■WFOT Symposium
The International Challenge for Occupational Therapy
Marilyn Pattison, Dip. C.O.T. (UK), B. App. Sc. (OT), MBA
WFOT Executive Director, Managing Partner MPOT

(Asian J Occup Ther 8: 1–4, 2010)

As occupational therapists we need to develop thecapacity and power to construct our own destiny. The future of the profession is ours to make and in 20 years ora hundred years time our success will be the only reliablemeasure of how effectively we have taken hold of our vision. By joining together we can take the future, fold itback into the present and make that destiny a reality.
An entrepreneurial approach to practice is about
thinking outside of the square, and finding increasingly
innovative ways to deliver services that positively influence people’s lives, health and well being. In order to do
this as occupational therapists we need to challenge ourselves to create the future of the profession and direct ourown destiny.
Occupational therapy is practiced in many countries
around the world. Occupational therapists are part of alarge (and growing) international workforce and like every other allied health profession it is impacted upon by
the changing world and changing health environment.
Occupational therapists need to understand what is
impacting on the health landscape of the future and be
ready to meet the changes. So what are the major issues
impacting on the healthcare environment now and in the
future?
There is a global move towards change and healthcare
reform and occupational therapists need to consider what
are the trends and drivers affecting the health and social
services sector.
Demographic and societal change
Rising expectations and consumerism
Health informatics and telemedicine
New medical technologies
Increasing costs of health and social services provision
There are calls for the traditional paradigm of thehealth workforce to be changed. Part of the problem is
Received: 21 September 2009, Accepted: 21 September 2009
Corresponding to: Marilyn Pattison, WFOT Executive Director, Managing Partner MPOT, PO Box 1001, Rowland Flat, SA 5352, Australia
e-mail: marilyn@mpot.com.au© Japanese Association of Occupational Therapiststhat the system is geared to deal with episodes of acutecare rather than ongoing care of chronic conditions.
In Japan the basic principle governing the deliveryof health care services is that all citizens should be able,
at any time and place, to receive the care they require,with an affordable personal contribution.
The health situation in Japan remains one of thebest in the region. The majority of health-related statistics, such as life expectancy and the under-five mortality
rate, continue to improve. The health disparities within
the country are also relatively small compared with thosein other industrialised nations. Due to the increasingly
complex social environment created by a high-tech andcompetitive society, it is said that the stress levels felt by
all age groups are rising.
With advancement of the ageing society, disease patterns have shifted to lifestyle-related diseases, such as
cancer, heart disease, cerebrovascular disease and diabetes. These diseases account for 60% of mortality and thistrend is expected to continue.
So where do occupational therapists fit in?
I practice my profession in the best way that I canand from time to time I feel frustrated that others don’t
always share my views on the value and contribution ofoccupational therapy. I tire of explaining what we do inmuch the same way as I am sure we all do. But as I start
to explain I always reignite my belief that as occupational
therapists we can have significant impact on the lives ofothers whether it as is as individuals, families or communities. I love my profession and hold a vision and a dreamfor the future, which I am sure many of you share.
I believe we need to strive to move beyond the traditional boundaries because that is what they are – boundaries. They fence us in and limit our practice. This doesn’tmean walking away from our core skills rather it means
applying those core skills in more and more sophisticatedand most importantly effective ways.
Our expertise lies in the design of creative solutions
to complex problems. It is the integration of multi levelvariables into workable, effective and sustainable solu-

2

THE INTERNATIONAL CHALLENGE FOR OCCUPATIONAL THERAPY

tions that is the core of occupational therapy practice. We
need to think entrepreneurially. If we are going to imagine
the future we must make sure we see ourselves in it. An
old Japanese proverb tells us: “Vision without action is a
daydream, but action without vision is a nightmare”. So
we need to implement that vision.
How often have we heard or said:
Nobody knows what we do.
I can’t really tell you what we do because it’s too complicated.
The trouble with O.T.’s is that there are so few of us.
Is occupational therapy destined to remain the best
kept secret? It will if occupational therapists don’t face
the challenge to take their rightful place in health care.
Occupational therapists are expanding the current
dominant focus on curative and preventative practice withindividuals toward a focus on the right of all people to occupational engagement and enrichment. Wilcock (2005)
told us that occupational therapists have much more to offer than a service solely for those with a medically definedillness or dysfunction.
The expanded focus involves a community and population orientation, which addresses the health promotion
needs of groups, communities and populations. It requires
understanding the fundamental ways in which health ispromoted and ill health is avoided and establishing equitable opportunities and resources to enable engagement in
occupation at all levels.
Globalisation has led to enormous and sweepingchanges in the world. New technologies such as the Internet have made people much more aware of modern
trends. Better preventative medical systems, new drugs
and improved medical care have led to an increase inlife expectancy in many societies. The changes add up to
great opportunities and vast challenges. But in some instances they have also led to socioeconomic inequalities
and political instability. Two years after the historic callfor action by the United Nations, the World Health Organisation published its annual health report, Reducing risks,
promoting healthy life (Sinclair 2004).
It stated the obvious. It reiterated the close and selfevident links between poverty and disease. It added thatdisease often meant people could not work which in turnled to a lack of food on family tables with the inevitable
results; malnutrition and other health issues. More thanhalf of the world’s people suffer from malnutrition andsubstandard healthcare.
So where should we occupational therapists place
our priorities? How should we be addressing the awesome
challenges? How best can we use our knowledge, skills
and dedication to bring about lasting improvements in thehealth of our people and our communities?
Well you must be the change you wish to see in theworld. Much is to be done. In communities around theworld, proactive therapists have been addressing issues at
the heart of these global concerns, looking at ways we caneffectively tackle the base causes of deprivation causedby occupational and social injustice.
The World Federation of Occupational Therapists(WFOT) is the key international representative of occupational therapist and occupational therapy and it links 66
countries and organisations (WFOT website 2009) world
wide. The Federation believes that occupational therapy
has a valuable contribution to make to occupational performance as it affects the health and well-being of people.
The Federation maintains that it can positively influence
health, welfare, education and vocation at an international
level combined with the development of excellence within the profession.
In 2006 during the Focus Day prior to the commencement of the World Council Meeting in Australia, WFOT
considered the future of the profession.
The Delegates including the Delegate from Japan
met to consider the following questions:
What will be the health landscape of the future (2015)
What will be the “Roles” of the future (2015)
What will be the Occupational Therapy landscape in the
future (2015)
How WFOT can lead the profession into this future (2015)
WFOT saw that there will be a link between research,education and practice, with increased self confidence tohave a broader role for occupational therapy; there will beroles for occupational therapists at policy levels to influence delivery models and political agendas. Occupational
therapists will advocate for health promotion and prevention from the results of chronic conditions. Occupational
therapists will advocate for participation in “good decent
human life”.
Occupational therapists will have more to offer than
traditional “health” and will distance themselves evenmore from the medical model. They will work with individuals, groups and society and work with healthy people
as well as ill people through preventative and rehabilitative healthcare models. Many services will be delivered
via a community based model whilst still acknowledging
the need for acute care services. There will be increased
use of technology e.g. telecare, virtual home visits via
webcams.
Occupational therapists will develop wider andstronger liaison with other professions outside of healthe.g. town planners, architects as well as developing
emerging areas of practice (Pattison, 2007). Informationand communication technologies (ICT) have arrived andtherapists need to be innovative in how they participate.
These technologies include personal computers, the Internet, email, videoconferencing, telehealth and mobile

Asian J Occup Ther 8: 1–4, 2010

technologies.
One of the common occupations we observe is thetask of grocery shopping – can the individual put together
a shopping list, physically go to the supermarket, choose
the items needed, purchase them and return home. In the
not too distant future, an individual is going to be referred
to an occupational therapist for a similar assessment of
their ability to live independently in the community. But
instead of the ‘standard’ grocery store expedition, the occupational therapist is going to have to work with the person to make sure they have the cognitive skills needed tocontinue to use the Internet fridge in their kitchen. The
person will have no need to physically visit the store but
will attach meaning and purpose to being able to use theInternet fridge and to communicate with the family andthe local doctor via the telecare link in the laser TV. The
occupational therapist will need to focus on the skills andoccupations of meaning to the individual.
But application of technology does not have to becomputer or engineering based. Students in the Ugandan
occupational therapy education programme had to learn
not only how adaptive equipment could help people withdisabilities but also how to make the equipment they prescribed. Students learnt basic carpentry and needlework
skills and liaised closely with local craftsmen; however
wood and specialised skills were still costly and a low
cost alternative was needed.
APT (Appropriate Paper Technology) uses waste
paper and cardboard and glue made from local flour andwater. In the dry season constructions can dry quickly
enabling occupational therapists to make large pieces ofequipment over a number of days/weeks. APT involves
layering pasted paper strips to make a shape, sometimes
cardboard is used to give larger constructions sturdiness;the paste dries clear and adds strength; all equipment canbe painted and take on an individual theme finally a layerof varnish makes the product waterproof.
Ugandan occupational therapists also use APT as atherapeutic tool; the activity is a messy one and allows individuals a structure to work with whilst developing problem solving and decision making skills. Clients have been
involved in making equipment for others and/or pieces
that they themselves can use at home occasionally income
generating projects have been developed.
If occupational therapists are really serious about
working with all people they need to be where all people
are – in the community. There are a multitude of opportunities to put occupational therapy amongst the general population. One area of practice is workplace based
programmes. This is not just about putting in place programmes for injured workers and assisting them to return
to work but more importantly working within a safety,
health and environment context to promote health andPattison M

3well being.
It is well documented that the population is ageing, particularly in the high resource countries and it is
up to occupational therapists to make the links between
occupation and health clear. Programmes to maintain theelderly and older people in the community involved andactive could easily be developed and implemented by occupational therapists rather than waiting until there is illness of disability.
Of course these resources are not available in every
country – in fact not in many countries. Thibeault (2006)
in her keynote address at the WFOT 2006 World Congressdescribes what she refers to as the “Majority World”. This
world is where she has worked with child soldiers, torturesurvivors, people disabled by landmines and survivorsof natural disasters. This is about the rebuilding of sustainable communities and the contribution occupational
therapy can make.
Occupational therapists around the world are involved in working with many of these groups of people incommunity based rehabilitation programmes (CBR).
Traditionally occupational therapists have not been
automatically involved in disaster response however
through the WFOT Disaster Preparedness and Response(DP&R) the opportunity to have occupational therapists
further involved has been explored.
So what roles can the occupational therapist playin DP&R. In Indonesia two days after the earthquake in
May 2005 occupational therapists and occupational therapy students were already involved in undertaking needs
analyses identifying people with disabilities and the requirements for immediate rehabilitation services.
In Thailand 16 months post tsunami occupational
therapists were developing proposals to assist communities with community development projects. Relocatedsurvivors described an aimless, meaningless and incomplete community. They were grateful for the government
assistance but they felt the organisations had not completed their work. They had to be careful to live on the money
they had and they felt they should be given assistance togo back to their original vocations. They didn’t believe
the assistance had been given equitably and they were
worried and frightened about their future (Pattison, 2006).
The occupational therapists identified what skills
they had to deal with this situation and as outcomes they
developed a project to assist these villagers as well as anational action plan for occupational therapy involvement
in disaster preparedness and response in Thailand. These
occupational therapists are there and working within thecommunities, making a difference to hundreds of people
and we can all do it.
Of course there are still many countries where occupational therapy is not a recognised profession and so the

4

THE INTERNATIONAL CHALLENGE FOR OCCUPATIONAL THERAPY

work must continue.
If we seek to understand a people, we have to put
ourselves, as far as we can, in that particular and cultural background… One has to recognise that countries
and people differ in their approach to life and ways ofliving and thinking. In order to understand them, we haveto understand their way of life and approach. If we wish toconvince them, we have to use their language as far as we
can – not language in the narrow sense of the word, but
the language of the mind (Jawaharlal Nehru).
And our language is the language of occupation or
activity – the language of participation, engagement andmeaningful living. That language is spoken in every country in every culture.
Before concluding I would like to answer the questions I raised earlier in this paper.
Nobody knows what we do
We are experts in the science of doing and living
I can’t really tell you what we do because it’s too complicatedWe are performance improvers
The trouble with occupational therapists is that there areso few of us
We are a select and highly specialised group with a major
contribution to make to the health and well being of all
people

The future of the profession is ours to make and our
success will be the only reliable measure of how effectively we have taken hold of our vision. I would like to thinkthat we embrace the notion of strategic intent to enable us
all to turn our visions into reality. By joining together we
can take the future, fold it back into the present and makeit happen right now. So the next time someone asks youwhat occupational therapy is – look at them quizzicallyand say incredulously - “you mean you don’t know?”

References
Pattison, M. (2006). OT – Outstanding talent: An entrepreneurial approach to practice: Feature article WFOT Congress. Australian Journal of Occupational Therapy. 53,
166–172. [CrossRef]
Pattison, M. (2007, November) . The occupational therapy“Landscape of the Future”. WFOT Bulletin.
Sinclair, K. (2004). International perspectives on occupationand participation. WFOT Bulletin. 50, 5–8.
Thibeault, R. (2006). Globalisation, universities and the future of occupational therapy: Dispatches for the Majority
World. Australian Journal of Occupational Therapy. 53,
159–165. [CrossRef]
Wilcock, AA. (2005). Occupational Science: Bridging occupation and health: 2004 CAOT Conference Keynote Address. Canadian Journal of Occupational Therapy. 72,
5–12.

■ORIGINAL ARTICLE
Psychological Distress of Women Newly Diagnosed
with Breast Cancer: Relationship with a Self
Management Intervention Program
Siew Yim Loh1,2, T. Packer2, A. Passmore2, C. H. Yip1, F. L. Tan1, M. Xavier1
1 Faculty of Medicine, University Malaya

2 Centre of Research into Disability & Society, Curtin University of Technology

Abstract: Psychological distress is especially common with any cancer diagnosis. This study examined the psychologicaldistress in a cohort of women newly diagnosed with breast cancer. A longitudinal study of a cohort of women (n=147) diagnosed with breast cancer (within the past 1 year), were conducted at University Malaya Medical Centre, Kuala Lumpur.
Data were collected at baseline and at post 4-week intervention. Analysis of variance was conducted to examine for any
significant differences in the change-scores between the experimental group (n=69) and the control group (n=78). Using thechange scores, analysis of variances shows significant differences between groups for stress, F(1,140) =13.68, p<0.0001,
anxiety, F(1,140) = 8.44, p<0.004, and depression, F(1,140) =11.57, p<0.0001. Levels of stress, anxiety and depression generally decreased significantly in the experimental groups (p<0.05), but either maintained or increased in the control group.
This study indicates that the level of psychological distress of women with breast cancer can be ameliorated with a 4 week
self management intervention. Lower stress was also found in women who reported engagement in higher physical activity
than women with low physical activity. Future studies may examine role of physical activity in ameliorating distress.
Key words: patient self management, women, breast cancer, psychological distress(Asian J Occup Ther 8: 5–11, 2010)

Introduction
Emotional distress, a common sequela of a cancer
diagnosis, is a core indicator of a patient’s wellbeing andhas been promoted as the sixth vital sign in cancer care
(Bultz & Carlson, 2005). Emotional distress varies inlevel of intensity, depending on severity of disease andphase of treatment (Simonton & Sherman, 1998). Earlier research have documented that up to 50% of womenwith breast cancer experience psychiatric morbidity (Hall,
Fallowfield & A’Hern, 1996), coupled with anxiety anddepression commonly faced right from the moment they
are diagnosed with breast cancer (Dow, 2000). It has
also been reported that the onset of reactive anxiety anddepression also often coincides with the fatigue experienced with daily radiation treatments (Rowland & Holland, 1990). Thus, management of emotion is crucial as
Received: 13 November 2009, Accepted: 25 January 2010
Corresponding to: Dr Siew Yim Loh, Department of Rehabilitation,
Faculty of Medicine, 50630 Kuala Lumpur, Malaysia
e-mail: syloh@um.edu.my©2011 Japanese Association of Occupational Therapists

one quarter to one third of women undergoing chemotherapy experienced distress (Campora, Naso & Vitullo,
1992; Newell, Sanson-Fisher, Girgis & Ackland, 1999).
Breast cancer, among all cancers, is the leading causeof cancer mortality in women worldwide. Out of the 35
million people who died from chronic disease in 2005,
half were under 70 years and half were women (WHO,2005). Breast cancer is primarily a woman’s disease, although among males there is a minimal risk of developing
breast cancer as well, with a ratio of 1:100 as reportedby the American Cancer Society (American Cancer Society, 2005). This paper examines the Depression, Anxiety
and Stress of women newly diagnosed with breast cancer
who participated in a 4 week self management clinicalcontrolled trial in University Malaya Medical Centre, alarge teaching hospital situated in the central part of Kuala
Lumpur, Malaysia.

6

PSYCHOLOGICAL DISTRESS OF WOMEN NEWLY DIAGNOSED WITH BREAST CANCER

Fig. 1. Line graph of repeated measures between the experimental and control group.

Methods
Design & subjects
A longitudinal study with repeated measures was
conducted on an experimental group and followed by acontrol group (Fig. 1). There were 147 women newly diagnosed (within one year) with breast cancer from December 2006 to February 2008 who were recruited. The
experimental group undertook the 4-week self management sessions and the control group were those from theusual-care group. Both groups completed the questionnaire as the baseline, and at 4 weeks as well as 8 weeks
from baseline. The participants were selected based on
the following eligibility criteria: (i) more than 18 years ofage, (ii) confirmed by physician, a diagnosis of Stage 1-III(within one year since diagnosis), (iii) completed surgery,may or may not be undergoing chemotherapy and/or radiotherapy, (iv) may or may not be undergoing Tamoxifen(or other endocrine therapy), (v) can read and understandEnglish, and (vi) give informed-consent. The exclusion
criteria are (i) marked cognitive impairment or learning
disabilities (through observation/ interview), and (ii) has
other form of medical problem interfering with participation and attendance (from self report).
Tools
The Depression, Anxiety and stress (DASS) tool
was used to measure psychological distress in Malaysian
women diagnosed with breast cancer. The DASS tool has
been established as having excellent psychometric properties (Crawford & Henry 2003). It measures 3 distinct
items - the depression, anxiety and stress. DASS-21 is aself report questionnaire (Lovibond & Lovibond, 1995)
which allows simultaneous assessment of three emotional
states - depression, anxiety (hyper arousal) and stress. A
Likert-type scale is used to rate items according to symptoms experienced in the past week, ranging from 0 (notat all) to 3 (most of the time). Alpha value for the 7-item
scales ranged from 0.73 (anxiety), 0.81 (depression)and 0.81 (stress) and has adequate convergent and discriminate validity (Crawford & Henry, 2003; Lovibond& Lovibond, 1995). It is a valid, reliable routine clinicaloutcome measure of these constructs in clinical and nonclinical groups (Antony, Bieling, Cox, Enns & Swinson,
1998; Brown, Chorpita, Korotitsch & Barlow, 1997) andfor inpatient setting (Ng et al., 2006).

The intervention program
The intervention group went through usual care andthe 4 week self management program is a group format
for 8 to 15 women who meet weekly (about 2 ½ hours)
for four consecutive weeks. The sessions with its respective self-management themes for each sequential week,on medical management tasks, emotional managementtasks, healthmanagement and role management tasks (seeFig. 2). The facilitation style was based on Tuckman’s
theory (Tuckman, 1965). Use of didactic and experiential
exercises, were drawn from the social cognitive theory
and cognitive behavioral principles. The first session wasscheduled one hour earlier while the final session wasscheduled one hour later than the middle two sessions,to cater for the pen-paper testing. Group work, mini lectures and homework were incorporated in each of the four
sessions. The last session also finished off with a tea andAsian J Occup Ther 8: 5–11, 2010

Loh SY et al.

7

Fig. 2. Overview of the sessions, exercises and facilitation style. SAMA* = Staying Abreast, Moving Ahead, a4-week program. ‘Buddy system’* - a SAMA strategy to improve groupwork and cohesiveness of members

exchange of gifts to show mutual support to their new
partner (or known as the SAMA buddy). The 2-tier buddy
system was added to the program as an inbuilt supportmechanism for the participants to encourage each other aswell as to discuss their homework. The usual-care groupwent through the typical treatment which comprises ofsurgery and combination of chemotherapy, radiotherapy

and targeted therapy. Details of the trial have been published elsewhere (SY Loh, 2009).

Data analysis
The data was entered into the SPSS (Version 15).
All missing data from dropouts at post test and follow up
were input using the last observation of carried forward

8

PSYCHOLOGICAL DISTRESS OF WOMEN NEWLY DIAGNOSED WITH BREAST CANCER

Table 1. Demographic of participants
ALL
n=147

Variables

Experiment
n=69

Control
n=78

Test
p-value

n

%

n

%

n

%

χ2

Age Rang
20–49
50–79

72
75

49.0%
51.1%

31
38

44.8%
55.1%

41
37

52.5%
47.4%

0.022*

Ethnicity
ChineseIndian
Malay(22) &Others(9)

95
21
31

64.6%
14.3%
21.1%

54
7
8

78.3%
10.1%
11.6%

41
14
13

52.6%
17.9%
29.5%

0.040*

Marital Status
SingleMarriedWidowed/Divorced

26
111
10

17.7%
75.5%
6.8%

9
56
4

13%
81.2%
5.7%

17
55
6

21.8%
70.5%
7.7%

0.312

Living Companion
Alone
Spouse, kids and parent
Parents & siblings
Friends/Others

11
108
12
16

7.5%
73.5%
8.2%
10.9%

5
51
6
7

7.2%
73.9%
8.7%
10.1%

6
57
6
9

7.7%
73.1%
7.7%
11.3%

0.989

Additional Roles
Yes
No

40
107

27.2%
72.8%

16
53

23.2%
76.8%

24
54

30.8%
69.2%

0.303

No. of ChildrenNone< 2 kids> 3 kids

33
62
52

22.4%
42.2%
35.4%

14
30
25

20.3%
43.5%
36.2%

19
32
27

24.4%
41.0%
34.6%

0.840

Education Level
Nil -Primary
Secondary
College
University

7
65
39
36

4.8%
44.2%
26.5%
24.5%

2
30
21
16

2.9%
43.5%
30.4%
23.2%

5
35
18
20

6.4%
44.9%
23.1%
25.6%

0.999

Insurance
Yes
No

78
69

53.1%
46.9%

45
24

65.2%
34.8%

33
45

42.3%
57.7%

0 .005*

Physical activity level
Sedentary-low
Moderate -high

92
55

62.6%
37.4%

30
39

43.5%
56.5%

62
16

79.5%
20.5%

0.02

method (for those missing at later time). Mean substitution was used for those missing at an earlier time. Data
from participants on the experimental group who attend
at least three sessions were input and data accepted foranalysis. Descriptive analysis and analysis of variancewere conducted.

Results
Demographic data were obtained from the Patient
Information Questionnaire (PIQ) and tabulated in Table 1
below. A total of 147 women participated in the study. The
majority of the participants were Chinese (65%), with amean age of 50 years (± 9 SD) and within a range of 25–
75 years. Most were married (76%), living with spouseand children (68%), had fewer than 2 children (42%), andhad at least a secondary education (44%). Most had no

extra role looking after aged parents (73%). Only about
6.8 percent were living alone, the rest were living withsomeone, indicating the traditional Asian trend of living
within an extended family system which is still highly
prevalent, although the family today have fewer children.
More than half the women had some form of insurance
policy (53%) and had a household income of 1000-5000
ringgit per month (55%). The independent Chi-square
tests (Tables 1, 2) showed only two personal demographic
variables were significant at baseline. These were ethnicity (p=0.04) and insurance status (p= 0.005).
Prior to the analysis the baseline differences between
the two groups were assessed using t-test. There were no
statistically significant differences in the mean scores of
the two groups for stress (p=0.08), anxiety (p=0.299) anddepression (p=0.44) suggesting that the two groups arefrom the same population. Thus any changes in the find-Loh SY et al.

Asian J Occup Ther 8: 5–11, 2010

9

Table 2. Descriptive (mean +SD) at repeated measures with percentages of change scores
DASS
subscales

Repeated Measures
Baseline(T1)

Post-test(T2)

Follow Up(T3)

ChangeScore(T2-T1)

Mean

SD

Mean

SD

Mean

SD

Mean

SD

% change
scores(at T2)

ChangeScore(T3-T1)Mean

SD% change
scores(at T3)Stress

Exp
Ctrl

12.67
10.31

8.22
8.05

9.86
11.92

7.21
9.82

8.29
11.33

6.98
9.89

–2.81
1.62

6.9
6.6

–22.2*
15.7

–4.38
1.02

8.15
8.27

–34.6*
9.9

Anxiety

Exp
Ctrl

9.13
7.92

7.57
6.47

7.16
9.05

6.45
7.95

6.64
8.97

6.90
7.84

–1.97
1.13

5.37
5.45

–21.6*
14.3

–2.49
1.05

5.46
5.75

–27.3*
13.3

Depression

Exp
Ctrl

9.28
8.21

8.7
8.04

6.09
9.26

6.59
9.53

5.54
9.41

6.33
9.92

–3.19
1.05

7.21
6.46

–34.4*
18.3

–3.74
1.21

7.04
8.16

–40.3*
14.7

DASS= Depression, Anxiety and Stress scale. Exp= experimental arm [n=69], ctrl=control arm [n=77]. * significant at p<0.05

ings can be interpreted with confident as changes werelikely due to the intervention. Descriptive statistic (Table2) shows that with the experimental group, a favorable
decrease on all three scales ranging from –19.8 percent(stress) to 33.3 percent (depression) at T1 to T2 and afurther decrease of 13.7 percent anxiety to 17.1 percent
stress at T2 to T3. In the control group, all three scales
had unfavorable increase with higher measures on stress,
anxiety and depression with a percentage ranging from
8.9 percent to 14.9 percent on T1 to T2 period and 4.5
percent to 4.4 percent stress improves slightly with a decrease mean score of 2.5 percent for T2 to T3. Overall,
the trend of change from baseline T1 to Post test T2 wasfavorable for the experimental group, but unfavorable inthe control group.

Changes over time between the two groups for depression, anxiety and stress
Using the change scores (T2-T1), analysis of variances shows significant differences between groups forstress, F(1,140) =13.68, p<0.0001, anxiety, F(1,140)= 8.44, p<0.004, and depression, F(1,140) =11.57,
p<0.0001. Figure 1 showed the changes over time in theexperimental and control groups. There were no significant difference between the age group (young and old),
mental status and ethnic groups. With level of physicalactivity, significant differences were found between thelow (sedentary to light physical activity) and high (moderate to active) group for stress (p=0.031) but not for depression and anxiety. The within subject repeated measure (on just the experimental group, n=69) showed thatthe changes were statistically significant (p<0.001) for all
three variables on stress, anxiety and depression.

Discussion
At baseline the level of distress of women with breast
cancer who were allocated to a 4 weeks self management
program were higher although the differences were notstatistically significant at the level of p<0.05. This also
shows that the two groups did not differ at baseline andthus are comparable. It is postulated that a reason for thehigher scores in the experimental group could be due tothe added psychological arousal from the knowledge thatthey needed to come into the medical centre for an additional five sessions on top of all the other multiple appointments that they need to adhere to like chemotherapy
or radiology.
The pattern of reduced distress appears significant
over the repeated measures for the experimental group(p<0.05). However, a pattern of unfavourable increase in
distress (stress, anxiety and depression) was observed in
the control group. Cancer diagnosis can lead to enduring
feelings of vulnerability (Bower et al., 2005) resulting in
cognition errors and faulty beliefs which can lead to distress and interfere with physiologically ready states for
self-management. Thus, the 4 weeks self management
intervention was purposefully designed to provide components of cognitive behavioural exercises such as identifying negative self deprecating thoughts and challenging
them with positive statement and practice of relaxation
skills. Cognitive behavioural therapy (CBT) utilize a multimodal approach and is particularly effective in decreasing symptom severity for patients with cancer (Antoni etal., 2001; Dodd & Miaskowski, 2000; Sherwood et al.,2007). The favourable findings in this study is supported
by a study which shows that CBT was effective for depression (ES = 1.2; 95% CI = 0.22–2.19), anxiety (ES =1.99; 95% CI = 0.69–3.31), and QOL (Osborn, Demoncada & Feuerstein, 2006).
This provision of knowledge, skills and support ina group of about 6-10 people, increase the women self
efficacy to self manage the medical, emotion and roletasks. Thus, although there were extra demands for themto attend the sessions, the women reported feeling supported by the health team. The unavailability of information (Loh et al., 2007) – a barrier to self management,
may have been addressed in the program. In a group for-

10

PSYCHOLOGICAL DISTRESS OF WOMEN NEWLY DIAGNOSED WITH BREAST CANCER

mat, stressors may be mediated by the embedded buddy
mechanism where each person was assigned a buddy, andcan select a second buddy based on needs. Thus the program provided a built-in support system from their peers’(buddies) and from the health team. This perhaps led to afavourable outcome for the experimental group. The positive results have been supported by several studies that
promotes that groups produce greater benefits than individual therapy, e.g. in weight loss programs (Renjilian etal., 2001), gastrointestinal symptom reduction (Vollmer &Blanchard, 1998) and in the level of QOL of breast cancer patients (Sakiko et al., 2000). Evidence suggest thatstructured support group intervention can significantly
improve depression (p=0.0001), anxiety (p=0.0001) andQOL (p=0.0009) (Lindemalm, Strang & Lekander, 2005).
Also, the health of disadvantaged women is compromised
due to a lack of education, lack of information and lack ofawareness of factors that contribute to the disease (Luddy,
2007). Thus facilitating them with information, skill andinbuilt support system may have improved their confidence in self management and consequently reduces theirstress level. Indeed, self-management education ‘complements traditional patient education in supporting patients
to live the best possible quality of life with their chronic
condition’ (Bodenheimer, Davis & Holman, 2007).
On the aspect of depression, the profile in the control group shows a sharper rise even at the third repeatedmeasure. One study has shown that in a large cohort ofbreast cancer patients (n=2943), the post-hoc multivariate
analysis revealed that chemotherapy (HR: 1.2; 95% CI:
1.0 –1.5), and hormonal receptor positive status (HR: 1.2;
95% CI: 1.0–1.5) were significantly and independently
associated with an increased risk for developing depression (Lee, Ray, Thomas & Finley, 2007). A cut off scoreof 5 for anxiety and 12 for depression is recommended.
This study found significant improvement in the experimental group in terms of cut off score. Nevertheless, any
clinical significance (as a means of assessing outcome asappropriate), should be interpreted with caution. This isbecause improvement can also be expected upon completion of treatment. Another significant finding is that women who reported higher physical activity level showedsignificant difference in terms of stress. Larger study isneeded to confirm the role of physical activity in buffering stress during treatment. These findings suggest thatwomen with breast cancer need support in managing themultiple tasks even after breast surgery, as chemotherapy
and radiation can be equally distressing and it alters participation in life because of its duration of treatment. One
limitations of the study is that data were obtained by self
report. Future studies can include larger cohorts and examine the role of physical activities on the psychologicaldistress of these women.

Conclusion
Having a diagnosis of breast cancer is distressing
to most women but women who were offered the self
management support as they go through the multiple
appointments for treatment, showed statistically significant reduction in their psychological distress. Women
with breast cancer who went through a 4 week patient
self management programme led by health professionals showed significant reduction in stress, anxiety anddepression over time. In contrast, women who were in
the usual care group showed unfavourable increases
in distress over time. Having a higher physical activity
level is also significantly associated to a lowered stress,
and as such exercise as a lifestyle strategy should be offered to women newly diagnosed with breast cancer. The
psychosocial rehabilitation of women with breast cancerneeds to be emphasised as increasingly more women areliving with this condition. The 4 week self management
intervention is a timely blueprint to improve education,
information and awareness amongst women with breast
cancer. The program can be embedded as an essential
part of clinical practice guidelines to be delivered by occupational therapists, as an early intervention therapy for
women with breast cancer.
Funding: This research was supported by grants from the
University Malay’s fundamental grant and the Malaysian
National Cancer Association (MAKNA). The first author
received an International Postgraduate Research Scholarship from the Australian Government.
Acknowledgements: The authors express gratitude to all
the women who participated in this study, and to all staff
especially, Nurse Ong, Nurse Selvi, Dr Patricia Gomez(FRCS).

References
American Cancer Society. (2005). Breast cancer facts and figures, 2005-2006. Atlanta, Georgia: ACSo.
Antoni, MH., Lehman, JM., Kilbourn, KM., Boyers, AE., Culver, JL., Alferi, SM., et al. (2001). Cognitive-Behavioral
stress management intervention decreases the prevalenceof depression and enhances benefit finding among women
under treatment for early-stage breast cancer. Health Psychology. 20, 20–32. [Medline] [CrossRef]
Antony, M., Bieling, P., Cox, B., Enns, M., & Swinson, R.
(1998). Psychometric properties of the 42-item and 21item versions of the depression anxiety stress scales inclinical groups and a community sample. Psychological
Assessment. 10, 176–181. [CrossRef]
Bodenheimer, T., Davis, C., & Holman, H. (2007). Helping
patients adopt healthier behaviors. Clinical Diabetes. 25,

Asian J Occup Ther 8: 5–11, 2010

66–70. [CrossRef]
Bower, JE., Meyerowitz, BE., Desmond, KA., Bernaards,
CA., Rowland, JH., & Ganz, PA. (2005). Perceptions ofpositive meaning and vulnerability following breast cancer: predictors and outcomes among long-term breast cancer survivors. Annals of Behavioral Medicne: a publication of the Society of Behavioral Medicine. 29, 236–245.
[Medline] [CrossRef]
Brown, TA., Chorpita, BF., Korotitsch, W., & Barlow, DH.
(1997). Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behaviour
research and therapy. 35, 79–89. [Medline] [CrossRef]
Bultz, BD., & Carlson, LE. (2005). Emotional distress: The
sixth vital sign in cancer care. Journal of Clinical Oncology. 23, 6440–6441. [Medline] [CrossRef]
Campora, E., Naso, C., & Vitullo, M. (1992). The impact ofchemotherapy breast cancer patients. Journal of Chemotherapy. 4, 59–63. [Medline]
Crawford, JR., & Henry, JD. (2003). The Depression Anxiety
Stress Scales (DASS):Normative data and latent structure
in a large non-clinical sample. British Journal of ClinicalPsychology. 42, 111–131. [Medline] [CrossRef]
Dodd, MJ., & Miaskowski, C. (2000). The PRO-SELF program: A self-care intervention program for patients receiving cancer treatment. Seminars in Oncology Nursing. 16,
300–308. [Medline] [CrossRef]
Dow, K. (2000). Rehabilitation and follow up. Updates forhealth professionals. Retrieved Jun 6, 2006, from http://
cope.uicc.org/Updates/rehab.shtml.
Fukui, S., Kugaya, A., Okamura, H., Kamiya, M., Koike, M.,
Nakanishi, T., et al. (2000). A psychosocial group intervention for Japanese women with primary breast carcinoma.
Cancer. 89, 1026–1036. [Medline] [CrossRef]
Hall, A., Fallowfield, LJ., & A’Hern, RP. (1996). When breast
cancer recurs: A 3-year propective study of psychologicalmorbidity. The Breast Journal. 2, 197–203. [CrossRef]
Lee, KC., Ray, GT., Hunkeler, EM., & Finley, PR. (2007).
Tamoxifen treatment and new-onset depression in breast
cancer patients. Psychosomatics. 48, 205–210. [Medline][CrossRef]
Lindemalm, C., Strang, P., & Lekander, M. (2005). Support
group for cancer patients. Does it improve their physicaland psychological wellbeing? A pilot study. Supportive
Care in Cancer. 13, 652–657. [Medline] [CrossRef]
Lovibond, S., & Lovibond, P. (1995). Manual for the Depression Anxiety Stress Scales (2nd. Ed.).Sydney: Psychology
Foundation.

Loh SY et al.

11

Luddy, G. (2007). Women, disadvantage and health. Irish
Medical Journal. 100, 71–73. [Medline]
Newell, S., Sanson-Fisher, RW., Girgis, A., & Ackland, S.
(1999). The physical and psychosocial experiences ofpatients attending an outpatient medical oncology department: A crosssectional study. European journal of cancercare. 8, 73–82. [CrossRef]
Ng, F., Berk, M., Campbell, S., Callaly, T., Dodd, S., & Trauer,T. (2006). The 21-item Depression Anxiety Stress Scales
as a valid routine clinical outcome measure in the private
in-patient setting. Acta Neuropsychiatrica. 18, 277–312.
Osborn, RL., Demoncada, AC., & Feuerstein, M. (2006). Psychosocial interventions for depression, anxiety, and QOL
in cancer patient survivors: Meta-analyses. International
Journal of Psychiatry in Medicine. 36, 13–34. [Medline][CrossRef]
Renjilian, DA., Perri, MG., Nezu, AM., McKelvey, WF.,
Shermer, RL., & Anton, SD. (2001). Individual versus
group therapy for obesity: Effects of matching participants
to their treatment preferences. Journal of Consulting andClinical Psychology. 69, 717–721. [Medline] [CrossRef]
Rowland, J., & Holland, J. (1990). Breast cancer. In J. C. Holland, & J. H. Rowland (Eds.), Handbook of psychooncology: Psychological care of the patient with cancer (pp.
188–207). New York: Oxford University Press.
Sherwood, P., Given, BA., Given, CW., Champion, VL.,
Doorenbos, AZ., Azzouz, F., et al. (2005). A Cognitive
behavioral intervention for symptom management in patients with advanced cancer. Oncology Nursing Forum. 32,
1190–1198. [Medline] [CrossRef]
Simonton, SS., & Sherman, AC. (1998). Psychological aspects of mind-body medicine: promises and pitfalls fromresearch with cancer patients. Alternative Therapies in
Health and Medicine. 4, 50–58. [Medline]
Loh, SY., editor.(2009). Patient self management for womenwith breast cancer: Enabling Quality of life and participation. Beau-Bassin, Mauritius: VDM Publishing House Ltd.
Tuckman, BW. (1965). Developmental sequence in small
groups. Psychological Bulletin. 63, 384–399. [Medline][CrossRef]
Vollmer, A., & Blanchard, EB. (1998). Controlled comparisonof individual versus group cognitive therapy for irritablebowel syndrome. Behavior Therapy. 29, 19–33. [CrossRef]
WHO (2005). Chronic disease: Ten facts about chronic diseases. Retrieved November 17, 2007, from http://www.who.
int/topics/chronic_disease/en/index.html.

■ORIGINAL ARTICLE
Study of Visual Function Evaluation for People with
Severe Motor and Intellectual Disabilities Utilizing
Near-Infrared Spectroscopy
Yuji Nakamura, OT, PhD1, Yasuhito Sengoku, OT, PhD1,
Sonomi Nakajima, OT, PhD1, Toshio Ohyanagi, Dr. of Engineering2,
Kosuke Sugama, OT, MS3, Yositaka Horimoto, PT, PhD3,
Nobutada Tachi, MD, PhD1
1 Department of Occupational Therapy, School of Health Sciences, Sapporo Medical University

2 Department of Liberal Arts and Sciences, Center for Medical Education, Sapporo Medical University
3 Rehabilitation, Nishi Otaru Hospital, Midori-no-Sato Institution for the SMID

Abstract: The purpose of this study was (1) assess the effectiveness of near-infrared spectroscopy (NIRS) for evaluating
visual function of people with severe motor and intellectual disabilities (SMID), and (2) investigate the inference of characteristics of visual stimuli to response from them and to dynamics of cerebral blood flow. Twenty-one SMID were presented
Visual Task 1 which uses a photograph, and classified into four groups based on subjects’ eye movement. Additionally,
oxy-Hb which was most increased was measured. Results, the averages of oxy-Hb for “gaze” and “habituation” group were0.45 and 0.83 mM*mm, “non-gaze” was almost 0 mM*mm, and “non-judgment” were resembled “gaze”. In Visual Task
2 which uses a moving image, most subjects were classified in “gaze”, and an oxy-Hb had increased. This study indicatedthat NIRS is an effective instrument for visual function evaluation, and that difference in the characteristics of stimuli could
affect the responses and oxy-Hb of SMID.
Key words: people with severe motor and intellectual disabilities, near-infrared spectroscopy, visual function(Asian J Occup Ther 8: 13–19, 2010)

Introduction
In Japan, people with severe motor and intellectual
disabilities, termed people with SMID hereafter, live ininstitutions and get long-term living support and rehabilitation. This is an administrative program of Japanese government, and there are more than one hundred such institutions in Japan. It is often the case that people with SMID
have difficulties in rolling over or walking by themselves
and they cannot talk with others. Furthermore they cannot
express themselves and have disorder in their upper limb
function. These disabilities make it very hard for them totake action or respond to their ambient environment. The
Received: 22 July 2009, Accepted: 2 February 2010
Corresponding to: Yuji Nakamura, Department of Occupational
Therapy, School of Health Sciences, Sapporo Medical University,
South 1 West 17, Chuo-ku, Sapporo 060-8556, Japane-mail: yujin@sapmed.ac.jp©2010 Japanese Association of Occupational Therapists

rehabilitation staffs realize that setting up suitable living
environment and making personal rehabilitation program
according to their disabilities are indispensable for them.
However, the severity of their disabilities makes it difficult for the staff even to assess their developmental stage,
especially mental development, properly.
Regarding mental development of people with
SMID, Nakamura, Taniguchi, and Adachi (1990) reported
that the abilities of sensory-motor intelligence, the orienting responses and the gazes have related to their intellectual development. The authors found that the people
with SMID who could orientate to and habituate to visual
stimuli were age of higher developmental stage and had
higher activities of daily livings (ADL) performance (Nakamura, Sengoku, Nakajima, Yanagiya & Tachi, 2006).
The habituation is a reaction of the subject who was satedwith the stimulus after having recognized the characteristics of it. Hotz et al. (2006) reported that an environmentof intelligibly arranged physical sensory stimuli has im-

14

VISUAL FUNCTION EVALUATION AND NEAR-INRARED SPECTROSCOPY

proved their active behavior. Especially under so-called
Snoezelen and Multi-sensory environment that gave moving visual stimuli with high contrast to people with SMID,
they have continued exploring and paying attentions tothe stimuli for longer duration of time (Hotz et al., 2006).
These findings indicate that it is necessary to properly
measure their fixation to and gaze at stimuli for evaluating
their mental development. And also setting up an environment, which promotes the fixation and the gaze of people
with SMID, is important. However, even identifying the
fixation is not easy in case the people with SMID havenystagmus or difficulty in controlling their head, since theidentification is mainly done by just observation of rehabilitation staff.
Recently, the near-infrared spectroscopy (NIRS) has
been introduced to evaluate human’s response to visual
stimuli. Although NIRS has low spatial resolution andprovides only two-dimensional surface mapping, it was
shown that NIRS was robust to subject’s body movement(Takahashi et al., 2000). Kato, Kamei, Takashima, andOzaki (1993) employed NIRS to evaluate activity of optic
area in the brain of normal adults for the first time. They
have revealed that the changes in oxygenation hemoglobin concentration (oxy-Hb changes) in optic area had increased right after the onset of flashlight as visual stimuli,
and decreased right after disappearing of the stimuli.
The similar changes had been observed in infants (Taga,
Asakawa, Maki, Konishi & Koizumi, 2003; Wilcox,
Bortfeld, Woods, Wruck & Boas, 2005). NIRS is simple
equipment for measuring the brain activity but has a characteristic that the identification of visual stimuli can bemeasured objectively as the oxy-Hb changes in optic area.
As NIRS has been used for infants, the authors consideredthat it is effective to evaluate the visual function of people
with SMID who have difficulty in understanding the tests
themselves. A multi-channel NIRS, which can monitor
different sites in the brain simultaneously, is more suitable equipment to identify the activated sites of people
with SMID within a short time period after the onset ofa visual stimulus than other means to test the brain function, since such means make the subjects tightly restricted
and then cannot be applied to people with SMID. In orderto clarify the suitable living environment for people with
SMID, dynamics of their cerebral blood flow and their
responses along with changes of visual stimuli should be
investigated with NIRS.
The purpose of this study was twofold: (1) assess theeffectiveness of NIRS for evaluating visual function ofpeople with SMID, and (2) investigate the inference ofcharacteristics of visual stimuli to response from people
with SMID and to dynamics of their cerebral blood flow.

Methods
Subjects
Twenty-one people with SMID (11 males and 10 females; age, 19 to 57 yr; mean age, 38.5 yr) participatedin this study. All of them lived in institutions, and theyneeded to get full assistance in all of their ADL. Thirteenamong of them were cerebral palsy, three were abnormal
chromosome, two were aftereffect of hypoxic encephalopathy, two were intractable epilepsy, and one was aftereffect of cerebral meningitis. The results of Japanese Denver Developmental Screening Test (JDDST) (Ueda, 1980)
showed that their developmental ages of gross motor activity were from zero to six months, and those of language
development were from one to twenty three months. They
did not have clear visual deficit, and they had blinking reflex. In addition, they could gaze at human faces or reach
their hands to toys in their daily livings. These criteria for
selecting subjects were chosen from the evaluation items
that we have developed to apply for people with SMID
by modifying the Visual Acuity Scores originally madeby Katsumi et al. (Katsumi, Chedid & Kronheim, 1998).
Table 1-1 and 1-2 show the profiles and visual activitiesof twenty-one subjects.
Seven normal adults (4 males and 3 females; age, 22
to 32 yr, mean age, 27.3 yr) who did not have anamnesis of visual function were recruited as controls for NIRS
evaluation. The subjects with low visual acuity wore
glasses or contact lens.
Visual tasks
The first task, termed Visual Task 1, was composedof four slides, numbered from 1 to 4. An illustration was
drawn in the slide 1 to get subjects’ attention paid to thistask. Both the slides 2 and 4 were just black screen. These
slides were added in order to make subjects resting. The
slide 3 was a photo of Japanese infant face for subjects ofpeople with SMID, while a photo of landscape for thoseof normal adults. We considered that the people with
SMID and the normal adults were much interested in thephoto of infant face and landscape, respectively.
The second task, termed Visual Task 2, was also composed of four slides, numbered from 1 to 4. The slides 1, 2
and 4 were identical to those of Visual Task 1. A moving
image of the bubble unit of Snoezelen apparatus that wascaptured by a digital camera for 30 seconds was used forthe slide 3 of Visual Task 2. The bubble unit is a clear tube
filled with water in it and in which bubbles flow upwardwith gently changing colors as visual stimuli.
Figure 1 shows a protocol to conduct Visual Task
1 and Visual Task 2. The slide 1 was presented to eachsubject until it was confirmed that the subject paid an attention to the slide. After that, the slide 2, 3 and 4 wereNakamura Y et al.

Asian J Occup Ther 8: 13–19, 201015

Table 1-1. Profiles of the subjects with SMIDJDDST (Mon.)

Case
No.

Sex

Age
(Yr.)

Diagnosis

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

Male
FemaleFemaleMale
Male
FemaleFemaleFemale
Male
Male
Male
Male
Male
Male
FemaleMale
FemaleMale
FemaleFemaleFemale

44
53
42
43
46
44
28
44
57
33
26
24
23
49
57
19
27
42
42
38
28

Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Hypoxic Encephalopathy
Cerebral Palsy
Abnormal Chromosome
Cerebral Palsy
Cerebral Palsy
Abnormal Chromosome
Intractable Epilepsy
Intractable Epilepsy
Hypoxic Encephalopathy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Meningitis

Gross motor Language
5
5
5
0
6
1
5
0
1
6
5
1
5
5
1
0
1
5
6
0
1

Blink
Reflex

1
18
1
1
23
1
1
9
1
18
3
5
5
5
5
3
5
5
23
1
1

+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+

“Yr.” indicates the age in years, and “Mon.” indicates the age in months. “SMID” indicatessevere motor and intellectual disabilities, “JDDST" indicates Japanese Edition Denver
Development Screening Test.

Table 1-2. Visual activities of subjects with SMID
Investigation item
Squints in bright sunlight?
Detects a small thing like a glass marble?
Follows a small thing like a glass marble?
Gazes at a face of human?
Follows a face of human?
Detects a toy?
Follows a toy?
Gazes at a television screen?
Gazes at a tool of Snoezelen?
Tries to reach a toy?

1

2

3

4

5

6

7

8

9

Case No.
10 11 12 13 14 15 16 17 18 19 20 21

+
–
–
–
–
–
–
–
–
+

+
+
+
+
+
+
+
+
+
+

+
–
–
+
+
+
–
–
+
–

+
–
–
+
–
–
–
–
+
+

+
+
+
+
+
+
+
+
+
+

+
–
–
+
+
–
–
–
+
–

+
–
–
+
–
–
–
–
+
–

+
+
+
+
+
+
+
+
+
+

+
–
–
+
+
+
+
+
+
–

+
+
+
+
+
+
+
+
+
+

+
+
+
+
+
+
+
–
+
+

+
+
+
+
+
+
+
+
+
+

+
+
+
+
+
+
+
+
+
+

+
+
+
+
+
–
–
+
–
+

+
+
+
+
+
+
+
+
+
+

+
–
–
+
+
+
–
+
+
–

+
+
+
+
+
+
+
+
+
–

+
+
+
+
+
+
+
+
+
+

+
+
+
+
+
+
+
+
+
+

+
–
–
+
+
+
–
–
+
+

+
–
–
+
+
+
+
–
+
–

Investigation item were employed from Visual Acuity Scores developed by Katsumi et al., which was modified by us to apply for people with
SMID. “+” shows that an answer of an investigation item is “yes”, “–” shows “no”.

presented for 30 seconds each in this order. Firstly, allsubjects were tested with Visual Task 1. Secondly, Visual
Task 2 was used only for people with SMID who wereselected based on the result of Visual Task 1. The normal
adults were required to gaze at the slides during all thetime of Visual Task 1.

Equipments and their setting
Figure 2 illustrates the equipments and their settings
for this study. A multi channel NIRS instrument (ETG4000, Hitachi Medical) was used for this study. According as the International 10–20 System of Electrode Place-ment, the set of 22 optical fibers (gross area, 6 cm × 12cm) was placed at subject’s occipital area to measure
oxy-Hb changes at 10 Hz of sampling rate. The lowest
fibers were placed symmetrically at 0.5 cm directly abovefrom inion. The slides of visual tasks were presented on
a 19-inch LCD display (LCD92V-V, NEC) by using Microsoft® Office PowerPoint 2003 software running on amobile PC (CF-W5, Panasonic). A digital video camera(DCR-TRV30, SONY) was set up over the LCD display
to capture the subject’s eye movement. NIRS and the camera were synchronously controlled. People with SMID sat
in front of the LCD display at a distance of 80–100 cm by

16

VISUAL FUNCTION EVALUATION AND NEAR-INRARED SPECTROSCOPY

Fig. 1. Protocol of Visual Task 1 and Visual Task 2. Contents in each square show presented slides, and the upper time showspresentation time.

Fig. 2. Equipments and their settings for this study. This study was carried out in the darkroom where visual
stimulation and auditory stimulation were controlled. The circumference of a 19-inch LCD display
which showed visual stimulation was covered with a black screen.

using a seating system. For those who could not control
their heads, we assisted their heads manually.

Analysis1) Classify people with SMID
Visual task 1: The first author and an occupational
therapist who has 15 years of experience in the field ofdevelopmental disease classified people with SMID into
four groups based on their eye movement during presenting the slide 3 of Visual Task 1: (a) subjects who gazedat the slide obviously but were not habituated to it wereclassified into “gaze group”; (b) subjects who gazed at theslide obviously and were habituated to it were classified
into “habituation group”; (c) subjects who did not gaze at
the slide obviously were classified into “non-gaze group”;(d) the other subjects were classified into “non-judgmentgroup”. For each subject, the two occupational therapists
did the classification separately, and discussed on theirclassifications. After they agreed on the classifications, all
the subjects were classified into one of the four groups.
Visual task 2: Subjects classified into groups of “nongaze group” and “non-judgment group” were furthermore

Nakamura Y et al.

Asian J Occup Ther 8: 13–19, 2010

tested with Visual Task 2. The first author and the occupational therapist classified them into three groups basedon their eye movement during presenting the slide 3 ofVisual Task 2: (a) subjects who gazed at the slide obviously were classified into “gaze group”; (b) subjects who
did not gaze at the slide obviously were classified into
“non-gaze group”; (c) the other subjects were classified
into “non-judgment group”. The procedure of the classification was same as that of Visual Task 1.
2) NIRS evaluation
It is known that oxy-Hb changes show the same direction as the changes of blood flow but deoxy-Hb changes and the total Hb changes do not (Hoshi, 2005). This is
the reason why oxy-Hb changes have been widely used
for an index of brain activities. We used the data of oxyHb changes obtained by the NIRS for the evaluation ofbrain activities of the subjects.
Visual task 1: Data measured by the NIRS were5-seconds moving averages at 10 Hz of sampling rates. We
used the data measured at two points of each 22 channels.
One point was at the beginning time of presenting slide
3, termed B1, and the other one was at the time oxy-Hbchanges be most increased, termed M1. Since the valueof oxy-Hb changes is a relative value from the beginningof the measurement, the value of oxy-Hb changes at M1,
termed M1 data, was recalculated by assuming the valueat B1 be 0 mM*mm. Among of M1 data at 22 channels
for a subject, we used the largest one as the subject’s data.
We calculated the average of subjects’ M1 data foreach four groups and seven normal adults.
Visual task 2: Just like analysis of data from Visual
Task 1, we used the data measured at two points of each
22 channels. One point was at the beginning time of presenting slide 3, termed B2, and the other one was at thetime oxy-Hb changes be most increased, termed M2. The
value of oxy-Hb changes at M2, termed M2 data, was recalculated by assuming the value at B2 be 0 mM*mm.
Among of M2 data at 22 channels for a subject, we used
the largest one as the subject’s data. In order to discuss aninference of the difference of visual stimuli, we comparedM1 data and M2 data.
In accordance with the regulations set forth by the
Ethics Committee of Sapporo Medical University, thisstudy has passed an examination of the Committee, andinformed consent was obtained from all people with
SMID or their parents and from all normal subjects.

Results
Visual task 1
1) Normal adults
By observing eye movements of seven normal adults,
we confirmed that they gazed at the slides during all the17time of Visual Task 1 as required. The average of M1 data
for them was 0.36 ± 0.08 mM*mm.
2) People with SMID
Nine people with SMID were classified into “gazegroup”, seven of them were into “habituation group”, twoof them were into “non-gaze group”, and three of themwere into “non-judgment group”. Table 2 shows M1 data.
The averages of M1 data for “gaze group” and “habituation group” were 0.45 and 0.83 mM*mm, respectively.
M1 data of two subjects in “non-gaze group” were 0.019
and 0.005 mM*mm, while those of three subjects in “nonjudgment group” were 0.263, 0.251 and 0.207 mM*mm.
From these results, the M1 data of subjects in “gazegroup” and “habituation group” is greater than those in“non-gaze group”.

Visual task 2
Table 3 shows the results of classifications and NIRS
data obtained from both Visual Task 1 and Visual Task 2.
All subjects in “non-gaze group” and two of three subjects in “non-judgment group” classified after Visual Task
1 were classified into “gaze-group” as a result of Visual
Task 2, and the M2 data had increased.

Discussion
The M1 data of normal adults
Some previous studies on evaluating visual functionof infants and normal adults by using NIRS have employed flashing stimuli or checkerboard as visual stimuli(Takahashi et al., 2000; Kato et al., 1993, Taga et al., 2003;
Obrig et al., 2002). These stimuli were originally used tomeasure visual evoked potential to diagnose organic disorders in visual pathway. Since our study was aimed toevaluate visual function of subjects in the environment
like their daily livings, we used a photo of landscape. As
a result, we could confirm that the M1 data of all normal
adults increased after seeing the photo of landscape justlike the previous studies using flashing stimuli or checkerboard. Csibra et al. (2004) has also reported that oxy-Hbchanges have increased at occipital lobe of normal adults
during presenting a photo of human face as a visual stimulus. From these results, it is suggested that NIRS can beused to evaluate oxy-Hb changes by using even not specific stimuli such as a landscape picture and a photo ofhuman face.
The M1 data of people with SMID
The M1 data of subjects in “gaze group” and “habituation group” were larger than those of subjects in “nongaze group”. In some previous studies it has been reported
that the increase and decrease of oxy-Hb changes of infants and normal adults corresponds to the On-Off of vi-

18

VISUAL FUNCTION EVALUATION AND NEAR-INRARED SPECTROSCOPY

Table 2. The M1 data for each group
Case No.

M1 data (mM*mm)

Mean M1 data (mM*mm)

Gaze groupClassification

3
4
8
9
13
14
15
18
19

0.29
0.48
0.50
0.11
0.80
0.64
0.36
0.59
0.31

0.45

Habituation group

2
5
6
10
11
16
17
12
20
1
7
21

1.24
0.72
0.98
0.65
0.80
0.60
0.84
0.02
0.005
0.26
0.25
0.21

0.83

Non-gaze group
Non-judgment group––

The number of people classified into “non-gaze group” and “non-judgment group” wasfew; mean M1 data were not calculated.
Table 3. Classification and NIRS evaluation between Visual task 1 and Visual task 2
Visual Task 1

Visual Task 2

Case
No.

Classification

M1 data (mM*mm)

Classification

M2 data (mM*mm)

12
20
1
7
21

non-gaze
non-gaze
non-judgment
non-judgment
non-judgment

0.019
0.005
0.263
0.251
0.207

gaze
gaze
non-judgment
gaze
gaze

1.349
0.787
-0.001
0.731
0.734

Case No.7, 12, 20, and 21 were classified into “gaze group” and the M2 data increased.
Case No.1 has no change in result of classification and the M2 data.

sual stimuli (Kato et al., 1993; Taga et al., 2003). Fromthese results, it is suggested that the oxy-Hb changes in
SMID people from “gaze group” and “habituation group”
derived from active gaze at the stimulus. The M1 data ofsubjects in “non-gaze group” were almost zero. We considered that the behavior of “non-gaze” could be detectedby the value of M1 data being almost zero. The M1 data ofsubjects in “non-judgment group” were similar to those of
normal adults. In addition, we confirmed that they watched
TV and reached out for toys in their daily livings. A study
using a checkerboard with infants and normal adults hasreported that oxy-changes at occipital lobe were about
0.1mM*mm (Takahashi et al., 2000; Taga et al., 2003).
As the M1 data of subjects in “non-judgment group” werelarger than 0.2mM*mm, we considered that they at least
watched the visual stimuli, and they may show clear gazeat some other stimuli in which they are more interested.

An inference of the different characteristics of visual
stimuli toward people with SMID
Four subjects out of five classified into “non-gazegroup” or “non-judgment group” after Visual Task 1 wereclassified into “gaze group” as a result of Visual Task
2, and their M2 data increased. It suggests that a visual
stimulus with high contrast and changing colors or figures, such as a bubble unit, can lead an active gaze of people with SMID. In previous papers, it was reported thatpeople with SMID have continued exploring and paying
attentions to the stimuli for longer duration of time underSnoezelen and Multi-sensory environment (Hotz et al.,2006; Kaplan, Clopton, Kaplan, Messbauer & McPherson, 2006). Yashiro, Ozawa, and Fujimura (1998) have reported that people with SMID of from zero to six months
developmental age were more interested in various kindsof sensory stimuli of Snoezelen among people with SMID
of from zero to eighteen months developmental age. The

Asian J Occup Ther 8: 13–19, 2010

language developmental ages of people with SMID whowere classified into “non-gaze group” or “non-judgmentgroup” after Visual Task 1 in this study were from one toseven months by JDDST. From this result and NIRS datafrom subjects classified into “non-gaze group” or “nonjudgment group”, it was suggested that a visual stimulus
like the third slide of Visual Task 2 could not only getinterests but also promote visual orientation and gaze of
people with SMID whose developmental age were low.
In this study, we presented that the increase or decrease of oxy-Hb changes of people with SMID depended
on gazing or non-gazing at visual stimuli by using NIRS
to evaluate their visual function. We also showed thatNIRS could be used to infer visual function of a subject
whose gaze could not be evaluated by visual observation.
The data of oxy-Hb changes alone are not capable forneither assessing subjects’ understanding of the presented
stimuli nor judging just watching or gazing at the stimuli.
By gathering information on their daily livings and evaluating the information together with oxy-Hb changes, thesubjects’ visual function might be assessed in properly andobjectively. Since it is impossible for people with SMID
to use MRI with NIRS, it is difficult to identify the primary visual area of them by using NIRS alone. However,by using a multi channel NIRS and employing the International 10–20 system of Electrode Placement, we could
capture responses from people with SMID to visual stimuli by analyzing data from the channel that showed thelargest oxy-Hb changes. This result suggests that a multichannel NIRS is more applicable for evaluating people
with SMID than other NIRS evaluations. The differencein the characteristics of visual stimuli could affect the responses and the dynamics of blood flow in brain of people
with SMID. A continuous support from infant to adulthood is required in occupational therapy for people with
SMID. A program of occupational therapy that is aimed topromote their visual attention is necessary and important.
We presented that there was a visual stimuli that tended to
attract visual interests of people with SMID. An activityof employing such visual stimuli should be conducted in
the daily living of people with SMID as well as in theirrehabilitation program.

References
Csibra, G., Henty, J., Volein, Á., Elwell, C., Tucker, L., Meek,J., et al. (2004). Near infrared spectroscopy reveals neural activation during face perception in infants and adults.
Journal of Pediatric Neurology. 2, 85–89.
Hoshi, Y. (2005). Functional near-infrared spectroscopy; Limitations and potential. The Journal of Japanese College
Angiology. 45, 61–67.

Nakamura Y et al.

19Hotz, GA., Castelblanco, A., Lara, IM., Weiss, AD., Duncan,
R., & Kuluz, JW. (2006). Snoezelen: A controlled multisensory stimulation therapy for children recovering fromsevere brain injury. Brain Injury. 20, 879–888. [Medline][CrossRef]
Kaplan, H., Clopton, M., Kaplan, M., Messbauer, L., &McPherson, K. (2006). Snoezelen multi-sensory environments: task engagement and generalization. Researchin Developmental Disabilities. 27, 443–455. [Medline][CrossRef]
Kato, T., Kamei, A., Takashima, S., & Ozaki, T. (1993). Human visual cortical function during photic stimulation
monitoring by means of near-infrared spectroscopy. Journal of Cerebral Blood Flow & Metabolism. 13, 516–520.
[Medline] [CrossRef]
Katsumi, O., Chedid, SG., & Kronheim, JK. (1998). Visual
Ability Score - a new method to analyze ability in visually
impaired children. Acta Ophthalmol Scand. 76, 50–55.
[Medline] [CrossRef]
Nakamura, T., Taniguchi, T., & Adachi, K. (1990). The relationship between Sensory Motor Intelligence and Play of
Profoundly Retarded Children and Adults (in Japanese).
The journal of Japanese association of occupational therapists (Tokyo), 9, 270–278.
Nakamura, Y., Sengoku, Y., Nakajima, S., Yanagiya, S., &Tachi, N. (2006). Study of the abilities about habituationdishabituation in persons with severe motor and intellectual disabilities (in Japanese). The journal of Japanese association of occupational therapists (Tokyo), 25, 512–522.
Obrig, H., Israel, H., Kohl-Bareis, M., Uludag, K., Wenzel,
R., Muller, B., et al. (2002). Habituation of the visually
evoked potential and its vascular response: implications
for neurovascular coupling in the healthy adult. Neuroimage. 17, 1–18. [Medline] [CrossRef]
Taga, G., Asakawa, K., Maki, A., Konishi, Y., & Koizumi, H.
(2003). Brain imaging in awake infants by near-infrared
optical topography. Proceedings of the National Academyof Sciences of the United states of America. 100, 10722–
10727. [Medline] [CrossRef]
Takahashi, K., Ogata, S., Atsumi, Y., Yamamoto, R., Shiotsuka,S., Maki, A., et al. (2000). Activation of the visual cortex
imaged by 24-channel near-infrared spectroscopy. Journalof Biomedical Optics. 5, 93–96. [Medline] [CrossRef]
Ueda, R. (1980). Japanese Edition Denver Developmental
Screening Test. Tokyo: Ishiyaku, Publishers, (in Japanese).
Wilcox, T., Bortfeld, H., Woods, R., Wruck, E., & Boas, D.A.
(2005). Using near-infrared spectroscopy to assess neuralactivation during object processing in infants. Journal of
Biomedical Optics, 10, 11010-1–11010-8.
Yashiro, F., Ozawa, M., & Fujimura, M. (1998). Developmentof sensory stimulation guidance method applied Snoezelen
to persons with severe motor and intellectual disabilities(in Japanese). Yomiuri light and humanity association Report about nursing for people with severe motor and intellectual disabilities(Tokyo), 26, 55–63.

■ORIGINAL ARTICLE
A Preliminary Study on the Usability of Head Mount
Display (HMD) for Evaluating Attentional Behavioral
DisturbanceTsutomu Sasaki, OTR, PhD1,2, Hisae Kitajima, OTR, PhD3,
Kunihiro Kanaya, OTR, MS4,5, Kosuke Sugama, OTR, MS6,
Yasuhito Sengoku, OTR, PhD7
1 Division of Occupational Therapy, Shinshu University

2 Visiting Research Fellow of Sapporo Medical University

3 Department of Occupational Therapy, Hokkaido Bunkyo University
4 Graduate School of Health Sciences , Sapporo Medical University
5 Department of Rehabilitation Medicine, Sasson-Sugata Clinic

6 Department of Rehabilitation, Nishi Otaru Hospital, Midori-no-Sato Institution for the Severe Motor and Intellectual

Disabilities(SMID)

7 Department of Occupational Therapy , Sapporo Medical University

Abstract: To investigate the clinical applicability of head-mount display (HMD) in evaluating attentional behavioral disorders, we developed a new desk-task environment with HMD. 18 patients with right hemisphere damage were recruited.
We compared the results of traditional neuropsychological tests and tasks carried out under the HMD setting using attention
behavioral disturbances observed in daily life. The findings show that performance under HMD settings predicts the presence or absence of attention behavioral disturbance with higher accuracy than traditional tasks. Our newly developed HMD
system shows promise as an appropriate method for assessing attentional behavioral disturbances. Although necessarily
speculative at this stage, we believe that the more dynamic cognitive demands required to successfully accomplish the HMD
task might be linked to attentional behavior in ADL.
Key words: stroke, attention, head-mount display (HMD)(Asian J Occup Ther 8: 21–29, 2010)

Introduction
The purpose of Occupational Therapy (OT) is to help
people increase their functional independence in daily life
while preventing or minimizing disability. Physical, psychological, and cognitive factors, as well as personal history, are linked causally to disabilities. In the clinical setting, some patients show behavioral disorders mainly due
to cognitive deficits, and occupational therapists often apply several neuropsychological tests to verify the factors
causing their behavioral disorders. However, it has beenrecognized that some patients don’t show any abnormalities in neuropsychological tests, but do display behavioral
Received: 21 December 2009, Accepted: 15 August 2010
Corresponding to: Tsutomu Sasaki, Division of Occupational Therapy,
Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japane-mail: tusasaki@shinshu-u.ac.jp©2010 Japanese Association of Occupational Therapists

deficits in activities of daily living (ADL) (Sasaki, Sengoku, Nakajima, Sugama & Kitajima, 2005). The authors
investigated the relation between results of a revised bisection task and attentional performance in ADL in stroke
patients. The results showed that some patients exhibitedno behavioral abnormalities in spite of their lower scorein the task.
This clinical discrepancy has a negative impact on
our clinical practice because it restricts our understandingof the impairments causing patients’ behavioral disorders.
This in turn can lead to anomalies in communication withother medical staff and even patients’ families, resulting
in disagreements regarding treatment options. Accordingly, evaluations with higher accuracy in detecting behavioral abnormalities should be developed.
We assume that one of the reasons for these discrepancies could be environmental differences: static in desktask settings vs. dynamic in ADL settings. In general, it22

HEAD MOUNT DISPLAY AND ATTENTIONAL DISTURBANCE

Table 1. Demographic and clinical characteristics
case

age

sex

etiology

duration fromonset (month)

FIM

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

62
72
76
77
58
54
55
57
62
57
61
69
75
78
58
57
74
50

female
male
male
male
male
male
male
femalemale
male
femalemale
female
male
male
male
male
male

infraction
infraction
infraction
infraction
infraction
hemorrhage
hemorrhage
infraction
hemorrhage
infraction
hemorrhage
hemorrhage
infraction
infraction
infraction
infraction
infraction
infraction

11
1
1
2
1
3
5
1.5
1
4
1
3
1
0.5
1
2.5
0.5
1

95
87
70
103
101
71
77
74
91
101
119
114
110
126
63
115
99
122

23
24
28
28
20
18
26
27
28
29
26
29
25
30
25
29
30
30

ave.
SD

64.0
8.9

2.3
2.4

96.6
18.9

26.4
3.3

MMSE motor deficit
moderate
mild
mild
mild
mild
severesevereseveresevereseveremildmoderatemild
mildseveremoderate
mild
mild

sensory
deficit

USN

visual field
deficit

+++
+
+
–
+
+++
++
++
+++
+++
++
+
+
–
+++
+++
+
+

+
+
+
+
+
+
+
+
+
+
–
–
–
–
–
–
–
–

+
+
+
+
+
+
+
–
–
–
–
–
–
+
–
–
–
–

a. sensory deficit; +++, severe; ++, moderate; +, mild; –, absent. b. USN; +, present; –, absent. c. visual field deficit; +, present; –, absent.

has been thought that the desk-task setting is so static thatless sensory integration was needed to successfully accomplish a given task (Thompson & Sanderson, 2008).
Another reason, postulated by Deouell, Sacher, and Soroker (2005), was that desk tasks do not reflect the dynamic
character of the natural daily environment, in which relevant stimuli (e.g. background of objects and changing
shadow) occur. That is, in most cases, patients sit andcarry out relatively one-dimensional tasks, e.g. vision fora search task. Patients no longer need to process stimuli
irrelevant to desk tasks and only less sensory information
has to be integrated to successively accomplish tasks. On
the other hand, ADL settings involve dynamic situations
that require patients to integrate external and internal incoming sensory information properly while performing
concurrent activities. Few studies have been reported inwhich the subjects were required to concentrate on environmental differences while performing desk-tasks, andin which the relationship between the results of desk tasks
and ADL performance was analyzed.
Hence, we developed a desk-task setting using a head
mount display (HMD) and a tablet, in which more sensory
integration is needed than in the traditional desk-task setting. The present work is intended to evaluate the clinicalapplicability of the test settings.

Materials and Methods
Subjects
18 patients (14 men and 4 women) with right hemisphere damage were the subjects of this study. Participants gave written informed consent, and the experiments
were approved by the local ethics committee of Sapporo
Medical University. All subjects had undergone a usual
rehabilitation program. The mean age was 64.0 with astandard deviation of 8.9. The score of the Mini-Mental
States of Examination (MMSE) ranged from 18 to 30
and its average ± SD was 26.4 ± 3.3. The mean months
from onset were 2.3 ± 2.4 (ranging from 0.5 to 11). 8 out
of 18 subjects had visual field deficit on confrontation.
10 patients exhibited spatial neglect in at least one task
including cancellation, copying, bisection, and behavior
in daily life. We excluded subjects who had severe dementia, aphagia, or apraxia as well as those who couldn’t
concentrate on successive tasks for about 45 minutes. The
clinical and demographic data are summarized in Table 1.
Patients who were mild to moderate in their severity wereselected because the discrepancy between results of desk
tasks and performance in ADL settings (proposed in the
introduction) occurs in mild patients.
Tasks in traditional settings
Subjects were seated in front of a table, on which
a task sheet was placed in front of their trunk midline.

Asian J Occup Ther 8: 21–29, 2010

Sasaki T et al.

23

Fig. 1. Schematic representation of experimental setting in HMD environment. In HMD setting, the tablet isplaced in front of subjects. Subjects wear HMD during the tasks. Subjects see only a task stimulus,
pen icon and the marks they make on the HMD display by manipulating the pen on the tablet. Thereis no apparent time lag between pen manipulation on the tablet and movement of pen icon on HMD
display.

The following three visuo-spatial tasks were administeredin the traditional setting: a line bisection task, a figure
copying task, and a figure cancellation task consisting of
20 triangles and 20 circles scattered on A4 paper (target“circle”). In the line bisection task, subjects were asked
to mark the midpoint on each line. We analyzed the averaged percent deviation with respect to the true midpoint,
defined as rightward and as a positive value in all trials.
Following Levine’s criteria (Levine, Warach, Benowitz &Calvanio, 1986), we also graded the deviation: less than
9.9% as 0, 10.0% to 39.9% as 1, 40.0% to 69.9% as 2, andmore than 70.0% as 3. In the figure copying task, subjects
copied a daisy. We analyzed the area of parts omitted andscored it 0 if there were no omissions, 1 if less than theleft-most 1/3 was omitted, 2 if more than 1/3 but less than
2/3 was omitted, and 3 for more than 2/3 omission. In the
figure cancellation task, subjects were asked to cancel out
all circles. We analyzed the number of targets canceledout and time taken. The same criteria were used for cancellation. We also calculated the performance score as afunction of the number of canceled targets and time takenusing the following formula: the number of canceled targets × the number of canceled targets / time taken. A higher score was considered to indicate a better performance.

Tasks in HMD setting1) Apparatus and experimental setting
A head mount display (Eye-Trek FMD-250W, Olympus) (HMD) was used. HMD is a type of eye-ware, andonly the task is displayed on it. Its screen resolution was

653×368 pixels: the viewing area was 37.5° (horizontal)
× 21.7° (vertical) of visual angle. Subjects operated a pen
icon displayed on the HMD with a stylus on a tablet. We
also used a tablet (intuos2 i-920 WACOM) with an A4size work space on which subjects conducted tasks withthe stylus. These two apparatuses were connected to a lap
top computer (Winbook WA2200C5, SOTEC) whose refresh rate and screen resolution was 60 Hz and 1024×768
pixels, respectively. Task stimulus for the HMD settings
was made using a drawing application.
A schematic representation of the experimental settings is shown in Fig.1. The computerized stimulus wasprojected on the HMD through a down scan converter,
allowing the experimenter to switch the projection on andoff. The subjects wore the HMD and carried out the tasks
with the stylus on the work area of the tablet. The top left
corner and the bottom right corner of the work area of thetablet corresponded approximately to those of the HMD
display.

2) TaskThe HMD setting includes two sessions. Firstly, tofamiliarize themselves with the use of the HMD and thestylus, subjects carried out a series of trial line drawing
and pointing tasks. In the line drawing task, subjects were
instructed to draw a horizontal line while wearing the
HMD. In the pointing task, they were asked to mark two
black dots presented on the HMD display. Their familiarization was evident if they correctly drew a horizontal
line and marked two dots. After familiarization, subjects

24

HEAD MOUNT DISPLAY AND ATTENTIONAL DISTURBANCE

Table 2. Directional attention behavioral questionnaire
item

score

1 to experience difficulty in finding people or objects on contralesional side
2 to experience difficulty in looking towards contralesional side
3 to forget to eat food on contralesional side of plate
4 to forget to eat food on contralesional side of dish5 to forget to groom or shave on contralesional side of face
6 to experience difficulty in adjusting contralesional side of sleeve
7 to forget to use wheelchair brake on contralesional side
8 to forget to use wheelchair foot-rest on contralesional side
9 to start to transfer without taking foot off contralesional side of foot-rest
10 to bump into something on contralesional side
11 to experience difficulty in finding way towards contralesional side
12 to be unaware of noise or people addressing him/her from contralesional side
13 to orient ipsilesional side when one is called

0. none0. none0. none0. none0. none0. none0. none0. none0. none0. none0. none0. none0. none1. sometime
1. sometime
1. sometime
1. sometime
1. sometime
1. sometime
1. sometime
1. sometime
1. sometime
1. sometime
1. sometime
1. sometime
1. sometime

2. frequently
2. frequently
2. frequently
2. frequently
2. frequently
2. frequently
2. frequently
2. frequently
2. frequently
2. frequently
2. frequently
2. frequently
2. frequently

sum ( 0 / 26 ) =(adapted and revised from Ishiai, S. (1999) and Azouvi, P. et al. (2003) )carried out a figure cancellation task. The number of thetargets (circles) and the distracters (triangles) was thesame as that in the traditional setting. We used the cancellation task in the HMD setting because this cancellation
task has several analytic components (Manly et al., 2009)
and a higher sensitivity to attentional deficit (Azouvi etal., 2002). We applied the same analysis used in the traditional setting.

Overall procedure
Subjects were seated in front of the table. Firstly,
they were asked to conduct tasks in the traditional setting:a line bisection task 5 times for each length, a figure cancellation task and a figure copying task. Then the tablet
was placed and they carried out the familiarization task inthe HMD setting. Finally, the figure cancellation task inthe HMD setting was carried out.
Behavior in ADL
To assess the subjects’ behavioral condition in ADL,
we used two questionnaires. One was designed to assess
the association of behavioral disorders with directional
attentional deficit (Ishiai, 1999; Azouvi et al., 2003), forexample “to bump into something on the contralesionalside,” and “to orient oneself to the ipsilesional side when
one is called.” 13 items were included and each item wasscaled from 0 (never) to 2 (frequently) (Table 2). Therefore, the total score ranged from 0 to 26. Another questionnaire was associated with general attentional deficit(Ponsford & Kinsella, 1991), including “to be slow inmovement,” and “to miss important details in what he/ she is doing.” This questionnaire has 14 items scoredfrom 0 (not at all) to 4 (always) for each item, and 0 to 56
as a total score (Table 3). Therapists who were in chargeof the patients answered these questionnaires.

Data analysis
In the first analysis, we classified subjects into positive groups and negative groups on the basis of the cutoff score for each task: subjects who scored higher than
1 were positive and a 0 score was negative. Subjects
showing attentional deficit on the tasks were identified as
positive and those who didn’t as negative. For the performance score in the figure cancellation task in both test
settings, the cut-off score was the median of the performance score. We compared the scores of each behavioral
questionnaire of the positive group with those of the negative group. Mann-Whitney’s U test was applied for thecomparison.
The second analysis was conducted to identify how
much influence the HMD setting had on attention behavioral disorders. The traditional setting to HMD setting ratio was calculated for their performance score andcompared with the total score of each attention behavioral
questionnaire. Spearman’s rank correlation coefficientwas performed.
To learn whether HMD tasks could be an index ofattention behavioral disorders, a third analysis examinedvariations in the results of tasks and attention behavioral
problems at an individual level.

Results
Positive group vs. negative group
In all tasks performed, the directional attention behavioral score of the subjects who were diagnosed as positive
was significantly higher: total score of the three visuo-spatial tests (p = 0.0009), line bisection (p = 0.0435), copying(p = 0.0341), traditional cancellation (number of omits)(p = 0.0016), traditional cancellation (performance score)(p = 0.0051), and HMD cancellation (performance score)Sasaki T et al.

Asian J Occup Ther 8: 21–29, 201025

Table 3. General attention behavioral questionnaire
item
1 seemed lethargic (i.e. lacking energy)
2 tired easily
3 been slow in movement
4 been slow to respond verbally
5 performed slowly on mental tasks
6 needed prompting to get on with things
7 stared into space for long periods
8 had difficulty concentrating
9 been easily distracted
10 been unable to pay attention to more than one thing at once
11 made mistakes because he/she wasn’t paying attention properly
12 missed important details in what he/she is doing
13 been restless
14 been unable to stick at an activity for very longscore
0. Not at all
0. Not at all
0. Not at all
0. Not at all
0. Not at all
0. Not at all
0. Not at all
0. Not at all
0. Not at all
0. Not at all
0. Not at all
0. Not at all
0. Not at all
0. Not at all

1. Occasionally
1. Occasionally
1. Occasionally
1. Occasionally
1. Occasionally
1. Occasionally
1. Occasionally
1. Occasionally
1. Occasionally
1. Occasionally
1. Occasionally
1. Occasionally
1. Occasionally
1. Occasionally

2. Sometimes
2. Sometimes
2. Sometimes
2. Sometimes
2. Sometimes
2. Sometimes
2. Sometimes
2. Sometimes
2. Sometimes
2. Sometimes
2. Sometimes
2. Sometimes
2. Sometimes
2. Sometimes

3. Almost always
3. Almost always
3. Almost always
3. Almost always
3. Almost always
3. Almost always
3. Almost always
3. Almost always
3. Almost always
3. Almost always
3. Almost always
3. Almost always
3. Almost always
3. Almost always

4. Always
4. Always
4. Always
4. Always
4. Always
4. Always
4. Always
4. Always
4. Always
4. Always
4. Always
4. Always
4. Always
4. Alwayssum ( 0 / 56 ) =(adapted from Ponsford & Kinsella. (1991))

Fig. 2. Behavioral score of positive group and negative group for each task in (a) and (b). For both directional and general attention behavior, the positive group exhibits a much higher score than the negative group.

(p = 0.0003) (see Fig. 2a). The same was true for the general attention behavioral score, except in the figure copying task, in which no difference between the two groups
was found. In the other 5 tasks and indexes, the positive
group achieved a significantly higher score than the negative group: total score of the three visuo-spatial tests (p =0.0012), line bisection (p = 0.0114), traditional cancellation (number of omits) (p = 0.0256), traditional cancellation (performance score) (p = 0.0095), and HMD cancellation (performance score) (p = 0.0003) (see Fig. 2b).

Traditional / HMD ratio and behavior
Although all subjects showed lower performance
scores in HMD tasks, the mean of the traditional / HMD
ratio was 5.6, ranging from 2.0 to 15.5. As shown in
Fig. 3a, subjects with a significantly higher ratio achieved
a higher score in the directional attention questionnaires(r = 0.78, < 0.0005). A similar tendency was found ingeneral attention behavior (r = 0.68, < 0.005; Fig. 3b). A
separate correlation of the HMD task vs. each attentional
behavior score and of traditional cancellation (perfor-

26

HEAD MOUNT DISPLAY AND ATTENTIONAL DISTURBANCE

Fig. 3. Correlation between severity in behavior and traditional / HMD ratio in their performance score in the cancellation task in (a) and (b). In both behavioral scores, subjects who present higher ratio showed more severe
behavioral problems. Each diamond represents one subject.

Table 4. Correlation between tasks and attentional behavior
Attentional Behavior Score
HMD
Cancellation (performance score)
Cancellation (number of omit)
Bisection
Copying

Directional Attention

General Attentionr = 0.75 (p<0.01)
r = 0.65 (p<0.05)
r = 0.84 (p<0.01)
r = 0.47 (p<0.1)
r = 0.54 (p<0.05)

r = 0.78 (p<0.01)
r = 0.56 (p<0.05)
r = 0.58 (p<0.1)
r = 0.52 (p<0.1)
r = 0.5 (p<0.1)(** p < 0.01, * p < 0.05. n.s. : not significant)mance score) vs. attentional behavior score are summarized in Table 4. The correlation between other traditionaltasks, including cancellation as a function of the numberof omits, bisection task and copying task and attentional
behavioral questionnaires are also shown in Table 4. No
significant correlation was found except in cancellation(number of omits) vs. directional attentional behavior (r= 0.84, < 0.01) and in the copying task vs. directional attentional behavior (r = 0.54, < 0.05).

Variations at the individual level
We used the total score of the three visual-spatial
tests and the performance score in the traditional cancellation task and in the HMD task as indexes for behavior
deficit. For directional attention behavior, three subjects
diagnosed as negative in the total score showed more than
one behavioral problem. In the other three subjects, morethan one directional attention behavior problem was evident, whereas they were diagnosed as negative throughthe performance score in the traditional cancellation task.
On the other hand, only one subject who was diagnosed
as negative in the HMD task showed directional attention
behavior, but his score in the behavioral questionnaire
was extremely low (1/26) (Fig. 4a).

8 subjects diagnosed as negative in the total score of
the desk-tasks displayed general attention behavior problems. In 7 subjects, general attention behavioral problem
were evident despite their performance score on the traditional cancellation task being below the cut-off score. For
the HMD task, three subjects who scored higher in thegeneral attention questionnaires were diagnosed as positive. The remaining 6 subjects diagnosed as negative inthe HMD task showed general attention behavioral problems, however their score was not higher than the othersubjects (Fig. 4b).

Discussion
Theoretical framework of the HMD setting
As described in the introduction, we assumed thatenvironmental differences, static in desk-task settings anddynamic in ADL settings, could lead to the discrepancy
whereby patients show abnormalities in ADL but not in
desk-task settings. To evaluate this assumption, we newly
devised a more dynamic task environment than the traditional task environment using a HMD and a tablet, basedon the theory of frame of reference proposed by Karnath(1994).

Asian J Occup Ther 8: 21–29, 2010

Sasaki T et al.

27

Fig. 4. Severity in behavior at the individual level. Left row of each column represents subjects(○) diagnosed as positive,
marks in the right row(□) corresponds to negative. (a) For directional attention behavior, all but one subject diagnosed
as negative by HMD task did not show behavioral problems. (b) For general attention behavior, subjects diagnosed as
negative by the HMD task exhibited lower behavioral score.

According to Karnath (1994), Karnath, Fetter, andNiemeier (1998), and Karnath and Dieterich (2006), humans behave accurately in space by integrating incoming
sensory information such as vision, proprioception, andvestibular sensation, and these should be integrated into
an egocentric reference frame. This successive and concurrent process is the key concept of the HMD setting. We
postulated that a more dynamic task environment could
be accomplished by taxing such a process during testing.
Subjects wear HMD and handle a stylus in the HMD
setting. As shown in Fig.1, the only things subjects candirectly see on the HMD display are task stimulus and thepen icon, which represents the real pen they manipulate
on the tablet. Subjects cannot see the movement of theirhand or upper extremity while operating the pen. Indirect
vision of the hand trajectory induces conflicting visualand proprioceptive signals (Clower & Boussaoud, 2000).
This experimental environment must strongly encourage
subjects to integrate proprioceptive sensation from theirarm and finger movements with vision on the HMD display while testing. In other words, subjects need to reorganize their work space by integrating the proprioceptive
space and visual space while performing the HMD task
(Vakalopoulos, 2007).

Relation between the results of the HMD task and attention behavior
The most interesting result of this study was that inboth directional and general attentional behavior, almost
all the subjects who were classified into the negative
group in the HMD task did not display attentional disturbance in ADL or vice versa. This implies that the HMD
setting has a similar cognitive feature to that of the ADL
environment. As mentioned earlier, the ADL environment
is so dynamic that sensory information relevant to concurrent activity must be integrated (Deouell, Sacher &Soroker, 2005; Thompson & Sanderson, 2008). According to this idea, the present results support our postulationthat the HMD setting induces a dynamic situation and requires subjects to perform much more sensory integration
more than in the traditional setting. In the HMD setting,subjects have to rely more on proprioception to adapt tosensory-motor conflict. In fact, Thompson and Sanderson(2008) have pointed out that one of the reasons why results of the traditional desk-task were not fully congruent with conditions in ADL was that the desk-task wasless dynamic. Tilikete, Rode, Rossetti, Pichon, Li, andBoisson (2001) reported that reorganization of the spatial framework led to amelioration in ADL performance.
Several studies concur with those reports (Karnath, Fetter& Niemeier, 1998; Karnath & Dieterich, 2006; Rorden,
Karnath & Driver, 2001; Niemeier & Karnath, 2003). As
in the HMD environment, in ADL, humans have to adapt

28

HEAD MOUNT DISPLAY AND ATTENTIONAL DISTURBANCE

to a constantly changing dynamic experience by correctly
selecting internal and external cues relevant to the subsequent action. This environmental similarity between
HMD and ADL may have led to the apparent correlation
between performance in the HMD setting and behavioral
disorders in ADL.
Another possible interpretation is provided by Burgess (2000). He insisted that daily activity consists ofmulti-tasking situations. In the HMD setting, subjects
were encouraged to conduct the cancellation task as wellas adapt to the HMD environment. However, the conceptof multi-tasking doesn’t fully explain the present results
because the same results should have been obtained fromthe traditional task setting, as this setting involves multitasking aspects to some degree.
In the present study, only the cancellation task wasused in the HMD setting. Considering that there are several neuropsychological tests available, further studies
incorporating different desk-tasks should be carried out.

Applicability in clinical settings
The present results reveal that although all subjects marked lower performance scores in HMD tasks
compared to traditional cancellation tasks, subjects whoscored above the cut-off in the HMD tasks seldom exhibited both directional and general attention behavioral
problems. This implies that HMD tasks are a more sensitive tool than traditional neuropsychological tests for theevaluation of presence / absence of attentional deficit in
ADL if evaluated by means of the cut-off score used in
the present study.
In recent years, the number of studies using an HMD
or a virtual environment is increasing. Knight and Baber(2007) reported the influence of HMD on posture. Cho,
Ku, Jang, Kim, et al. (2002) and Cho, Ku, Jang, Lee, etal. (2002) developed an attention training system using an
HMD and an HMD device for people with impaired vision (Culham, Chabra & Rubin, 2004). In addition, HMD
could be used to train patients with visuo-spatial problems(Castiello, Lusher, Burton, Glover & Disler, 2004; Kimet al., 2004; Baheux, Yoshizawa, Tanaka, Seki & Handa,
2005; Baheux, Yoshizawa, Seki & Handa, 2006; Glover &Castiello, 2006). In clinical practice in occupational therapy, Weiss, Naveh, & Katz (2003) and Katz et al. (2005)
introduced a training system for patients with spatial neglect to navigate road traffic safely. Almost all of thesestudies were addressing the issues of therapy or intervention as well as simple evaluation (the presence / absenceof a certain symptom). To the best of our knowledge, few
studies have addressed the issue of clinical applicability
through establishment of an index for attentional behavioral problems in everyday life.
As seen in Fig. 4, subjects who were classified as

negative according to their total score and performance
score in traditional cancellation showed attentional behavioral problems. By these criteria, the total score of thethree visuo-spatial tasks and performance score in traditional cancellation can’t be an index of behavioral problems: no data exists to the contrary. On the other hand,
HMD differentiated those subjects. As mentioned by Sasaki et al. (2005), changing the environment under whichtasks are conducted rather than changing the task stimulus
itself could account for the present results.
In conclusion, the present preliminary study would
appear to demonstrate that tasks carried out in the HMD
setting can function as a useful index of attentional behavioral problems.

References
Azouvi, P., Samuel, C., Louis-Dreyfus, A., Bernati, T., Bartolomeo, P., Beis, JM., et al. (2002). Sensitivity of clinicaland behavioral tests of spatial neglect after right hemisphere stroke. Journal of Neurology, Neurosurgery & Psychiatry. 73, 160–166. [Medline] [CrossRef]
Azouvi, P., Olivier, S., de Montety, G., Samuel, C., LouisDreyfus, A., & Tesio, L. (2003). Behavioral Assessment of
Unilateral Neglect: Study of the Psychometric Propertiesof the Catherine Bergego Scale. Archives of Physical Medicine and Rehabilitation. 84, 51–57. [Medline] [CrossRef]
Baheux, K., Yoshizawa, M., Tanaka, A., Seki, K., & Handa, Y.
(2005). Diagnosis and rehabilitation of hemispatial neglectpatients with virtual reality. Technology and Health Care.
13, 245–260. [Medline]
Baheux, K., Yoshizawa, M., Seki, K., & Handa, Y. (2006).
Virtual reality pencil and paper tests for neglect: a protocol. Cyberpsychology Behavior. 9, 192–195. [Medline][CrossRef]
Burgess, PW. (2000). Strategy application disorder: the roleof the frontal lobes in human multitasking. PsychologicalResearch. 63, 279–288. [Medline] [CrossRef]
Castiello, U., Lusher, D., Burton, C., Glover, S., & Disler, P.
(2004). Improving left hemispatial neglect using virtual
reality. Neurology. 62, 1958–1962. [Medline]
Cho, BH., Ku, J., Jang, D., Kim, S., Lee, Y., Oh, M., et al.
(2002). The effect of virtual reality cognitive training forattention enhancement. Cyberpsychology & Behavior. 5,
129–137. [Medline]
Cho, BH., Ku, J., Jang, D., Lee, J., Oh, M., Kim, H., et al.
(2002). Clinical test for attention enhancement system.
Stud Health Technol Inform. 85, 89–95. [Medline]
Clower, DM., & Boussaoud, D. (2000). Selective use of perceptual recalibration versus visuomotor skill acquisition.
Journal of Neurophysiology. 84, 2703–2708. [Medline]
Culham, LE., Chabra, A., & Rubin, GS. (2004). Clinical performance of electronic, head-mounted, low-vision devices. Ophthalmic and Physiological Optics. 24, 281–290.
[Medline] [CrossRef]
Deouell, LY., Sacher, Y., & Soroker, N. (2005). Assessment ofAsian J Occup Ther 8: 21–29, 2010

spatial attention after brain damage with a dynamic reaction time test. Journal of the International Neuropsychological Society. 11, 697–707. [Medline] [CrossRef]
Glover, S., & Castiello, U. (2006). Recovering space in unilateral neglect: A neurological dissociation revealed byvirtual reality. Journal of Cognitive Neuroscience. 18,
833–843. [Medline] [CrossRef]
Ishiai, S., editor.(1999). Behavioral inattention test. Japaneseedition ©1999. Tokyo, Japan: Shinkoh Igaku Shuppan.
Karnath, HO. (1994). Disturbed coordinate transformation in
the neural representation of space as the crucial mechanism leading to neglect. Neuropsychological Rehabilitation. 4, 147–150. [CrossRef]
Karnath, HO., Fetter, M., & Niemeier, M. (1998). Disentangling gravitational, environmental, and egocentric reference frames in spatial neglect. Journal of Cognitive Neuroscience. 10, 680–690. [Medline] [CrossRef]
Karnath, HO., & Dieterich, M. (2006). Spatial neglect - a vestibular disorder? Brain. 129, 293–305. [Medline] [CrossRef]
Katz, N., Ring, H., Naveh, Y., Kizony, R., Feintuch, U., &Weiss, PL. (2005). Interactive virtual environment training
for safe street crossing of right hemisphere stroke patientswith spatial neglect. Disability and Rehabilitation. 27,
1235–1244. [Medline] [CrossRef]
Kim, K., Kim, J., Ku, J., Kim, DY., Chang, WH., Shin, DI.,et al. (2004). A virtual reality assessment and training system for unilateral neglect. CyberPsychology Behavior. 7,
742–749. [Medline] [CrossRef]
Knight, JF., & Baber, C. (2007). Effect of head-mount displays
on posture. The Journal of the Human Factors and Ergonomics Society. 49, 797–807. [CrossRef]
Levine, DN., Warach, JD., Benowitz, L., & Calvanio, R.
(1986). Left spatial neglect: effect of lesion size and premorbid brain atrophy on severity and recovery following
right cerebral infraction. Neurology. 36, 362–366. [Medline]
Manly, T., Dove, A., Blows, S., George, M., Noonan, MP.,
Teasdale, TW., et al. (2009). Assessment of spatial neglect:

Sasaki T et al.

29

scoring star cancellation performance from video recordings - method, reliability, benefit, and normative data. Neuropsychology. 23, 519–528. [Medline] [CrossRef]
Niemeier, M., & Karnath, HO. (2003). Stimulus-driven andvoluntary saccades are coded in different coordinate systems. Current Biology. 13, 585–589. [Medline] [CrossRef]
Ponsford, J., & Kinsella, G. (1991). The use of a rating scale ofattentional behaviour. Neuropsychological Rehabilitation.
1, 241–257. [CrossRef]
Rorden, C., Karnath, HO., & Driver, J. (2001). Do neck-proprioceptive and caloric-vestibular stimulation influence
covert visual attention in 49 normals, as they influence visual neglect? Neuropsychologia. 39, 364–375. [Medline][CrossRef]
Sasaki, T., Sengoku, Y., Nakajima, S., Sugama, K., & Kitajima, H. (2005). The correlation between the results of theline bisection test with the test seat placed in different positions regarding the midsagittal plane of the USN patientsand their ADL. The journal of Japanese association of occupational therapists, 24, 584–592.
Thompson, MB., & Sanderson, PM. (2008). Multisensory integration with a head-mount display: sound delivery andself-motion. The Journal of the Human Factors and Ergonomics Society. 50, 789–800. [CrossRef]
Tilikete, C., Rode, G., Rossetti, Y., Pichon, J., Li, L., & Boisson, D. (2001). Prism adaptation to rightward optical deviation improves postural imbalance in left-hemiparetic
patients. Current Biology. 11, 524–528. [Medline] [CrossRef]
Vakalopoulos, C. (2007). Unilateral neglect: a theory of proprioceptive space of a stimulus as determined by the cerebellar component of motor efference copy (and is autism
a special case of neglect). Medical Hypotheses. 68, 574–
600. [Medline] [CrossRef]
Weiss, PL., Naveh, Y., & Katz, N. (2003). Design and testingof a virtual environment to train stroke patients with unilateral spatial neglect to cross a street safely. Occupational
Therapy International. 10, 39–55. [Medline] [CrossRef]

■Original Article
Association between Psychiatric Symptoms andDifficulty with Computer Operation in Schizophrenia:
Analysis Using a Questionnaire and a Computer
Operation Skills Test
Kaede Morimoto, OTR, MBA, PhD, Kayano Yotsumoto, OTR, PhD,
Takeshi Hashimoto, MD, PhD
Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences

Abstract: The objective of the study was to identify the reasons behind difficulties in learning computer operation skills
among persons with schizophrenia. Twelve persons with schizophrenia and 14 control subjects without neuropsychiatricdiseases took a course in personal computer usage consisting of ten 60-minute weekly lessons. All subjects took a computer
operation skills test before and after the course. For the persons with schizophrenia, relationships between the test results
and scores on the Brief Psychiatric Rating Scale (BPRS) were analyzed quantitatively. Difficulties with computer operation were identified using a questionnaire and analyzed qualitatively. The mean test scores after the course increased for thecontrol group, but were unchanged for the persons with schizophrenia. There was no correlation between the total BPRS
score and the test results, but ‘positive symptoms’ scores were negatively correlated with test scores and the number of input
letters. In the qualitative analysis, 24 items in 6 categories were identified as reasons for difficulty with computer operation,with 11 of these items being unique to the persons with schizophrenia. These findings indicate the need to develop a computer learning course that is compatible with the characteristics of persons with schizophrenia.
Key words: computer operation skills, psychiatric symptoms, schizophrenia(Asian J Occup Ther 8: 31–38, 2010)

Introduction
Schizophrenia is a mental disorder with chronic
marked disabilities. Functioning in an ordinary workplace is often difficult for persons with schizophrenia due
to psychiatric symptoms that accompany the condition.
However, many such persons want to become meaningfully employed. On the other hand, Marwaha and Johnson(2004) reported that work can both improve psychiatric
symptoms and produce better QOL outcomes for persons
with schizophrenia. Growing evidence has also shownthat work and psychiatric symptoms influence each other(Harvey et al., 1996).
Received: 22 December 2009, Accepted: 2 November 2010
Corresponding to: Kaede Morimoto, Division of Psychiatric Rehabilitation, Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Tomogaoka, Suma-ku, Kobe 654-0142,
Japan
e-mail: kaede.morimoto.pc@r4.dion.ne.jp© Japanese Association of Occupational Therapists

In recent years, computers have become widelyused in all aspects of work, entertainment and life. Basic computer operation skills are required in many work
situations and many persons with schizophrenia want tomaster these skills. However, this may be difficult due tothe psychiatric symptoms that accompany schizophrenia,
and difficulties may arise even in jobs that require only
simple computer operation skills. For this reason, it isnecessary to develop a computer learning program thatis suitable for persons with schizophrenia. This would be
useful in vocational training programs, in increasing employment opportunities and in improving social life. To
our knowledge, the aspects of computer operation withwhich persons with schizophrenia have difficulty, theassociation between difficulty with computer operationand psychiatric symptoms and the most efficient method
through which these persons can acquire computer operation skills have not previously been investigated.
Our recent study, we determined quantitatively if
persons with schizophrenia have learning difficulties

32

PSYCHIATRIC SYMPTOMS AND DIFFICULTY WITH COMPUTER OPERATION

when taking standard computer learning course (Morimoto, Yotsumoto & Hashimoto, 2009). We evaluated thetypes of errors made by persons with schizophrenia anda control group in learning computer operation skills andcompared the two groups’ scores on a computer operation
skills test. Moreover, a qualitative analysis of the learning difficulties of persons with schizophrenia was performed to identify reasons for difficulties with computer
operation (Morimoto et al., 2009). The mixed method(Creswell, 2007) was employed, in which quantitativeand qualitative data were collected in parallel in the same
step, with overlapping of the results in the analytical step.
In this study, we examined if the severity of psychiatric
symptoms made the learning of computer operation skills
more difficult and whether certain kinds of psychiatric
symptoms were associated with the learning difficulties.
Correlations of these results with the Brief PsychiatricRating Scale (BPRS) scores were examined for persons
with schizophrenia.

Subjects and Methods
Subjects
The 26 subjects were recruited by a public advertisement from people who were looking for a job. They
included 12 persons diagnosed with schizophrenia basedon ICD-10 and 14 control subjects without neuropsychiatric diseases or substance-related disorders. The 12
persons with schizophrenia (9 men and 3 women) had amean BPRS score of 26.1 ± 6.6 and all were stable outpatients. Their mean age was 35.3 ± 6.0 years old andthey had a mean school attendance of 13.4 ± 1.9 years.
The 14 controls (1 man and 13 women) had a mean ageof 40.5 ± 7.0 years old and a mean school attendance of
13.7 ± 1.5 years. Age and school attendance did not differ significantly between the groups, but there were moremen in the schizophrenia group and more women in thecontrol group. This study was approved by the Medical
Ethics Committee of Kobe University Graduate School of
Medicine, and consent for participation in the study andpublication of the results was obtained from the subjects.
Evaluation of psychiatric symptoms
The severity of the persons with schizophrenia wasevaluated by their attending physicians using the Japanese Version of the BPRS, which consists of 4 symptom categories (Mueser, Curran & McHugo, 1997) and
16 items (Miyata, Fujii, Inagaki, Inada & Yagi, 1995;
McEvoy, 2002). In addition to the total score, scores for
Positive symptoms: Grandiosity, Suspiciousness, Hallucinatory behavior, and Unusual thought content, Negative
symptoms: Emotional withdrawal, Motor retardation,
Uncooperativeness, and Blunted affect, Emotional symp-

toms: Somatic concern, Anxiety, Guilt feeling, Depressive mood, and Hostility, and Disorganized symptoms:
Conceptual disorganization, Tension, Mannerisms, andposturing were calculated.

Content of the computer learning course
The subjects took the standard Microsoft Word 2003
computer learning program consisting of ten 60-minutelessons between January and April, 2008. The subjects
took the class about once a week on days and at timesof their choice. A self-study system was used in whicha maximum of 8 students participated in one class, with
one instructor present per 1–3 students. The persons withschizophrenia and the control group took the same class.
The instructors did not actively intervene, and responded
only when a participant asked a question.
Evaluation of learning using a computer operation
skills test
To measure the effect of the computer learning program, a computer operation skills test was performed
before and after the course. In this test, word processing
skills in Microsoft Office Word 2003 were evaluated. The
subjects created a document, as shown in Appendix 1.
The evaluation method utilized a points system, in which
points were added for accurate entries and deducted forerrors. A total of 196 points were possible for accurate
entries, and if the errors exceeded 196 a score of zero was
assigned (therefore, a negative total score was not possible). The test time was set at 10 minutes. The same test
was administered before and after the course. The speedof computer operation was evaluated by the number ofkeyboard key strokes, and the accuracy of operation was
evaluated by the number of errors. The results between
the groups were compared, and correlations between the
results and symptom categories and items were analyzed
for the persons with schizophrenia.
Statistical analysis
The learning effect measured using the computer
operation skills test was evaluated using the total scoreson the test before and after the course. These scores werecompared between the persons with schizophrenia andthe control group by the Mann-Whitney test and within
the groups by the Wilcoxon signed-rank test. The numbers of input letters and errors were similarly compared.
The association between BPRS scores and test results wasinvestigated using Spearman rank correlation. The significance level was set at less than 0.05. SPSS ver. 11.5J for
Windows was used for data analysis.

Morimoto K et al.

Asian J Occup Ther 8: 31–38, 2010

Qualitative evaluation of the computer learning
courseAs previously stated (Morimoto et al., 2009), to evaluate the reasons for difficulty with computer operation, a
qualitative descriptive analysis of the computer learning
course was performed, based on the content analysis technique described by Krippendorff (1989). A free descriptive questionnaire (Kayama, 2007) concerning difficulties
with computer operation was given to the persons withschizophrenia and the control group at the end of each lesson. The instructors also completed a questionnaire concerning the questions they were asked, and the Microsoft
Word 2003 documents that were saved in the course by
subjects were collected. These documents were arranged
and analyzed to extract the reasons for difficulty using thefollowing process.
Phase 1: Inferring the reasons for difficulty for eachstudy task and each subjecta) Creation of a database of difficulties with computer operation
The database was created from subjective information provided by the persons with schizophrenia and thecontrol group based on their answers to the subjects’ questionnaires and objective information in the instructors’questionnaires.
b) Verification of the database
The authors and instructors verified that the questionnaire answers reflected difficulty in the course, using
the documents that the subjects saved. Each difficulty
was matched with a computer operation that the subject
performed. To discern the difficulties that the subjects
showed with actual computer operation, these situations
were reproduced and the difficulties of following the operation process were carefully examined. A difficulty that
could not be clearly reproduced was excluded.
c) Simplification of the database
Sentences were extracted from the database and simplified with care as not to change their significance. The
simplified sentences were added to the database as a third
category of difficulty.
d) Inferring the reasons for difficulty of each studytask
The reasons for difficulty of each study task were inferred from the difficulties. These reasons for difficulty
were added to the database as a fourth category for eachstudy task.
Phase 2: Systematization of all reasons for difficultye) Summarizing the reasons for difficulty
Since different representations were included in theinferred reasons for difficulty, those with the same significance were reduced to one representation. Summarizing
the database was performed separately for persons withschizophrenia and the control group, and was carried

33

Table 1. Total scores for the computer operation skills test
Persons withschizophrenia(N = 12)Control subjects(N = 14)

Before the course
Total score
number of input lettersnumber of errors

42.4 ± 35.9
93.7 ± 65.9
10.5 ± 7.7

38.0 ± 36.9
86.0 ± 71.1
11.5 ± 7.5

After the course
Total score
number of input lettersnumber of errors

52.6 ± 29.1
120.7 ± 64.0*
17.5 ± 19.3

71.9 ± 32.9**
148.6 ± 62.3**
7.7 ± 6.0*

The notation of value is mean ± standard deviation. Total score =(number of input letters - number of errors) × 100 / 196 (maximum
number of input letters). * p < 0.05, ** p < 0.01. (Morimoto, Yotsumoto & Hashimoto, 2009).

out until new reasons for difficulty did not arise in eithergroup.
f) Categorization of the reasons for difficulty
We formed a conglomerate of the data and categorized the data based on significant identity and similarity.
The reliability and validity of the approach describedin a) through f) were reviewed by OTs with extensive
experience in qualitative research in mental disorders toincrease the reliability of data interpretation. In carryingout step f), the categorization and category naming of thereasons for difficulty were performed by five researchers to increase the reliability. These persons included
one psychiatrist and four OTs with ten years or more ofclinical experience with mental disorders. These five persons were requested to individually check the semantic
contents of the reasons for difficulty, to categorize all thereasons and to give a name to each category. After the
categorization was completed, the category table was sent
to all five persons and their consent was obtained for eachcategory and name.

Results
Computer operation skills test
The total scores for the computer operation skills
test did not differ significantly between the persons withschizophrenia and the control group before or after thecourse (Table 1). In within-group comparisons, the mean
test score improved significantly after the course for thecontrol group (38.0 ± 36.9 vs. 71.9 ± 32.9 points, p <0.005), but did not change significantly for the persons
with schizophrenia (42.4 ± 35.9 vs. 52.6 ± 29.1 points),
indicating no significant learning effect.

34

PSYCHIATRIC SYMPTOMS AND DIFFICULTY WITH COMPUTER OPERATION

Table 2. Spearman’s rank correlation coefficient between BPRS and the computer operation skills test after thecourse results of the persons with schizophrenia
Computer operation skill test after
the course results

BPRS statistics
BPRS item
MeanStandard
Deviation

Total score

The numberof input letters

The numberof errors

26.1
5.9

6.921
1.929

–0.193–0.602*–0.239–0.684*–0.190–0.425Grandiosity
Suspiciousness
Hallucinatory behavior
Unusual thought content(2)Negative symptoms

1.4
1.3
1.3
1.9
6.4

0.669
0.866
0.492
1.165
2.678

–0.118–0.219–0.436–0.600*0.045–0.095–0.263–0.565–0.692*0.158–0.169–0.351–0.283–0.352
0.424

Emotional withdrawal
Motor retardation
Uncooperativeness
Blunted affect(3)Emotional symptoms

1.6
1.8
1.3
1.8
9

0.515
1.357
0.492
1.215
0.539

–0.098–0.0270.103–0.0080.051–0.025
0.073
0.283
0.028
–0.085

0.394
0.335
0.463
0.047
–0.420Somatic concern
Anxiety
Guilt feeling
Depressive mood
Hostility(4)Disorganized symptoms

2
2.6
1.8
1.3
1.3
4.8

0.953
1.165
0.866
0.492
0.651
0.638

0.017
–0.053–0.1970.359–0.069–0.177–0.102–0.107–0.2750.308–0.177–0.069–0.281–0.166–0.174–0.180
0.125
0.125

1.8
1.7
1.3

1.138
0.651
0.651

–0.181–0.027–0.374–0.1500.223–0.483–0.0980.585*–0.338BPRS total score(1) Positive symptoms

Conceptual disorganization
TensionMannerisms and posturing

The number of samples of the persons with schizophrenia is N = 12. (1)~(4) are total scores for symptom categories. * p < 0.05, ** p < 0.01.

Number of input letters on the computer operation
skills test
The numbers of input letters in the computer operation skills test performed before and after the course were
93.7 ± 65.9 and 120.7 ± 64.0, respectively, for the persons
with schizophrenia, and 86.0 ± 71.1 and 148.6 ± 62.3, respectively, for the control group (Table 1). These results
did not show a significant difference between the twogroups before or after the course. In within-group comparisons, the number of input letters increased significantly after the course for both the persons with schizophrenia(p < 0.05) and for the control group (p < 0.005).
Number of errors on the computer operation skills test
There was no significant difference between the twogroups in the number of errors made on the computer operation skills test before or after the course (Table 1). In
within-group comparisons, the number of errors made by
the persons with schizophrenia showed a tendency to increase from 10.5 ± 7.7 before the course to 17.5 ± 19.3
at the completion of the course, although the difference
was not significant. For the control group, the number of
errors significantly decreased from 11.5 ± 7.5 before thecourse to 7.7 ± 6.0 after the course (p < 0.05).

Correlation between BPRS score and the computer
operation skills test
The total BPRS score was not associated with thetotal score on the computer operation skills test or with
the number of input letters and errors (Table 2). However,significant negative correlations were found in the scoresfor the BPRS category ‘Positive symptoms’ and the item
‘Unusual thought content’ with total test scores and thenumber of input letters. A significant positive correlation
was found between the scores for the item ‘Tension’ andthe number of errors.
Reasons for difficulty in computer operation skills
The persons with schizophrenia identified 24 reasons for difficulty with computer operation (Table 3), of
which 13 were also given by the control group, and 11
were unique to the persons with schizophrenia. The 24
difficulties were divided into the following 6 categories:‘Ability to understand’, ‘Attention functions’, ‘Memory’,‘Motor functions’, ‘Problem-solving skills when difficulties arise’, and ‘Other disease characteristics’. The last
two of these categories were found only for persons withschizophrenia.

Morimoto K et al.

Asian J Occup Ther 8: 31–38, 201035

Table 3. Reasons for difficulties with computer operation reported by persons with schizophrenia
Reason for difficulty

Category

Cannot understand words (oral).
Cannot understand sentences.
Cannot understand a concept (such as a folder or file).
*Cannot understand when the text display is different from that on the Computer.
*Cannot understand what they need to know.

Ability to understandUnable to find differences in the detailed display.
Cannot appreciate small differences.
Cannot grasp a lot of information at once.
Monitoring failure (misrecognition).
Monitoring failure (oversight).
*Anxiety disturbs work (cannot keep a clear mind).
*Mind wanders from one thing (cannot focus).

Attention functions

Cannot remember the Roman alphabet.
Cannot learn new terms (input functions).
Cannot memorize (holding functions).

MemoryCannot drag.
Unable to set the pointer in the correct area.
*Cannot click properly (such as a double click).

Motor functions*Rely on their own resources rather than seek out other solutions when theyencounter something they do not understand.
*Physical symptoms emerge if something goes wrong.
*Irritation disturbs work if something goes wrong.

Problem-solving skills when difficulties arise*Easily become tired.
*Auditory hallucination disturbs work.
*Anxiety due to technical terms.

Other disease characteristics* Difficulty found in persons with schizophrenia, but not in control subjects. (Modified from Morimoto, Yotsumoto & Hashimoto,2009).

Discussion
Quantitative analysis
The total scores on the computer operation skills test
increased from before to after the course for the control
group, but did not change significantly for persons withschizophrenia. The number of input letters increased forthe persons with schizophrenia, but the number of errors
also increased, which may have resulted in the absence ofan increase in the total score. Thus, acquiring the ability
to input letters does not indicate an improvement in accuracy of computer operation as the course progressed.
Therefore, the standard computer learning course may
not improve the computer operation skills of persons withschizophrenia.
Evaluation of the association between BPRS scoresand computer operation skills in persons with schizophrenia suggested that the total computer operation skills testscore and the number of input letters decreased as the severity of ‘Positive symptoms’, and particularly ‘Unusual
thought content’ increased, and that the number of errors
increased as the severity of ‘Tension’ increased.
‘Unusual thought content’, which was observed in
the computer learning course, include delusions, thought

insertion, thought withdrawal, thought broadcast, etc. The
number of input letters may be due to the characteristic of‘Unusual thought content’. Examples of ‘Tension’ include
nervousness, agitation, finger tremors, etc. As persons
with schizophrenia experience tense posture, restlessness,
and anxiety, it is conceivable that the number of errors
increase.
These findings suggest that persons with schizophrenia are more likely to operate a computer effectively when
their positive symptoms are controlled, and that reductionof ‘Tension’ will decrease the number of errors.

Qualitative analysis
More reasons for difficulty with computer operation
were reported by the persons with schizophrenia than by
the control group. The persons with schizophrenia had
difficulty with all items with which the control group also
had difficulty; thus, no reported difficulty was unique tothe control group.
An impaired ability to understand is a characteristicof persons with schizophrenia (Weickert et al., 2000; Harvey & Sharma, 2002). Such persons are too concernedwith details and cannot grasp the overall view. The persons with schizophrenia made comments such as ‘Cannot

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PSYCHIATRIC SYMPTOMS AND DIFFICULTY WITH COMPUTER OPERATION

understand when the text display is different from that on
the PC’ and ‘Cannot understand what they need to know’,
reflecting their reduced ability in computer operation.
Persons with schizophrenia also have difficulty maintaining attention (Heinrichs & Zakzanis, 1998; Medalia,
Revheim, & Herlands, 2008), and this was also apparent
in the learning of computer operation skills.
Persons with schizophrenia exhibit impairment ofmotor and tactile dexterity (Heinrichs & Zakzanis, 1998),
with slow and unskilled motions (Hiruta, 2007) and slow
learning of movement and a high frequency of movement
errors (Walker, Lewis, Gold, Loewy & Palyo, 1999). In
our study, only persons with schizophrenia had difficultywith ‘Cannot click properly (such as a double click)’, supporting the presence of motor dysfunction.
Persons with schizophrenia have also been reported
to have disturbance of memory (Saykin et al., 1991; Gold,
Randolph, Carpenter, Goldberg & Weinberger, 1992;
Heinrichs & Zakzanis, 1998; Harvey & Sharma, 2002;
Medalia et al., 2008), but the controls also had difficultywith all items in the category of ‘Memory’. Therefore, theresults do not indicate a particular difficulty with memory
associated with learning computer operation skills in persons with schizophrenia. This may be because all people
go through the same process to memorize unfamiliar
terms and techniques, and this may account for the difficulties in this area being common to the two groups. Thisfinding is also consistent with a report showing no significantly greater loss of acquired information by persons
with schizophrenia compared to the control group (Cirillo& Seidman, 2003).
Difficulties with problem-solving in persons withschizophrenia when encountering a difficulty in task performance have also been found in previous reports (Heinrichs & Zakzanis, 1998; Weickert et al., 2000; Green etal., 2004; Medalia et al., 2008). Our subjects reported thereasons for difficulty in learning computer operation skills
using statements such as ‘Rely on their own resources
rather than seek out other solutions when they encountersomething they do not understand’, ‘Physical symptoms
emerge if something goes wrong’, and ‘Irritation disturbs
work if something goes wrong’. These statements wereunique to persons with schizophrenia and were categorized into ‘Problem-solving skills when difficulties arise’,
which reflects the disease characteristics.
The categories of ‘Other disease characteristics’,‘Easily become tired’, ‘Auditory hallucination disturbs
work’ and ‘Anxiety due to technical terms’ were also
identified as unique to persons with schizophrenia andmay have a direct association with the disease characteristics.

Overlap of the results of quantitative and qualitative
analysis
In quantitative analysis, ‘Positive symptoms’ influenced the difficulty in learning computer operation skills,
which indicates the need for medical improvement of thepsychiatric symptoms. The number of input letters increased for the persons with schizophrenia, but the number of errors also increased after the standard computer
learning course. It seems that difficulty maintaining attention to errors or omissions through self-monitoring
greatly influenced the increase in the number of errors.
Therefore, the qualitative results clarify the difficulty
maintaining attention in schizophrenia, as indicated bycomments such as ‘Cannot appreciate small differences’,‘Monitoring failure (misrecognition)’ and ‘Monitoring
failure (oversight)’. Furthermore, persons with schizophrenia reduce problem-solving skills when difficulties
arise, based on comments such as ‘Rely on their own resources rather than seek out other solutions when they encounter something they do not understand’, and this may
also have led to poor self-monitoring and a consequent
increase in the number of errors.
The information obtained from the quantitative andqualitative studies suggests that measures focusing on thetwo categories of ‘Attention functions’ and ‘Problem-solving skills when difficulties arise’ are important for promoting computer learning in persons with schizophrenia.
Many approaches are currently used to improve cognitive deficits in schizophrenia (Dixon et al., 2009). Development of a computer learning program which incorporates specific measures that permit self-monitoring oferrors and provides concrete approaches to effective problem-solving is important for persons with schizophrenia
to learn computer operation skills efficiently. Inclusionof these elements in the program may allow the person
to overcome difficulty maintaining attention and solving
problems when difficulties arise.
The difficulties faced by the control group may besolved by improvement of the course, which is currently
in progress, and this may also solve some learning difficulties of the persons with schizophrenia. However, this will
not resolve all the problems, and it is important to addressdifficulties that are unique to persons with schizophrenia.
In this study, comparisons were made between persons with schizophrenia and a control group regarding
their reported difficulties in learning computer operation
skills. However, the number of subjects was small and thefemale: male sex ratio in the control group was higher thanthat for the persons with schizophrenia. In addition, all the
persons with schizophrenia were stable cases. Given theselimitations, it will be important to continue this study withadditional persons with schizophrenia including thosewith a greater severity of symptoms and impairments.

Asian J Occup Ther 8: 31–38, 2010

Conclusion
Quantitative and qualitative comparisons of learning of computer operation skills by persons with schizophrenia and a control group suggested that the symptomsof schizophrenia have an influence on this process. Persons with schizophrenia had more difficulties in learning
computer operation skills, and the reasons for these difficulties were characteristic of the disease. These findings
indicate the need to develop a computer learning coursethat is compatible with the characteristics of persons withschizophrenia.
Acknowledgements: The authors wish to acknowledge
the contribution of Ms. Yoko Okui and Ms. Yuko Kitaoka.
We also wish to thank the persons with schizophrenia whojoined this study, their attending psychiatrist for the BPRS
assessment, and the staff of Kobe University Graduate
School of Health Science for their support and assistance.

References
Cirillo, MA., & Seidman, LJ. (2003). Verbal declarative memory dysfunction in schizophrenia: from clinical assessment
to genetics and brain mechanisms. Neuropsychology Review. 13, 43–77. [Medline] [CrossRef]
Creswell, JW. (2007). Chapter 11: Procedure of the mixed
method. In So, K., & Morioka, K. (Trans.), Research design: Qualitative, Quantitative, and Mixed methods (pp.
233-255). Tokyo: Japanese Nursing Association Publishing (in Japanese).
Dixon, LB., Dickerson, F., Bellack, AS., Bennett, M., Dickinson, D., Goldberg, RW., et al. (2009, December, 2). The
2009 Schizophrenia PORT Psychosocial Treatment Recommendations and Summary Statements. Schizophrenia
Bulletin, Retrieved December 11, 2009, from http://schizophreniabulletin.oxfordjournals.org/cgi/reprint/36/1/48.
Gold, JM., Randolph, C., Carpenter, CJ., Goldberg, TE., &Weinberger, DR. (1992). Forms of memory failure inschizophrenia. Journal of Abnormal Psychology. 101,
487–494. [Medline] [CrossRef]
Green, MF., Nuechterlein, KH., Gold, JM., Barch, DM., Cohen, J., Essock, S., et al. (2004). Approaching a consensus
cognitive battery for clinical trials in schizophrenia: the
NIMH-MATRICS conference to select cognitive domains
and test criteria. Biological Psychiatry. 56, 301–307.
[Medline] [CrossRef]
Harvey, PD., Lombardi, J., Leibman, M., White, L., Parrella, M., Powchik, P., et al. (1996). Cognitive impairment
and negative symptoms in geriatric chronic schizophrenic
patients: a follow-up study. Schizophrenia Research. 22,
223–231. [Medline] [CrossRef]

Morimoto K et al.

37

Harvey, PD., & Sharma, T. (2002). Understanding and treating
cognition in schizophrenia: a clinician’s handbook. London: Martin Dunitz Ltd.
Heinrichs, RW., & Zakzanis, KK. (1998). Neurocognitive deficit in schizophrenia: a quantitative review of the evidence.
Neuropsychology. 12, 426–445. [Medline] [CrossRef]
Hiruta, G. (2007). Chapter 1: Behavioral characteristics of patients with Schizophrenia. In Behavioral characteristics
of patients with schizophrenia: Support and ICF (pp. 26).
Tokyo: Kongo Shuppan (in Japanese).
Kayama, M. (2007). Chapter 3: Method of collecting qualitative data, Chapter 4: Analysis of qualitative data. In The
note of practicing qualitative research: the clue and point
for proceeding with research process (pp. 28–49). Tokyo:
Igaku-Shoin (in Japanese).
Krippendorff, K. (1989). Chapter 4: Planning logic of analysis design. In Mikami, S., Shino, N., & Hashimoto, Y.
(Trans.), Content analysis: An introduction to its methodology (pp. 67–77). Tokyo: Keiso Shobo (in Japanese).
Marwaha, S., & Johnson, S. (2004). Schizophrenia and employment. Soc Psychiatry Psychiatr Epidemiol. 39, 337–
349. [Medline] [CrossRef]
McEvoy, JP. (2002). Brief Psychiatric Rating Scale (BPRS). In
Barnes, T. R., & Someya, T. (Trans.), Guide to assessment
scales in Schizophrenia (pp. 2b1–2b5). Tokyo: Janssen
Pharmaceutical (in Japanese).
Medalia, A., Revheim, N., & Herlands, T. (2008). Remediation of cognitive deficits in psychiatric patients: a clinician’s manual. Tokyo: Seiwa Shoten.
Miyata, R., Fujii, Y., Inagaki, A., Inada, T., & Yagi, G. (1995).
Reliability of the Japanese version of the Brief PsychiatricRating Scale (BPRS). Clinical Evaluation. 23, 357–367.
Morimoto, K., Yotsumoto, K., & Hashimoto, T. (2009). Computer operation skills in persons with schizophrenia: aqualitative analysis. Bulletin of Health sciences Kobe 25,
Kobe University, Kobe, Hyogo-Japan (in Japanese).
Mueser, KT., Curran, PJ., & McHugo, GJ. (1997). Factor
structure of the brief psychiatric rating scale in schizophrenia. Psychological Assessment. 9, 196–204. [CrossRef]
Saykin, AJ., Gur, RC., Gur, RE., Mozley, PD., Mozley, LH.,
Resnick, SM., et al. (1991). Neuropsychological functionin schizophrenia. Selective impairment in memory andlearning. Archives of General Psychiatry. 48, 618–624.
[Medline] [CrossRef]
Walker, E., Lewis, N., Gold, JM., Loewy, R., & Palyo, S.
(1999). Motor dysfunction and risk for schizophrenia. Development and Psychopathology. 11, 509–523. [Medline][CrossRef]
Weickert, TW., Goldberg, TE., Gold, JM., Bigelow, LB.,
Egan, MF., & Weinberger, DR. (2000). Cognitive impairments in patients with schizophrenia displaying preservedand compromised intellect. Archives of General Psychiatry. 57, 907–913. [Medline] [CrossRef]

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Appendix 1