy,
and the impact on recovery within the context of suchprograms.

Acknowledgments
We thank the participants and staff members of the
Mental Support Soyokaze Hospital for participating inand supporting this study. The authors declare no conflicts of interest.

Asian J Occup Ther 13: 71−78, 2017

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■ORIGINAL ARTICLE

Possible Effectiveness of Collaboration between
Occupational Therapists and Care Managers
using the Management Tool for Daily Life Performancefor Stroke Patients in Transitional Care
Kazuaki Iokawa1, 2, Keiichi Hasegawa3, Takashi Ishikawa4
1

Preparing section for New Faculty of Medical Science, Fukushima Medical University, Fukushima, Japan
Division of Occupational Therapy, Department of Rehabilitation, Faculty of Health Science, Tohoku Fukushi University,
Sendai, Japan3
Department of Rehabilitation, Takeda General Hospital, Aizuwakamatsu, Japan
4
Department of Occupational Therapy, Graduate School of Health Sciences, Akita University, Akita, Japan
2

Abstract: Collaboration between medical care and long-term care professionals is very important in cases of stroke
rehabilitation in Japan. This study aimed to explore whether collaboration between occupational therapists and caremanagers using the Management Tool for Daily Life Performance (MTDLP) supports the daily life performance at 1
month after discharge in stroke patients. Participants were 15 patients [77.3 ± 7.9 years (mean ± SD)] in the acute careward and 22 patients (71.7 ± 9.6 years) in the convalescent rehabilitation ward. Patients were assessed using the Barthel
Index, Lawton and Brody Instrumental Activities of Daily Living Scale, and a measure of self-rated health at discharge
and 1-month follow-up to investigate the effects of collaboration between occupational therapists and care managers
using MTDLP. Collaboration tasks performed by occupational therapists using MTDLP prior to discharge included
creating and delivering the daily life performance transfer sheet, conducting patient home visits with care manager,
and attending the care service conference. In acute care ward patients, the Barthel Index was significantly increased at
1 month after discharge compared with that at discharge ( p = 0.044). Furthermore, self-rated health was significantly
improved in both the acute care and convalescent rehabilitation ward patients at 1 month after discharge compared withthat at discharge ( p = 0.035 and p = 0.019, respectively). These results suggest that the collaboration between occupational therapists and care managers using MTDLP contributed to a positive effect in promoting independent daily living
after discharge in stroke patients.
Keywords: occupational therapy, activities of daily living, instrumental activities of daily living, self-rated health,collaboration(Asian J Occup Ther 13: 79−86, 2017)

Introduction
Japan is experiencing a rate of population aging thatis unprecedented worldwide [1]. The Ministry of Health,Labour and Welfare is promoting the community-based
integrated care system, which aims in enriching longterm care, healthcare, support, and preventive services
Received: 21 February 2017, Accepted: 23 August 2017
Corresponding to: Kazuaki Iokawa, Preparing section for New Facultyof Medical Science, Fukushima Medical University, 1 Hikarigaoka,
Fukushima City, Fukushima 960-1295, Japane-mail: iokawa@fmu.ac.jp©2017 Japanese Association of Occupational Therapists

so that elderly individuals can maintain the lifestyle towhich they are accustomed [2]. The community-based
integrated care system that comprehensively ensures
the provision of healthcare, nursing care, prevention,
housing, and livelihood support will be established by2025 [2]. This system would allow elderly individuals
to follow their own habits and live in familiar environments, even when they require long-term care [2]. The
collaboration between medical care and long-term careis important in the community-based integrated caresystem.
Stroke is a leading cause of long-term disability
in Japan and worldwide [3,4]. Considering the aging
Japanese population, an increased incidence of stroke is

80

COLLABORATION USING THE MANAGEMENT TOOL FOR DAILY LIFE PERFORMANCE

expected [5]. Many stroke patients require rehabilitation
to reduce their degree of disability and enhance theirlikelihood of returning to functional independence athome [6]. In general, stroke rehabilitation in Japan inconsistent throughout the acute, convalescent, and maintenance phases [7]. Stroke rehabilitation during the acutephase aims to encourage the compensatory functions of
the cerebrum and facilitate the restoration of impairment
functions while preventing disuse syndromes at theacute care ward [7]. In the convalescent phase, patients
who are past the acute phase and who can be expected
to further improve functions with rehabilitation undergo
intensive rehabilitation in the convalescent rehabilitation
ward until discharge from the hospital [7]. The main
purpose of rehabilitation in the maintenance phase is tomaintain the acquired functions, activities, and social
participation for as long as possible. Throughout these
consistent stroke rehabilitation processes, collaboration
between medical care and long-term care professionals
is crucial to ensure continuous daily living support forpatients and their family caregivers, as well as for efficient use of social resources.
The Japanese Association of Occupational Therapists developed the Management Tool for Daily Life
Performance (MTDLP), which has been found to contribute to comprehensive community care based on a2008 geriatric health promotion project by the Ministryof Health, Labour and Welfare [8]. Daily life performance includes all aspects of life, including activities
of daily living (ADL), instrumental activities of dailyliving (IADL), work, hobbies, and leisure. Daily life
performance can be inhibited by decreased mental andphysical function due to illness or aging, unhealthy lifestyle, poor interpersonal relationships, and changes inliving environment [8]. MTDLP is an intervention tool
used in occupational therapy and a support method that
focuses on finding meaningful occupation for subjects
to increase recovery and improve disabilities that inhibit
daily life performance. MTDLP consists of a series ofprocesses that include intake, assessment, planning,intervention, and transference of tasks.
In stroke rehabilitation, transitional care is required
for the support of daily life performance for patients andtheir family caregivers after leaving the hospital. Consequently, collaboration between occupational therapists
in medical care and care managers in long-term care isvery important in the early stages after discharge. However, to our knowledge, no studies have reported theeffects of collaboration between occupational therapists
in medical practice and care managers in communities
regarding the care of stroke patients in the early stages
after discharge. This study aimed to explore whether
collaboration between occupational therapists and caremanagers using MTDLP supports the daily life performance at 1 month after discharge in stroke patients.

Methods
Subjects
Patients were admitted with stroke to seven acutecare wards and eight convalescent rehabilitation wards
and were prescribed rehabilitation for home discharge.
We prospectively enrolled 15 patients [77.3 ± 7.9 years(mean ± SD)] in the acute care ward and 22 patients (71.7± 9.6 years) in the convalescent rehabilitation ward
between September 2012 and January 2013. This study
was conducted based on the Ethical Standards of theJapanese Association of Occupational Therapists. All
subjects gave written informed consent to participate.
Each subject had the opportunity to refuse participatingin the study.
Study design
All participants received occupational therapy basedon MTDLP. Occupational therapists conducted collaborative tasks using MTDLP for care managers before discharge of all subjects. Collaborative tasks conducted byoccupational therapists using MTDLP included creating
and delivering the daily life performance transfer sheet(Fig. 1), conducting home visits with care managers, andattending a care service conference before discharge.
These collaborative tasks were carried out in order toenable continued support and to maintain and improvethe daily activities of subjects after discharge.
All subjects were assessed via the Barthel Index [9],which measured ADL; the Lawton and Brody IADL scale[10]; and a measure of self-rated health [11], which wasused as a quality of life (QOL) index for daily life performance. Participants were assessed both at discharge
and 1 month after discharge. Furthermore, transmission
items (i.e., information transmitted from occupational
therapists to care managers) relating to instructions
for patients’ daily living support after discharge werecollected using the daily life performance transfer sheet
at discharge. The Barthel Index has been widely used toassess ADL in stroke patients. It consists of the following ten items relating to basic ADL: feeding, transfer,grooming, toilet use, bathing, mobility, stairs, dressing,and control of bowels and bladder. Scores on the Barthel
Index range from 0 to 100, with lower scores indicating
greater dependency [12]. The Lawton and Brody IADL
scale has been widely used to assess IADL. Scores
range from 8 to 24, with lower scores indicating greater
dependency. The scale assesses the following functional
abilities: using the telephone, shopping, preparing
meals, doing housework, doing laundry, using transpor-

Iokawa K et al.

Asian J Occup Ther 13: 79−86, 2017

Daily Life Performance Transfer Sheet
Name:

Age:

years Sex (male/female)

Date of creation:(year)(month)(day)

I have instructed the following for the patient to maintain my health and living behavior after discharge from hospital.
I ask for support in a daily basis in order to continue performing these activities.
[Living status when healthy][Cause of present hospitalization]□Gradual decline in vital functions

Person in charge:[Difficulties and areas to improve thepatient´s status]□Onset (of cerebral infarction etc.)□Other ()[Current living status] (describe abilities) *Check the relevant box
Currently
Would like Improvement
SupportADL items
Eating & drinking
Moving to/from awheelchair
Grooming
Toilet activities
Bathing
Walking on levelgroundperforming

to perform

□

□

□

□

expectedneeded

□

□

□

□

□

□

□

□

□

□

□

□
□

□
□

□
□

□
□

□

□

□

Dressing
Moving indoors

□

□

□

□

Walking upstairs

Moving outdoors
Using transport
Shopping
Cooking
Cleaning
Laundry
Tidiness & taking
out garbage
Moneymanagement
Making atelephone call
Medication

□
□
□
□
□
□
□

□
□
□
□
□
□
□
□

□
□
□
□
□
□
□
□

[Goals and content of occupational therapy
during rehabilitation treatment]□□□

Special remarks□□□[Main daily activity]

□
□
□
□
□

□

□

□

□

□

□

□

□

□

□

□

□

management[Assessment summary and problems to be solved][Support content and programs to continue]

Fig. 1. Daily life performance transfer sheet.
Reproduced from the Japanese Association of Occupational Therapists. (June 17, 2014). Management tool for daily life performance. [Brochure]. p. 6, Document 4, with permission.
The copyright (personal and property rights) to this sheet belongs to the Japanese Association of Occupational Therapists. The
unauthorized use, copying, duplication, reproduction, input to recording media, or changes to the content are prohibited withexceptions to the copyright law.

81

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COLLABORATION USING THE MANAGEMENT TOOL FOR DAILY LIFE PERFORMANCE

tation, taking medications, and managing money [10].
Self-rated health is an important indicator of QOL [13]and was thus used as a proxy for QOL. Self-rated health
was assessed by asking respondents, “In general, howwould you rate your health today?” possible response
options were “very good” (1), “good” (2), “moderate”(3), “bad” (4), or “very bad” (5) [11].
The MTDLP process
The following section summarizes the standard
MTDLP process [8].
IntakeSubjects and their families are interviewed regarding their desired daily life performance using a daily
life performance interview sheet. A “wish and interests
checklist” is used when subjects cannot verbally express
their desires.
Daily life performance assessment
Subjects’ desired daily life performance and factorsthat inhibit daily activities are assessed using the International Classification of Functioning, Disability, andHealth (ICF) and the MTDLP sheet.
Daily life performance improvement plan
A support plan to enable subjects to implement
daily life performance is drafted based on the MTDLP
sheet. The intervention program is divided into a basic
program (approach for mental and physical function),
an application program (approach for activities andparticipation), and a social adjustment program (adaptive
approach for environmental adjustments to the subject’s
living environment).
Intervention, re-evaluation, and revision
Provide the training, support, adjustment, andreassessment required to improve daily life performancebased on planning.
Completion; transference of tasks
The outcomes and course of MTDLP are summarized in the daily life performance transfer sheet (Fig.
1). The support measures necessary to improve future
daily life performance are transferred to professionals
involved in the patient’s life support, including caremanagers and care staff. In this study, occupational therapists conducted collaborative tasks using the MTDLP
for care managers.
Data analysis
Paired t-tests and the Wilcoxon Signed-Rank Test
were used to compare scores on the Barthel Index,

the Lawton and Brody IADL scale, and assessmentsof self-rated health at discharge versus 1 month after
hospital discharge. P-values < 0.05 indicated statisticalsignificance. All statistical analyses were performed
using SPSS version 19 (SPSS, Tokyo, Japan).

Results
Subjects’ demographic characteristics and clinicaldata are shown in Table 1. Mean ages of patients in theacute care and convalescent rehabilitation wards were77.3 ± 7.9 years and 71.7 ± 9.6 years, respectively.
Patients (n = 37) included 15 (seven men and eight
women) from the acute care ward, and 22 (10 men and
12 women) from the convalescent rehabilitation ward.
Approximately 87% of acute care ward patients and
68% of convalescent rehabilitation ward patients had
experienced ischemic stroke. Eight patients from each of
the acute care and convalescent rehabilitation wards had
right-sided hemiparesis; whereas, five from the acutecare ward and nine from the convalescent rehabilitation
ward had left-sided hemiparesis. The percentages ofpatients from the acute care ward receiving different
care levels were as follows: support level 1, 7%; support
level 2, 13%; care level 1, 20%; care level 2, 7%; carelevel 3, 7%; care level 4, none; care level 5, 7%; andunapplied, 40%. The percentages of patients from theconvalescent rehabilitation ward receiving different carelevels were as follows: support level 1, 5%; support

Table 1. Characteristics of the study subjects
Variables
Age, years, mean ± SD
Female, n (%)
Type of stroke, n (%)
ischemichemorrhage
otherHemiparetic side, n (%)
right
left
other
Care levels in long-termcare insurance, n (%)
support level 1
support level 2
care level 1
care level 2
care level 3
care level 4care level 5
unapplied
SD: standard deviation

Acute care ward(n = 15)

Convalescentrehabilitation ward(n = 22)77.3 ± 7.9
8 (53.3)

71.7 ± 9.6
12 (54.5)

13 (86.7)
1 (6.7)1 (6.7)15 (68.2)2 (9.0)5 (22.7)

8 (53.3)
5 (33.3)
2 (13.3)

8 (36.4)
9 (40.9)
5 (22.7)

1 (6.7)
2 (13.3)
3 (20.0)
1 (6.7)1 (6.7)0
1 (6.7)6 (40.0)

1 (4.5)2 (9.1)2 (9.1)0
10 (45.4)
3 (13.6)2 (9.1)2 (9.1)

Iokawa K et al.

Asian J Occup Ther 13: 79−86, 2017

level 2, 9%; care level 1, 9%; care level 2, none; carelevel 3, 45%; care level 4, 14%; care level 5, 9%; andunapplied, 9%.
Table 2 shows ADL, IADL, and self-rated healthscores at discharge and 1-month follow-up. Scores on
the Barthel Index increased significantly from discharge
to 1 month after discharge among acute care ward
patients ( p = 0.04). In contrast, assessment of self-rated
health decreased significantly from discharge to 1 monthafter discharge in both acute care and convalescentrehabilitation ward patients ( p = 0.04 and p = 0.02,
respectively). There were no significant differencesin other scales of daily life performance at discharge
versus 1 month after discharge. Figure 2 shows theitems transmitted from occupational therapists to caremanagers relating to patient support after discharge.

Among patients from the acute care ward, transmission
items primarily related to outdoor and indoor movement, bathing, toilet use, shopping, and use of public
transportation. Among patients from the convalescentrehabilitation ward, transmission items primarily related
to indoor and outdoor movement, transfers, toilet use,stair use, bathing, dressing, and shopping. In general, awider variety of items were transmitted for patients fromthe convalescent rehabilitation ward compared to theacute care ward.

Discussion
Findings of the present study indicated that ADL
scores among acute care patients improved significantly
from discharge to 1-month follow-up, indicating less

Table 2. C omparisons the daily life performances between at discharge and 1 month after discharge in the acute care and convalescent rehabilitation ward patients

Acute care ward (n = 15)
Barthel index, mean ± SD
Lawton and Brody IADL scale, mean ± SD
Self-rated health, mean ± SD
Convalescent rehabilitation ward (n = 22)
Barthel index, mean ± SD
Lawton and Brody IADL scale, mean ± SD
Self-rated health, mean ± SD

discharge

1 month
after dischargep69.3 ± 30.1
3.1 ± 2.6
3.3 ± 0.8

76.3 ± 30.3
3.1 ± 2.9
2.9 ± 0.9

0.04
0.83
0.04

71.6 ± 26.3
2.3 ± 1.8
3.2 ± 0.7

74.8 ± 26.0
2.7 ± 1.9
2.7 ± 0.9

0.15
0.16
0.02

SD: standard deviation; IADL: instrumental activities of daily living

outdoor mobile
indoor mobile

bathing
toilet use
shopping

use public transportation
putting out the garbage
laundry

grooming
dressing
transfers

cleening
food preparation
stairsresponsibility for own medications
ability to use telephone
ability to handle finances

feeding

20

10
Acute care ward

0

83

(%)

0

10
Convalescent rehabilitation ward

Fig. 2. The items transmitted from occupational therapists to care managers.

20

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COLLABORATION USING THE MANAGEMENT TOOL FOR DAILY LIFE PERFORMANCE

dependence a month after discharge. Furthermore, IADL
scores were maintained from discharge to 1-monthfollow-up in both acute care and convalescent rehabilitation patients. These results suggest that the patients’plan of ADL and IADL may have been included in thecare plan after discharge, and the intervention support
may have worked effectively. Therefore, collaboration
between occupational therapists and care managers
using MTDLP may have worked effectively on the careplan after discharge and may have promoted independent daily living in stroke patients.
Some studies have reported that ADL among stroke
patients were maintained for 1 year after discharge [14,15]. On the other hand, Yoshino, et al. reported that
ADL among stroke patients were significantly decreased
1 month after discharge [16]. Research findings haveattributed this decreased activity following discharge topoor health services, effects of climate, negative family
attitudes, indoor movement, and low motivation [17].
These previous reports indicate that ADL tend to decline
immediately after discharge in stroke patients. Therefore, collaboration between medical care and long-termcare professionals is crucial to ensure continuous living
support for patients and their family caregivers, as wellas efficient use of social resources.
Costs associated with the collaboration between
medical care and long-term care professionals (e.g.,patient home visits during hospitalization) is covered by
medical insurance in Japan. Likewise, it covers the costs
associated with transfer of information from medical
professionals to care managers during hospitalization ofpatients regarding their care plans following discharge.
However, due to medical fees, daily occupational andphysical therapy tend to be regarded as more important
than patients’ home visits or providing information tocare managers. Moreover, patients who independently
perform ADL often do not receive the certification of
long-term care and the care plan for preventive by longterm care or community support system. As a result, theability of more independent patients to perform ADL
and IADL may be reduced, making daily living carenecessary. Furthermore, the method of collaboration
between occupational therapists and care managers fordischarge of stroke patients was not established. This
problem in the collaboration method was also considered to be caused by the fact that occupational therapists
often neglect collaboration with care managers. In thisstudy, occupational therapists conducted collaborative
tasks using MTDLP for care managers before patientdischarge. Specifically, occupational therapists contacted
care managers using the daily life performance transfer
sheet before discharge to ensure continuous daily living
support and maintain and improve patient’ abilities after

discharge. Furthermore, occupational therapists conducted home visits together with care managers and attended
the care service conference before patient discharge. Bysystemizing the collaboration method using MTDLP,
occupational therapists will be able to further promote
cooperation with care managers and reliably transfer
information of daily living support after discharge forstroke patients.
In the present study, the items transmitted fromoccupational therapists to care managers in regarding
patients from the acute care ward related primarily to
outdoor and indoor movements, bathing, toilet use,
shopping, and use of public transportation. In patientsfrom the convalescent rehabilitation ward, transmission
items related primarily to mostly indoor and outdoor
movement, transfers, toilet use, stair use, bathing, dressing, and shopping. The daily life performance transfer
sheet makes it possible to clearly transmit informationnecessary for the support of ADL and IADL after discharge. To maintain and improve ADL and IADL after
discharge, it is important that these transmission items
are reflected in the patient’s care plan in the long-termcare system.
In this study, improved self-rated health in acutecare and convalescent rehabilitation ward patients wasobserved 1 month after discharge following an MTDLP
intervention involving collaborative tasks between occupational therapists and care managers. Self-rated healthis well known to be an important indicator of QOL; it
has also been reported to predict mortality [18−20] andthe prognosis of stroke patients [21]. Stroke has beenshown to lead to depressive and anxiety disorders andother emotional effects [22]. One-third of all stroke patients experience significant depressive symptoms after
the onset of stroke [23]. Accordingly, one study reported
that reducing the number of depressive symptoms among
disabled older adults would be beneficial in improving
self-rated health as well as maintaining and promoting
QOL [24]. Subjective ratings of overall health remainstrongly and independently associated with depressive
symptoms, even when controlling for physical illness
and functional disability [25]. Greater attention should
therefore be given to the self-rated health of older adults
with stroke, particularly in relation to the significant
impact of depression on their self-rated health [26].
Addressing elements of daily life that affect subjective
well-being are also being increasingly recognized as
beneficial to recovery from and adaptation to stroke [27].
In a randomized controlled multi-center trial, Noto etal. showed that occupational therapy using MTDLP improved QOL for dependent community-dwelling elderly
individuals [28]. MTDLP is a support method focusing
on providing meaningful occupation to patients to aid

Asian J Occup Ther 13: 79−86, 2017

in their recovery and to improve disability in daily life
performance. Collaboration between occupational therapists and care managers using MTDLP may improve
QOL for stroke patients through sharing the information
on patients’ meaningful occupation.

Study limitations
The present study had several limitations. First,
the sample size was small due to an insufficient numberof stroke patients who required daily living support
after discharge. Second, as a control group was notestablished, we cannot verify the effect of collaboration
between occupational therapists and care managers onpatient outcomes after discharge. Future studies could
utilize a control group to assess the effects of an intervention involving collaborative tasks using MTDLP.
Third, collaboration skills of occupational therapists andcare managers were not sufficiently controlled in thisstudy. The meeting we held regarding collaborative tasks
using MTDLP was attended by occupational therapists;
care managers received individual explanations only. Finally, it was unclear whether the items transmitted fromoccupational therapists to care managers were reflectedin the care plan after discharge. Going forward, it will
be necessary to further promote patient home visits andthe care service conference to care managers in order toensure transmission items are reflected in the care plan.

Conclusion
The findings of this study suggest that collaboration
between occupational therapists and care managers
using the MTDLP might be effective in promoting
independent daily living after discharge in stroke patients. Based on these findings, collaboration between
occupational therapists and care managers using the
MTDLP should be encouraged to support the daily life
performance of stroke patients.
Acknowledgments: This study was supported by a2012 geriatric health promotion project by the Ministryof Health, Labour and Welfare (Grant-in-Aid for thepromotion of geriatric health projects).

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■ORIGINAL ARTICLE

Current Situation and Challenges Regarding
the Social Participation of Syrian Refugees
with Disabilities in Urban Areas of Jordan
Seiji Yamamoto, Hiroya Matsuo
Department of International Health Sciences, Kobe University Graduate School of Health Sciences

Abstract: Introduction: The conflict in the Syrian Arab Republic has been ongoing since 2011. Since the war broke out,
many Syrians have evacuated Jordan as refugees. 28% of refugees have some kind of functional disorder. We conducted
the present study to identify the health conditions of Syrian refugee with disabilities (Person With Disabilities: PWDs)
in urban area of Jordan and the situations of their and their families’ social participation. Methods: The subjects of thestudy were twelve participants of PWDs and their families in Jordan. We conducted semi-structured interview between
August 2014 and December 2016. Qualitative Content Analysis Method was performed to assess the social participation of them. Results: The social participation of PWDs were categorized under five main themes:【Lack of healthcare for PWDs in urban areas】,【Insufficient health literacy of PWDs and their family members】,【Restriction of social
participation of PWDs and their family members】,【Spreading of disuse syndrome】and【Care burden on family members】. Conclusion: The study identified that the social participation of PWDs and their families in urban area could beoften restricted, and that insufficient health care services, health literacy, disuse syndrome, and burdens of nursing carebe correlated to the level of social participation of PWDs and their families. Therefore, It is essential that health professionals including occupational therapists provide knowledge and health services concerning the prevention of disuse
syndrome and support for the empowerment of PWDs.
Keywords: Syrian refugee with disabilities, community based rehabilitation, social participation, disuse syndrome(Asian J Occup Ther 13: 87−93, 2017)

Introduction
The conflict in the Syrian Arab Republic has beenongoing since 2011. Since the war broke out, many Syrians have evacuated abroad as refugees. As of January
2015, more than 4.9 million Syrians were registered as
refugees in Syria’s neighboring countries—Jordan, Lebanon, Iraq, and Egypt [1, 2]—with the number in Jordan
totaling 635,324. Approximately 78% of Syrian refugees
in Jordan live in urban areas, including the governoratesof Amman [3], Irbid and Mafraq. In recent years, thenumber of refugees in urban areas has been increasing[2]. It is reported that many Syrian refugees in urban
areas have difficulty accessing health care services due
Received: 25 April 2017, Accepted: 30 August 2017
Corresponding to: Seiji Yamamoto, Department of International Health
Sciences, Kobe University Graduate School of Health Sciencese-mail: talktoseiji@hotmail.com©2017 Japanese Association of Occupational Therapists

to the rapid increase in the population and insufficientsocial resources [4]. According to an investigation by
Handicap International, 22% of refugees registered with
the United Nations High Commissioner for Refugees(UNHCR) have some kind of functional disorder, while
6% have severe functional disorders [5]. These Syrian
refugees with disabilities (person with disabilities, or
PWDs) are in a vulnerable social position [6]. They need
not only basic support, such as housing, livelihoods,
food and human rights, but also specific support such as
rehabilitation services and the provision of orthoses [5].
Community-based organizations (CBOs) in urban
areas carry out support programs for Syrian refugees
with disabilities in cooperation with the Jordanian
government and international agencies [7]. In those organizations and agencies, occupational therapists workin support program for Syrian refugees with disabilities
in urban area. However, there are no studies demonstrating whether these programs comply with the needs of
PWDs and their families, and promote their health and88

SOCIAL PARTICIPATION OF SYRIAN REFUGEE WITH DISABILITIES

social participation. Therefore, we conducted the present
study to identify the health conditions of PWDs and thesituations of their and their families’ social participation
through semi-structured interviews. Furthermore, we
analyzed the results using a community-based rehabilitation (CBR) matrix on the themes of the PWDs’ healthconditions and social participation [8]. The purpose of
the present study was to clarify challenges of provisionof support by health professional including occupational
therapist for Syrian refugee with disabilities and theirfamilies.

Methods
1. Participants
The subjects of the study were Syrian refugees withdisabilities (PWDs) and their families in the governorates of Amman and Irbid in Jordan. Twenty-five participants were chosen randomly for this study from a listof Syrian refugee with disabilities, which was provided
by the nongovernmental organization Mobility Solution.
We explained that the study would comprise recordedinterviews, followed by analysis of the interview data.
We received letters of consent and acceptance from 12
participants, and conducted the study interviews withthem.
2. Questionnaire and Interview
This study involved the use of a questionnaire and arecorded semi-structured interview in Arabic. The interview was conducted with each participant individually
between August 2014 and December 2016. The questionnaire inquired about the name, sex, age, diagnosis,
transfer status, duration of stay in Jordan, refugee status,
and income of the PWDs and his/her family members.
The semi-structured interview was conducted withan interview guide. The interview covered the healthcondition of the PWD (“Has your health conditionchanged between living in Syria and Jordan?”); his/her relationships with members of the community (“Doyou have any relationships or support from members of
the community?”); recognition of the disability by the
PWDs and his/her family members (“What do you needregarding your disability?”); current difficulties faced by
the PWDs and his/her family members (“Do you face
any difficulties in your daily life?”); knowledge and recognition of the type of support available from the hostcommunity by the PWDs and his/her family members(“Do you know of any assistance programs provided by
the Jordanian government or NGOs?”); and the needs of
the PWDs and his/her family members (“What kind of
support do you expect from the Jordanian government
and NGOs?”) (Table 1). The interviews were recorded
by IC recorder.
3. Data Analysis
The interview data were then analyzed. The analysis
was conducted by three researchers familiar with the international health field, and comprised the following twophases. First, the researchers listened to the interview
data and transcribed the contents. For the language bias,
we conducted back-translation. The transcriptions werethen coded to identify elements of each participant’scomments about health and social participation. The
codes were sorted into sub-categories and categories,
and the relevance of each category was analyzed. The
codes were then classified into components of the CBRmatrix (Fig. 1) [8]. Then, we analyzed the tendencies
and challenges of the social participation of the Syrian
refugees with disabilities and their families.
4. Ethical Considerations
The study carried out the research with the approval(Number 309) of the Kobe University Ethical Committee.

Table 1. Interview guide to Syrian refugee with disabilities (Person With Disabilities: PWDs) and their family.
TopicsQuestion

Health condition of the PWDs

“Has your health condition changed between living in Syria and Jordan?”His/her relationship with the community“Do you have any relationships or support of the community?”

Recognition of the disability by the PWDs and his/her family
members“What do you need regarding your disability?”

Current difficulties faced by the PWDs and his/her family member“Do you face any difficulties in your daily life?”

Knowledge and recognition of the type of support available fromthe host community by the PWDs and his/her family members“Do you know of any assistance programs provided by the Jordanian
government or NGOs?”

the needs of the PWD and his/her family members“What kind of support do you expect from the Jordanian government andNGOs?”Yamamoto S et al.

Asian J Occup Ther 13: 87−93, 201789

CBR Matrix
HEALTHEDUCATIONLIVELIHOODSOCIALEMPOWEMENTPROMOTIONEARLY
CHILDHOOD

SKILLSDEVELOPMENTPERSONALASSISTANCEADVOCACY AND
COMMUNICATIONPREVENTIONPRIMARYSELFEMPLOYMENTRELATIONSHIPSMARRIAGE AND
FAMILYCOMMUNITY
MOBILIZATIONMEDICAL CARESECONDARY ANDHIGHERWAGE
EMPLOYMENTCULTURE ANDARTSPOLITICALPARTICIPATIONREHABILITATIONNON-FORMALFINANCIALSERVICES

RECREATION,LEISURE AND
SPORTSSELF-HELPGROUPSASSISTIVE
DEVICE

LIFELONG
LEARNING

SOCIALPROTECTIONJUSTICEDISABLEDPEOPLE'SORAGANIZATION

Fig. 1. Community-Based Rehabilitation Matrix (WHO 2010)

The category【Lack of health care for PWDs in
urban areas】comprised two sub-categories:［Difficulty
1. Characteristics of Participantsin receiving medical treatment in Syria］and［Difficulty
There were 12 participants, all male. Amount of inin receiving health care services in Jordan］. One family
terview time was 301 minutes. Median of interview timemember of a PWDs talked about［Difficulty in receiving
and SD were 24 ± 5.9 minutes. Their mean age was 20.5
medical treatment in Syria］as follows:『Our hospital± 12.9 years (range: 15−56 years), and their mean durain Syria was destroyed by bombing, so nobody can gettion of stay was 1.7 ± 0.4 years. All of the participating
treatment even if they’ re injured. There are no doctors,
PWDs had physical disorders. Five of the participants
so it’s impossible to have an operation』. One family
had dependence in transferring motion and seven of themember of a PWDs talked about［Difficulty in receivparticipants had independence in transferring motion.
ing health care services in Jordan］as follows:『My son
All the participants were registered as refugees by thewas able to have an operation in Jordan, but he couldn’t
UNHCR. Two of the PWDs’ families had incomes,
receive rehabilitation treatment at the hospital. He could
while 10 families did not have incomes (Table 2).
have rehabilitation at a private hospital, but we can’t
afford the medical fees』.
2. Health conditions and social participation
The category【Insufficient health literacy of PWDs
A total of 621 codes relating to the health conand their family members】comprised two sub-categoditions and social participation of the subjects wereries:［Lack of recognition of disorders among PWDs
extracted from the transcriptions. From the codes, 10
and their family members］and［Lack of information
sub-categories and 5 categories were classified along
about health care services among PWDs and their familywith the “current situation of social participation of themembers］. One family member of a PWDs talked about
Syrian refugees with disabilities and their families in ［Lack of recognition about disorders among PWDs andurban areas” (Table 3). Then, the categories, subcategotheir family members］as follows:『The doctor said thatrehabilitation would be necessary after discharge fromries, codes, and personal narratives were described as
category,
subcategory,
andpersonal
narrative
,
【
】［
］
『
』 the hospital. But we don’t know what we should do』.
One family member of a PWDs talked about［Lack ofrespectively.

Results

90

SOCIAL PARTICIPATION OF SYRIAN REFUGEE WITH DISABILITIES

Table 2. Profile characteristics of participants (21.Aug.2014~28.Dec.2016)
No

GenderAgeDiagnosis

Status of transfer

Duration ofstay (year)

Registration

Interviewees

Income1

M

20

Spinal Cord Injury

Dependence

1.4

UNHCR

Brother

2
3
4
5

M
M
M
M

21
56
37
13

Spinal Cord Injury
Head Injuary
Cerebrovascular Disease
Spinal Cord Injury

Independence (W/C)
Dependence
Dependence
Dependence

1.5
1.9
2.1
2

UNHCR
UHNCR
UNHCR
UNHCR

PWDs
Brother
Brother
Father

6
7
8
9
10
11
12

M
M
M
M
M
M
M

39
18
20
33
19
15
43

Spinal Cord Injury
Peripheral Nerve Disorder
Peripheral Nerve Disorder
Cerebrovascular Disease
Spinal Cord Injury
Peripheral Nerve Disorder
Peripheral Nerve Disorder

Independence (W/C)
Independence
Independence
Independence
Dependence
Independence
Independence

2.4
1.4
1.3
2.3
2.2
1.2
0.7

UNHCR
UNHCR
UNHCR
UNHCR
UNHCR
UNHCR
UNHCR

PWDs
PWDs
PWDs
PWDs
PWDs
PWDs
PWDs

Employment(Father)
None
None
None
Employment(Father)
None
None
None
None
None
None
None

Interview
time
27min
20min
21min
33min
19min
29min
37min
22min
30min
19min
18min
26min

Table 3. Current situation about social participation of Syrian refugee with disabilities and their family member in urban area
Sub-category【10】Category【5】Difficulty in receiving medical treatment in Syria
Difficulty in receiving health care services in Jordan

Lack of health care for PWDs in urban areas

Lack of recognition of disorders among PWDs and their family members
Lack of information about health care services among PWDs and their family members

Insufficient health literacy of PWDs and theirfamily members

Vulnerable position of Syrian refugees
Limitation of PWDs’ activities due to their physical disabilities

Restriction of social participation of PWDs
and their family members

Deterioration of health condition
High risk of disuse syndrome

Spreading of disuse syndrome

Long time required for nursing care
Variety of nursing care

Care burden on family members

information about health care services among PWDs
and their family members］as follows:『Actually there islittle information available. Especially I’ m in a country
that I don’t know anything about. I can’t go anywhere』.
The category 【Restriction of social participationof PWDs and their family members】comprised two
sub-categories: ［Vulnerable position of Syrian refugees］, ［Limitation of PWDs’ activities due to their
physical disabilities］. One family member of a PWDs
talked about the［Vulnerable position of Syrian refugees］as follows:『We have limitations in many areas
including work and education, because I can’t work andI can’t pay my house rent.』. One PWDs talked about［Limitation of PWDs’ activities due to their physicaldisabilities］
as follows:『I can’t even go outside, because
I have a disabled foot』.
The category 【Spreading of disuse syndrome】
comprised two sub-categories:［Deterioration of healthcondition］and［High risk of disuse syndrome］. One
family member of a PWDs talked about［Deteriorationof health condition］ as follows: 『The wounds (bedsores) on my son’s body are hard to cure』and『He has
stiff joints (contracture)』.
One PWDs talked about the［High risk of disuse
syndrome］as follows: 『I spend most of my time inbed. I can’t look after myself, so I need support from myfamily』.
The category【Care burden on family members】
comprised two sub-categories:［Long time required for
nursing care］and［Variety of nursing care］. One family
member of a PWDs talked about the［Long time required for nursing care］as follows:『We have to attend
to his nursing care 24 hours a day. It’s very hard…』.
One family member of a PWDs talked about the［Varietyof nursing care］as follows:『Because my son can’t lookafter himself, I need to help him go to the toilet, change
his clothes, and so on. Of course, if he goes outside, wehave to support him』.
3. Evaluation of health conditions and social participation using the CBR matrix
We classified the codes in this study into compo-

Yamamoto S et al.

Asian J Occup Ther 13: 87−93, 2017

nents of the CBR matrix (Health, Education, Livelihood,
Social and Empowerment). Some 444 codes were thusclassified. Of these, 160 codes were classified into thecomponent “Health” (seven codes under “Promotion,”
two codes under “Prevention,” 56 codes under “Medicalcare,” 60 codes under “Rehabilitation,” and 35 codes
under “Assistive devices”); 25 codes were classified
into the component “Education” (14 codes under “Early
childhood,” 11 codes under “Primary education,” zerocodes under “Secondary and higher education,” zerocodes under “Non-formal education,” and zero codes
under “Lifelong learning”); 119 codes were classified
into the component “Livelihood” (zero codes under“Skills development,” nine codes under “Self-employment,” 36 codes under “Wage employment,” 39 codes
under “Financial services,” and 35 codes under “Social
protection”); 105 codes were classified into the component “Social” (66 codes under “Personal assistance”;
35 codes under “Relationships, marriage and family”;
zero codes under “Culture, arts and recreation”; zerocodes under “Leisure and support”; and four codes
under “Justice”); and 35 codes were classified into thecomponent “Empowerment” (29 codes under “Advocacy
and communication,” zero codes under “Community
mobilization,” six codes under “Political participation,”zero codes under “Self-help groups,” and zero codes
under “Disabled people’s organization”) (Table 4). Then,the components of the CBR matrix and the personal
narratives were described as “components of the CBRmatrix” and『personal narratives』.
Within the component of “Health,” one PWDs
talked about “Promotion” as follows:『I started to suffer
bad health after I came to Jordan』. One PWDs talked
about “Prevention” as follows:『I don’t know how I can
prevent health impairment』. One PWDs talked about“Medical care” as follows:『We can’t get check-ups at
the hospital, because we have no money』. One PWDs
talked about “Rehabilitation” as follows:『We don’t haveany opportunity to receive rehabilitation』. One PWDs
talked about “Assistive device” as follows:『There areno wheelchairs for going outside』.
Within the component of “Education,” one family
member of a PWDs talked about “Early childhood” asfollows:『I haven’t let my child go to school since wecame to Jordan』. One PWDs talked about “Primary education” as follows:『I can’t go to school because I can’twalk』.
Within the component of “Livelihood,” one PWDs
talked about “Self-employment” as follows:『Refugees
can’t work in Jordan』. One PWDs talked about “Wageemployment” as follows:『We need to get permission inorder to work』. One family member of a PWDs talked
about “Financial services” as follows:『There are no organizations that lend money』. One PWDs talked about

Table 4. Cord classification of CBR Matrix component
compornents
health (160)

education (25)livelihood (119)social (105)empowerment (35)

total

91

elements

code

original data

promotion
prevention
medical carerehabilitation
assistive devices
early childhood
primary
secondary and higher
non-formal
lifelong learningskils development
self-employment
wage employment
financial services
social protection
personal assistance
relationships marriage and family
culture and arts
recreation, leisure and sports
justiceadvocacy and communication
community mobilization
political participation
self-help groups
disabled people’s organization

7
2
56
60
35
14
11
0
0
0
0
9
36
39
35
66
35
0
0
4
29
0
6
0
0
444

I started to suffer bad health after I came to Jordan
I don’t know how I can prevent health impairment
We can’t get check-ups at the hospital, because we have no money
We don’t have any opportunity to receive rehabilitation
There are no wheelchairs for going outside
I haven’t let my child go to school since we came to Jordan
I can’t go to school because I can’t walk

Refugee can’t work in Jordan
We need to get permission in order to work
There are no organizations that lend money
The social situation of refugees is vulnerable
There aren’t many caregivers in our family
We don’t have much interaction with members of the community
There is little information about the rights of persons with disabilities
I don’t know who I should tell about my difficulties
There are no opportunities to take part in politics

92

SOCIAL PARTICIPATION OF SYRIAN REFUGEE WITH DISABILITIES“Social protection” as follows:『The social situation of
refugees is vulnerable』.
Within the component of “Social,” one PWDs talked
about “Personal assistance” as follows:『There aren’t
many caregivers in our family』. One PWDs talked about“Relationships, marriage and family” as follows:『Wedon’t have much interaction with members of the community』. One PWDs talked about “Justice” as follows:『There is little information about the rights of persons
with disabilities』.
Within the component of “Empowerment,” one
PWDs talked about “Advocacy and communication”
as follows:『I don’t know who I should tell about my
difficulties』. One PWDs talked about “political participation” as follows:『There are no opportunities to takepart in politics』.

Discussion
The study identified that the social participation of
Syrian refugees with disabilities (PWDs: persons withdisabilities) and their families in urban area is often
restricted. The findings suggested that insufficient healthcare services and health literacy, disuse syndrome, andburdens of nursing care might be correlated to the levelof social participation of PWDs and their families.
In general, governments normally guarantee thebasic human rights and physical security of citizens.
However, in the case of refugees, this safety net often
disappears [9]. Almost all Syrian refugees are in avulnerable position in terms of social participation, forexample, with regard to health care access, education,and livelihood. In particular, persons with disabilities
face disproportionate risks in disaster situations such as
the Syrian conflict and are often excluded from relief
and rehabilitation processes [10]. Furthermore, PWDs
face limitations to their activities due to their physicaldisabilities.
Nearly six years of conflict in Syria have resulted in
the destruction of countless livelihoods and health careservices [11]. Therefore, there are more than 4.9 million
Syrians who have migrated to Syria’s neighbors as refugees, as of January 2017. In Jordan, host communities
and humanitarian organizations are grappling with thechallenge of accommodating significant numbers of
Syrian refugees over the long term [12]. Furthermore,
many of the participants had difficulties accessing healthcare services due to the lack of medical care providers,
the need for transportation to medical institutions, andthe medical expenses required. It was considered thatthese factors might lead to a lack of health care for
PWDs in urban areas.
Some of the participants had incorrect understand-ings of their disorders, and lacked information on healthcare services. These situations may be based on a lack of
information on social resources in residential areas, suchas how to access health care services and how to apply
for them. Insufficient orientation by medical providers
about rehabilitation, nursing care and prevention relating to their disorders may be contributing factors to theinsufficiency of health literacy among PWDs and theirfamilies.
Lack of health care and insufficient health literacy
are connected with the spread of disuse syndrome. Someof the participants presented disuse syndrome in theform of joint contracture, muscular atrophy, or bedsores.
Almost none of the participants had information on
disuse syndrome and approaches to its treatment andprevention. Furthermore, as almost all the PWDs had
physical disabilities and needed support for transportation, they tended to spend their daily lives at home.
These factors may have contributed to the deteriorationof their health conditions and the high risk of disuse
syndrome. Almost all the participating PWDs needed
support from their families in basic daily activities suchas eating, washing, going to the toilet, grooming, andtransportation. Therefore, family members of PWDs
must be able to provide a variety of nursing care fora long period of time. Subsequently, some family
members had difficulties accessing social resources or
employment due to their engagement in nursing care.
This study indicated that each category had somedegree of relevance. PWDs and their family members
may face restrictions in social participation due to theirvulnerable positions as refugees and also limitations totheir activities due to their physical disabilities. Such
restrictions might result in difficulties in gathering information on health care or accessing health care services.
The insufficient health literacy and lack of health careof PWDs might result in the spread of disuse syndrome.
The deterioration of PWDs’ health conditions and theonset of disuse syndrome might in turn increase thecare burden on their family members. Disuse syndrome
among PWDs and the increasing care burden theyrequire from their family members are thus linked to
the restrictions on the social participation of PWDs andtheir family members (Fig. 2).
We elucidated our study on the social participation of PWDs using a community based rehabilitation(CBR) matrix [8]. PWDs and their family members haddifficulties in terms of education and livelihood, justlike refugees in normal health. Furthermore, they had
little recognition of the prevention of disuse syndrome
and health promotion, difficulties in receiving personal
assistance, and lack of empowerment. From the resultsof the evaluation using the CBR matrix, it can be sug-Yamamoto S et al.

Asian J Occup Ther 13: 87−93, 2017

Restriction of social participation of PWDs and their family members

Care burden on familiy member

Vulnerable position of Syrian refugees

Long time required for nursing care

93

Variety of nursing careInsufficient health literacy of PWDs and their family members

Spreading of disuse syndrome

Lack of recognition of disorders among PWDs and their family members

Deteriorate in health condition

Lack of information about health care services among PWDs and their family members

High risk of disuse syndrome

Lack of health care for PWDs in urban areas
Difficulty in receiving medical treatment in Syria
Difficulty in receiving health care services in Jordan

Fig. 2. Relationship about difficulties of Syrian refugee with disabilities and their family members

gested that health professionals need to guide preventive
measures and the promotion of health among PWDs,
and cooperate with them in their empowerment.
Our study was limited by the small size of thesample. The recruitment of subjects for the study wasdifficult, because the participants were afraid to havetheir social status revealed. However, this was the firsttime for a study to be conducted on the current situationsof the health and social participation of Syrian refugees
with disabilities and their family members in urban
areas.

Conclusions
Our current study concluded that Syrian refugees
with disabilities presented disuse syndrome related totheir health conditions, and that they and their family
members faced restrictions in terms of social participation. Furthermore, it was indicated that the PWDs’ insufficient health literacy, lack of health care services, disuse
syndrome, vulnerable positions as refugees, limitations
on activities due to physical disabilities, and care burden
on their families might be related to the restrictions insocial participation that they experienced. It is essentialthat health professionals including occupational therapists provide knowledge knowledge and health services
concerning the prevention of disuse syndrome andsupport for the empowerment of Syrian refugees withdisabilities.

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