■ORIGINAL ARTICLE

Influence of Shoulder Joint Function
and Postoperative Subjective Symptoms
on Health Related QOL of Breast Cancer Patients
Tetsuya Sano1, 2, Ryota Izumi3, Motohiro Ogawa4, Shinichi Noto5
1

Department of Rehabilitation, Suzukake Health Care Hospital, Iwata, Japan
Doctoral Program in Health and Welfare, Graduate School of Niigata University of Health and Welfare, Niigata, Japan3
Department of Occupational Therapy, Seirei Christopher University, Hamamatsu, Japan
4
Department of Rehabilitation, Hamamatsu University School of Medicine, Hamamatsu, Japan
5
Department of Occupational Therapy, Niigata University of Health and Welfare, Niigata, Japan
2

Abstract: Purpose: The purpose of this study was to investigate the psychological effects on health-related quality oflife (HRQOL) of postoperative range of motion of the shoulder joint and subjective symptoms in patients with breast
cancer who underwent rehabilitation.
Methods: In 79 patients with breast cancer surgery who underwent rehabilitation during hospitalization, we investigated temporal changes in the range of shoulder joint function (flexion of shoulder joint/abduction angle), postoperative
subjective symptoms (surgical site pain, tightness, and anxiety regarding the disorder), and HRQOL scales (FACT-B
and EQ-5D-5L) from before to 6 months after surgery and examined the factors relating to HRQOL.
Results: The range of shoulder joint movement was significantly decreased even from pre-operation to 1 month after
surgery, but subjective symptoms had significantly improved at 6 months after surgery. Multivariable regression analysis showed that postoperative feelings of anxiety felt at 1, 3, and 6 months after surgery were a significant variableinfluencing the FACT-B and EQ-5D-5L scales. The path coefficients of the standard partial regression coefficients ofbreast cancer patients at 6 months postoperatively by covariance structure analysis were 0.66 for the EQ-5D-5L effective value, 0.94 for FACT-B, 0.47 for shoulder joint function, and −0.64 for postoperative subjective symptoms as thelatent variables of HRQOL.
Conclusion: The results suggested the importance of interventions that focus on postoperative subjective symptoms topossibly improve not only patient function but also postoperative HRQOL.
Keywords: breast cancer, health-related QOL, shoulder joint, subjective symptoms, structural equation modeling(Asian J Occup Ther 15: 1−10, 2019)

1. Introduction
About 70,000 people were affected with breast
cancer in Japan in 2012, and the prevalence rate was
113 per 100,000 people. Although breast cancer affects
a high number of patients and the incidence rate ishigh, the 5-year relative survival rate is 91.1%. Amongcancers with high survival rates, thyroid cancer has theReceived: 3 September 2018, Accepted: 26 December 2018
Corresponding to: Tetsuya Sano, Department of Rehabilitation, Suzu­
kake Health Care Hospital, 2042-4 Oowara-Cho, Iwata, Shizuoka,
438-0043 Japane-mail: 11mr05@g.seirei.ac.jp©2019 Japanese Association of Occupational Therapists

highest rate, skin cancer is second, and breast cancer
is third [1]. Thus, treatment of breast cancer is highly
likely to be lifesaving.
Breast cancer treatment is performed through a
combination of surgical therapy, radiotherapy, chemotherapy, and endocrine therapy. Over time, surgicaltherapy has changed to less invasive surgery. Sentinel
lymph node biopsy reduces upper limb dysfunction
associated with breast cancer surgery. The onset ofupper limb dysfunction was reported to occur in 66%
of patients in an axillary lymph node dissection groupand in 36% in a sentinel lymph node biopsy group [2].
However, after sentinel lymph node biopsy, the frequency of limited shoulder joint flexion is 37−100%, that oflimited abduction is 40.8−100%, and that of upper limb

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INFLUENCE OF SHOULDER FUNCTION AND SYMPTOMS ON HRQOL OF BREAST CANCER

dysfunction is high [3]. McNeely et al. [4] reviewed theeffects of postoperative rehabilitation in 24 randomized,
controlled trials against upper limb dysfunction causedby breast cancer treatment. Rehabilitation of 3 months
or more performed on the operation-side shoulder jointof postoperative breast cancer surgery patients significantly improved the range of shoulder joint flexion
over the short term compared with the control group.
Shoulder joint function was also reported to improvesignificantly at 1 month postoperatively. Another reporton the prevention of breast cancer recurrence showedthat the risk of breast cancer recurrence is suppressed byphysical activity [5]. Also, a review of 31 prospective
studies of the association between physical activity andbreast cancer risk reported a high relative risk of 0.88
for the recurrence of female breast cancer in womenwith low physical activity [6].
However, Shimozuma [7] considered not only hardoutcome measures such as postoperative impaired upper
limb function and survival but also quality of life (QOL),
an outcome measured from the patient’s point of view.
From the idea of measuring or evaluating areas that canbe improved (or worsened) by interventions such astreatment and care, healthcare providers promote health,which is one part of the four main elements reported by
Ferrell and colleagues [8] that makes up health-related
QOL (HRQOL) of cancer patients: physical, psychological, social, role, and functional. In addition, HRQOL
is based on patient-reported outcomes (PROs), i.e., any
report on patient health status obtained directly fromthe patient without any interpretation. PROs can comprehensively measure the effect of mental and physicalfunctions, approaches to activities, and participation
on an individual’s levels of happiness, satisfaction, andother factors [9]. In their review, Naaman et al. [10] reported a moderate improvement effect of psychologicalintervention on the HRQOL of breast cancer patients at
all stages.
Leach et al. [11] reported that a 24-week exercise
intervention improved HRQOL and depression, andWittmann et al. [12] reported that postoperative HRQOL
involves physical pain, anxiety, and depression. Gordon
et al. [13] found that an 8-month exercise intervention
was effective in improving HRQOL and cost-effectiveness.
Taghian et al. [14] reported that postoperative
lymphedema development is associated with worseningof HRQOL. Coyne et al. [15] reported that breast cancer
patients have been in good communication with theirfamilies, that they can play a domestic role that is thesame as before surgery, and Ristevska-Dimitrovska
et al. [16] reported that having resilience, which they
defined as “Psychological resilience represents an abilityof a person to protect his/her mental health when facedwith adversity such is the cancer diagnosis [17]”, is afactor that can keep HRQOL high. These reports on
HRQOL of breast cancer patients showed multifaceted
improvement in HRQOL due to psychological/motor
intervention, the presence of lymphoedema, HRQOL interms of family relations and psychological resiliencefor breast cancer. However, it has not been clarified how
the HRQOL of the postoperative breast cancer patientis related to disorders of shoulder joint range of motion(ROM) and changes in the psychological state that may
occur postoperatively. By considering these changes
over time, we can clarify how rehabilitation after
surgery contributes to the improvement of HRQOL inpatients after breast cancer surgery.
Structural equation modeling (SEM) has attracted
attention as a statistical method to verify causal relations[18]. SEM allows a visual understanding of the relation
between variables and can verify the relation between
latent variables by assuming multiple observation
variables as latent variables. Thus, the causal relation offactors contributing to HRQOL of patients after breast
cancer surgery can be concretely and visually verified
using SEM. Furthermore, rehabilitation of breast cancer
surgery patients to improve their HRQOL is thought tobe possible.
The purpose of this study was thus to investigate
psychological changes and HRQOL, mainly in termsof shoulder joint motion and subjective symptoms due
to surgical invasion, from the preoperative period to 6
months postoperatively in patients with breast cancer
who underwent rehabilitation to elucidate the factors
relating to HRQOL and their causal relations.

2. Methods
2-1. Subjects
The subjects comprised patients admitted to thehospital affiliated with Hamamatsu University School of
Medicine from April 2016 to September 2017. Patients
receiving postoperative rehabilitation prescribed tofemale breast cancer surgery patients agreed to participate in the research and were investigate up to 6 months
postoperatively. Exclusion criteria included patients who
required reoperation due to wound infection, who underwent bilateral resection, who had serious complications
such as dementia or higher brain dysfunction, who were
judged as inappropriate by their attending physician,and who did not provide consent to participate in thisresearch.
2-2. Investigation
Patients were evaluated at 5 points: the day before

Asian J Occup Ther 15: 1−10, 2019

surgery, the start date of postoperative rehabilitation,
and at 1, 3, and 6 months postoperatively. Survey items
were shoulder joint ROM, passive shoulder joint flexion/abduction ROM (shoulder joint flexion/abduction),and the Visual Analogue Scale (VAS), which was used
to evaluate subjective symptoms after surgery, including
pain, the feeling of tightness (tightness), and the senseof anxiety about the disease (anxiety). There is muchclinical experience with these three items. Regarding
pain and tightness, Verbelen et al. [3] reported that at 2
years after surgery, rates of tightness accompanied bypain and numbness associated with shoulder dysfunction
ranged from 5 to 50%.
In addition, because Naaman et al. [10] reported
that reduction in anxiety (in terms of illness and futurelife) and alleviation of depression improved QOL ofbreast cancer surgery patients and Wittmann et al. [12]reported that postoperative HRQOL involves physicaldistress, anxiety, and depression, anxiety was thus used
as an indicator of a change in the patients’ psychologicalstate.
In the VAS, the left end of the 10-cm scale wasdefined as “no subjective symptoms at all”, and the rightend was defined as “the subjective symptoms were verystrong”. The distance from the left end to the positionindicated by the subject was then measured.
As breast cancer disease-specific scales assessing
HRQOL, the Functional Assessment of Cancer TherapyBreast (FACT-B) [19] and the inclusive scale EuroQol-5
Dimension-5 Level (EQ-5D-5 L) [20−23] were used.
The FACT-B consists of 37 items, including sub-items
related to physical, social, mental, and functional health,and breast cancer, and the score of the FACT-B: TOTAL
ranges from 0 to 144. We also used the 24-item FACT-B
Total Outcome Index (FACT-B: TOI), which assesses
physical + functional + breast cancer-related items andis regarded as the indicator most reflecting the effect ofintervention research. Scores range from 0 to 92.
The EQ-5D-5L calculates utility value. Healthcon­ditions of five items, “degree of movement”, “management of personal belongings”, “activities of ordinary
people”, “pain/discomfort”, and “anxiety/obsessive”, areassessed at 5 stages: stage 1, “none”; stage 2, “slight”;
stage 3, “moderate”; stage 4, “quite”; and stage 5, “notpossible” or “extreme”. The utility value ranges from−0.025 to 1.000, with values closer to 1.000 indicating
a more complete health condition. The utility value,
which is calculated using a conversion table based ona healthy person in Japan [20], makes it possible tocompare HRQOL for each disease. It is one indicatorused to judge intervention effectiveness in the rehabilitation field in Japan and is the most frequently usedcomprehensive scale in Japan [24]. The English version

Sano T et al.

3

was finalized in 1990 [20, 21], and the Japanese version
was finalized in 1997 [22]. Originally comprised ofthree levels in 2015, the EQ-5D-5L Japanese version
with 5 levels for higher accuracy subsequently became
available as a comprehensive measure to calculate utility
value [23].
We obtained the following basic attributes of thesubjects from their medical records: age, time fromoperative day to each evaluation, sex, surgical side,
handedness, occurrence (initial incidence/recurrence),
cancer stage classification, operation type (partial excision/total resection), breast reconstruction surgery, rangeof lymph node dissection (sentinel lymph node biopsy/
axillary lymph node dissection), and adjuvant therapy(chemotherapy/radiotherapy/endocrine therapy).
2-3. Rehabilitation intervention
During hospitalization and after receiving physician
approval, an occupational therapist provided postoperative rehabilitation five times/week for 20 minutes eachweek. The intervention included automatic movementof the shoulder joint through flexion, external rotation,and lateral rotation within the pain range and stretching of the pectoralis major muscle including the skin/subcutaneous tissue and the incision site. Preoperatively
and at discharge, guidance was provided on surgical site
protection and prevention of lymphedema (guidance on
three points of ADL/IADL behavior: 1) avoiding pressure on the operative side, 2) infection prevention, and 3)
skin care). After discharge, we confirmed and provided
the patients with self-practice and living instructions at
the time of evaluation.
2-4. Statistical analysis
The results of the FACT-B and EQ-5D-5L were calculated using conversion tables. To examine the changes
at the five evaluation time points, we used the multiple
comparison test (Steel-Dwass method). We analyzed theassociation of HRQOL of the breast cancer patients at
the five times with Spearman’s rank correlation coefficient. The correlation between scores (i.e., r value) was
graded as absent (< 0.20), poor (0.20−0.34), moderate(0.35−0.50), and strong (> 0.50) [22]. We used stepwise
selection in multiple regression analysis to search forfactors related to HRQOL at four times: postoperatively
and at 1, 3, and 6 months later. Dependent variables
included the HRQOL scales FACT-B: TOI/TOTAL andEQ-5D-5L, and the independent variables were the fiveitems of flexion/abduction of the shoulder joints and the
postoperative subjective symptoms of pain, tightness,
and anxiety.
We used SEM to create a causal model of the
HRQOL of the patients after breast cancer surgery. The

4

INFLUENCE OF SHOULDER FUNCTION AND SYMPTOMS ON HRQOL OF BREAST CANCER

postoperative HRQOL of the patients affected the utility
value of the FACT-B: TOI/TOTAL and EQ-5D-5L, andfrom the evaluated items, it was hypothesized that two
factors were influenced by the latent variables: postoperative shoulder joint function and postoperative subjective symptoms. Anxiety was used as the indicator of achange in psychological state. Thus, pain, tightness, andanxiety were assumed to represent the latent variables of
postoperative subjective symptoms.
We examined the path diagram created by SEM.
The degree of conformity in the figure was judged by
the degree of freedom, χ2 value, comparative fit index(CFI), and root mean squares error of approximation(RMSEA). For the degree of conformity of the path
diagram, the CFI is close to 1, RMSEA is < 0.1, and thefit is good. Analysis results were examined by the pathcoefficient, which directly represents the strength of
the relation between the variables; the relation becomesstronger as the numerical value increases.
Because the number of patients required for SEM
and multiple regression analysis is large, we determined
the number of patients required on the basis of the detection power of the multiple regression analysis. We set
one dependent variable and five independent variables.
G-POWER 3.0 showed an α = 0.05, 1 − β = 0.8, andthus, the required number of patients was estimated to
be 50. IBM SPSS Statistics, AMOS Ver 24, and Excel
Statcel 4 were used for the statistical analyses, and thesignificance level was set to p = 0.05.
2-5. Ethical proceduresThis research was approved by the Ethics Committee of Hamamatsu University School of Medicine(approval no. E16-142) and Niigata University of Healthand Welfare (17739). This study was conducted with
sufficient explanation of the procedures in writing, andwritten informed consent was obtained from all participants. Patients participated of their own free will andcould leave the study at any time.

3. Results
Among the original 103 subjects, 79 patients (allwomen) could be followed through the full 6 months
after surgery. Twenty-four patients met the exclusion
criteria, which included male (2), bilateral resection(3), reoperation due to wound infection (3), treatment
at another hospital (5), and exclusion due to patient
circumstances (11). Patient characteristics are shown in
Table 1. The average age of the subjects was 56.7 ± 12.0
years, and preoperative evaluations were carried out inall of them. The mean period from the operative day
to each postoperative evaluation point was as follows:

Table 1. Patient characteristics.

Age (yrs)

Period to evaluation (days)

Postoperative
1 month
3 mouths
6 mouths

Mean

SD

56.7

12.0

2.5
29.7
91.0
179

3.9
7.3
13.9
13.6

N (79)%

Operative side

Right
Left

30
49

38
62

Dominant hand

Right
Left

77
2

97
3

Onset

First
Recurrence

77
2

97
3

Stage classification0
I (A, B)
II (A, B)
III (A, B, C)
IV

21
23
25
10
0

26
29
32
13
0

Operation typePartial removal
Total removal

17
62

22
78

Breast reconstruction

Yes
No

13
66

16
84

Dissection area

Sentinel lymph nodebiopsyAxillary lymph nodedissection

66

84

13

16

Chemotherapy

Yes
No

31
48

39
61

Radiation therapy

Yes
No

26
53

33
67

Endocrine therapy

Yes
No

50
29

63
37

The average age of the subjects was 56.7 ± 12.0 years, and preoperative evaluations were carried out in all subjects. The mean period
from the operative day to each postoperative evaluation point was asfollows: postoperatively, 2.5 ± 3.9 days; 1 month, 29.7 ± 7.3 days; 3months, 91.0 ± 13.9 days; and 6 months, 179.0 ± 13.6 days.
The surgical side was right in 30 (38%) and left in 49 (62%) patients, and the dominant hand was right in 77 (97%) and left in 2 (3%)
patients. Surgical methods included partial surgical procedures in 17(22%) and total excision in 62 (78%) patients, and the lymph nodedissection range included sentinel lymph node biopsy in 66 (84%) andaxillary lymph node dissection in 13 (16%) patients.

postoperatively, 2.5 ± 3.9 days; 1 month, 29.7 ± 7.3
days; 3 months, 91.0 ± 13.9 days; and 6 months, 179.0 ±13.6 days.
The surgical side was right in 30 (38%) and left in
49 (62%) patients, and the dominant hand was right in
77 (97%) and left in 2 (3%) patients. Surgical methods
included partial surgical procedures in 17 (22%) andtotal excision in 62 (78%) patients, and the lymph node

Asian J Occup Ther 15: 1−10, 2019

Sano T et al.

5* Post vs 6M, † 1M vs 6M
Steel-Dwass method p < 0.05

* Pre vs Post, † Pre vs 1M, ‡ Post vs 1M, § 1M vs 3M
Steel-Dwass method p < 0.05

Fig. 1. Changes in shoulder joint function.
Both flexion and abduction of the shoulder joints
decreased significantly from the preoperative to
postoperative period but significantly improved from
1 month after surgery. However, even at 1 month
postoperatively, function was significantly lower
compared with that preoperatively.

Fig. 2. Changes in subjective symptoms after surgery.
Pain, tightness, and anxiety improved significantly
from immediately postoperatively to 6 months postoperatively.

dissection range included sentinel lymph node biopsy in
66 (84%) and axillary lymph node dissection in 13 (16%)
patients.
3-1. Transition of each scale
The transition of shoulder joint function is shownin Fig. 1. Both flexion and abduction of the shoulder
joints decreased significantly from the preoperative to
postoperative period and began to significantly improvefrom 1 month after surgery. Even at 1 month postoperatively, function was significantly lower comparedwith that preoperatively. The transition of postoperative
subjective symptoms is shown in Fig. 2. Pain, tightness,
and anxiety improved significantly from immediately
postoperatively to 6 months postoperatively.
The transition of each HRQOL scale is shown in
Fig. 3. The FACT-B: TOI and EQ-5D-5L scores decreased significantly from the preoperative to postoperative time points and began to improve significantly fromone month after surgery. The FACT-B: TOTAL score
improved significantly by 6 months after surgery.
3-2. Relation between the scales at each time point
The EQ-5D-5L showed poor positive correlation
with shoulder joint abduction after surgery (r = 0.234)
and moderate negative correlation with pain (r = −0.414),
tightness (r = −0.348), and anxiety (r = −0.408). Shoulder joint flexion/abduction showed poor positive correlations with EQ-5D-5L at 1 month (flexion/abduction:* Pre vs Post, † Post vs 1M, ‡ Post vs 3M, § Post vs 6M
Steel-Dwass method p < 0.05

Fig. 3. Changes in HRQOL scales.
The FACT-B: TOI and EQ-5D-5L scores decreased
significantly from the preoperative to postoperative
time points and began to improve significantly fromone month after surgery. The FACT-B: TOTAL score
improved significantly by 6 months after surgery.
EQ-5D: EuroQol 5 Dimension-5 Level, FACT-B:
Functional Assessment of Cancer Therapy-Breast,
TOI: Total Outcome Index.

r = 0.266/r = 0.340), 3 months (r = 0.320/r = 0.288), and6 months (r = 0.240/r = 0.300) after surgery. Postoperative subjective symptoms (pain/tightness/anxiety) also
showed poor positive correlation and moderate to strong
negative correlation with EQ-5D-5L at 1 month (pain/tightness/anxiety: r = −0.413/r = −0.330/r = −0.502), 3
months (r = −0.461/r = −0.418/r = −0.642), and 6 months(r = −0.480/r = −0.480/r = −0.550) after surgery.
The FACT-B: TOI showed poor to strong negative
correlations with postoperative subjective symptom(pain/tightness/anxiety) postoperatively (r = −0.320/

6

INFLUENCE OF SHOULDER FUNCTION AND SYMPTOMS ON HRQOL OF BREAST CANCER

r = −0.339/r = −0.434) and at 1 month (r = −0.453/r =−0.382/r = −0.562), 3 months (r = −0.347/r = −0.270/
r = −0.606), and 6 months (r = −0.411/r = −0.456/r =−0.626) after surgery. A poor to moderately positive
correlation with shoulder joint flexion/abduction wasobserved at 6 months (r = 0.333/r = 0.405) after surgery.
The FACT-B: TOTAL also showed poor to strong negative correlations with postoperative subjective symptom(pain/tightness/anxiety) postoperatively (r = −0.243/
r = −0.305/r = −0.504) and at 1 month (r = −0.443/r =−0.367/r = −0.560), 3 months (r = −0.313/r = −0.255/
r = −0.541), and 6 months (r = −0.476/r = −0.508/r =−0.587) after surgery. A poor positive correlation withshoulder joint flexion/abduction was present at 6 months(r = 0.325/r = 0.368) after surgery. All correlation coefficients were P < 0.05.
3-3. Factors influencing each HRQOL scale (Table 2)
The EQ-5D-5L was adopted as the model for anxiety/pain after surgery, anxiety at 1 month after surgery,shoulder joint abduction and anxiety at 3 months, andanxiety and pain at 6 months after surgery. The FACT-B:
TOI was adopted as the model for anxiety/tightness after
surgery, anxiety/pain at 1 month after surgery, anxiety at
3 months after surgery, and anxiety/shoulder joint flexion at 6 months after surgery. The FACT-B: TOTAL wasadopted as the model for anxiety after surgery, anxiety/pain at 1 month after surgery, anxiety at 3 months after
surgery, and anxiety/tightness at 6 months after surgery.
3-4. Covariance structure model of HRQOL in breast
cancer patients
Figure 4 shows the path diagram of a patient at 6
months after breast cancer surgery. The suitability ofthis study as indicated by the CFI of 0.929 and RMSEA
of 0.138 was generally good. The path coefficients forthe latent variables of “HRQOL of patients after breast
cancer surgery” were 0.93 for FACT-B: TOI, 0.94 for
FACT-B: TOTAL, 0.66 for EQ-5D-5L, 0.47 for “Surgical shoulder joint function”, and -0.64 for “Postoperative

Table 2. Predictive factors of HRQOL scales.
Extraction

EQ-5D-5L

FACT-B:TOI

FACT-B:TOTAL

B

95%CI

β

t

Adjusted R2

p

Postoperative

Pain
Anxiety−0.022−0.018−0.035− −0.010−0.029− −0.007−0.376−0.335−3.674−3.270

0.275

**

1M

Anxiety
Shoulder abduction−0.0160.002−0.023− −0.008
0.001−0.425−0.3900.376−4.017
3.874

0.312

**

3M

Anxiety−0.024−0.032− −0.015−0.587−5.753

0.334

**

6M

AnxietyPain−0.014−0.012−0.022− −0.007−0.021− −0.003−0.466−0.275−3.747−2.5390.311*

Postoperative

Anxiety
Tightness−1.293−0.961−1.998− −0.585−1.665− −0.258−0.384−0.286−3.600−2.726

0.260

**

1M

AnxietyPain−1.692−1.152−2.412− −0.971−1.949− −0.356−0.459−0.283−4.680−2.885

0.365

**

3M

Anxiety−2.563−3.456− −1.670−0.586−5.736

0.333

**

6M

Anxiety
Shoulder flexion−2.0770.211−2.745− −1.410
0.065−0.356−0.5770.268−6.217
2.888

0.422

**

Postoperative

Anxiety−2.528−3.444− −1.612−0.550−5.506

0.292

**

1M

AnxietyPain−2.523−1.282−3.526− −1.520−2.390− −0.173−0.495−0.277−5.014−2.305

0.358

*

3M

Anxiety−3.566−4.913− −2.219−0.555−5.290

0.297

**

6M

Anxiety
Tightness−2.440−1.360−3.502− −1.378−2.440− −0.280−0.484−0.266−4.588−2.515

0.408*

EQ-5D-5L: EuroQol 5 Dimension-5 Level, FACT-B: Functional Assessment of Cancer Therapy-Breast, TOI: Total Outcome Index,
CI: Confidence interval
Multiple regression analysis: Stepwise method *: p < 0.05, **: p < 0.01
The EQ-5D-5L was adopted as the model for anxiety/pain after surgery, anxiety at 1 month after surgery, shoulder joint abduction and anxiety at
3 months, and anxiety and pain at 6 months after surgery. The FACT-B: TOI was adopted as the model for anxiety/tightness after surgery, anxiety/pain at 1 month after surgery, anxiety at 3 months after surgery, and anxiety/shoulder joint flexion at 6 months after surgery. The FACT-B: TOTAL
was adopted as the model for anxiety after surgery, anxiety/pain at 1 month after surgery, anxiety at 3 months after surgery, and anxiety/tightness
at 6 months after surgery.

Asian J Occup Ther 15: 1−10, 2019

Sano T et al.

7

Fig. 4. Six-month postoperative path diagram.
The path coefficients for the latent variables of “HRQOL of patients after breast cancer surgery” were 0.93 for FACT-B: TOI, 0.94
for FACT-B: TOTAL, 0.66 for EQ-5D-5L, 0.47 for “Surgical shoulder joint function”, and −0.64 for “Postoperative subjective
symptoms”. Those of the latent variables for “Surgical shoulder joint function” were 0.96 for “Shoulder flexion” and 0.89 for“Shoulder abduction”, and those of the latent variables for “Postoperative subjective symptoms” were 0.86 for pain, 0.92 fortightness, and 0.62 for anxiety. CFI: comparative fit index, EQ-5D: EuroQol 5 Dimension-5 Level, FACT-B: Functional Assessment of Cancer Therapy-Breast, RMSEA: root mean squares error of approximation, TOI: Total Outcome Index.

subjective symptoms”. Those of the latent variables of“Surgical shoulder joint function” were 0.96 for “Shoulder flexion” and 0.89 for “Shoulder abduction”, andthose of the latent variables of “Postoperative subjective
symptoms” were 0.86 for pain, 0.92 for tightness, and0.62 for anxiety.

treatment. By investigating the causal relations, rehabilitation to improve the HRQOL of breast cancer patientscan be examined. We believe that the results of the present study are of high significance and discuss the threesalient findings obtained from the results of this study
below.

4. Discussion

4-1. 
Shoulder joint function, postoperative subjective
symptoms, and characteristics of HRQOL over time
Shoulder joint function decreased significantly at
1 month postoperatively compared to that preoperatively. The postoperative subjective symptoms of pain,tightness, and anxiety improved significantly 6 months
after surgery. HRQOL significantly decreased from thepreoperative to initial postoperative period as indicatedby the FACT-B: TOI and EQ-5D-5L scales but significantly improved from 1 month after surgery. Declining
shoulder joint function due to surgical invasion can havean effect even after more than 1 year of follow-up [26].
Thus, it seems that shoulder joint function cannot be
improved within the first month after surgery. Because
pain and tightness did not show significant improvement
until 6 months after surgery, the influence of surgicalinvasion was thought remain until then.
Anxiety was significantly improved at 6 months
postoperatively. Lessening of the degree of involvementof physical pain, anxiety about recurring metastasis, anddifficulty in adapting to life after treatment can help to

We investigated the psychological changes and factors affecting the HRQOL of breast cancer patients who
underwent rehabilitation primarily in terms of shoulder
joint movement and subjective symptoms due to surgery
from preoperatively to 6 months after surgery. Recent
HRQOL studies of breast cancer patients showed that 6
to 8 months of exercise intervention and also psychological interventions such as counseling improve HRQOL[11, 13]. The scales used to assess HRQOL outcomes ina previous study included the disease-specific FACT-B
scale and the comprehensive Short-Form-36-Item Health
Survey [10].
We could find no reports combining the use of theEQ-5D-5L and FACT-B to examine the changes in preoperative to postoperative HRQOL over time in patientswith breast cancer surgery. Calculating disease specificity and utility value at each time point after surgery candiversely capture the HRQOL of breast cancer patientsand can lead to analyses of the cost-effectiveness of8

INFLUENCE OF SHOULDER FUNCTION AND SYMPTOMS ON HRQOL OF BREAST CANCER

improve HRQOL [12], but the psychological burden canlower HRQOL even at 18 months after surgery [10]. Although significant improvement was shown at 6 months
after surgery in the present study, subjective symptoms
could still remain after surgery. FACT-B is a specificscale for breast cancer disease, and FACT-B: TOTAL
showed significant improvement from immediately postoperatively to 6 months after surgery. However, FACTB: TOI and EQ-5D-5L scores significantly decreased
from the preoperative to immediate postoperative period
but significantly improved from 1 month after surgery.
FACT-B: TOI is regarded as the index that mostclosely reflects the effect of intervention research, andits subitems include physical, functional, and breast
cancer-related items [19]. It is thought to best reflect thephysical and psychological burden of surgical invasion
and adjuvant therapy, and we thought that this influence
was reflected in this study as well. The EQ-5D-5L
comprehensively reflects the physical and psychologicalsituation during the measurement period [23], and it
similarly reflected the situation in the present study.
4-2. Elucidation of factors affecting HRQOL
There was a poor positive correlation between the
EQ-5D-5L and shoulder joint function. Postoperative
subjective symptoms showed a negative correlation withmoderate pain at all times, a poor-to-moderate negative
correlation with tightness, and a moderate-to-strong
negative correlation with anxiety. This suggests that interventions not only for shoulder joint function but also
for postoperative subjective symptoms are necessary.
The multiple regression analysis showed the factors
affecting the EQ-5D-5L to be pain and anxiety after surgery, anxiety and shoulder joint abduction at 1 month,anxiety at 3 months, and anxiety and pain at 6 months
postoperatively.
These findings revealed that surgical invasion fromimmediately postoperatively to 1 month postoperatively
affected pain at the operative site and ROM of theshoulder joint, especially the restriction of abduction. In
addition, anxiety affected both periods, and the relation
become stronger as the postoperative course continued.
As part of a rehabilitation program after surgery, automatic movement incorporating shoulder joint abduction
and stretching mainly of the pectoralis muscle, whichacts on the skin and subcutaneous tissue of the surgicalwound, within a range in which pain does not occur
to relieve subjective symptoms after surgery, and thenecessity of life guidance and psychological follow-up
after discharge are suggested.
However, both the FACT-B: TOI and TOTAL show­
ed a poor-to-moderate positive correlation with shoulder
joint function at 6 months after surgery. Postoperative

subjective symptoms showed a poor-to-moderate nega­tive correlation between pain and tightness and a nega­tive correlation with moderate-to-strong anxiety at all
times.
The multiple regression analysis revealed that thefactors influencing FACT-B: TOI were anxiety andtightness after surgery, anxiety and pain at 1 month, anxiety at 3 months, and anxiety and shoulder joint flexion
at 6 months after surgery. The factors affecting FACT-B:
TOTAL were anxiety after surgery, anxiety and pain at 1
month, anxiety at 3 months, and anxiety and tightness at
6 months after surgery. As with the EQ-5D-5L, anxiety
affects all periods, and the relation is stronger as the timecourse progresses. In addition to evaluating the comprehensive HRQOL of cancer patients, FACT-B contains
breast cancer-related items that include symptoms (hairloss, pain, lymphedema, weight change, and decrease inphysical strength) due to morphological changes after
excision and adjuvant therapy and the patient’s identification as a woman. Also, because anxiety was present
across the entire time course, it was thought that thesefactors were also affected.
4-3. Causal relation of factors constituting HRQOL ofpatients after breast cancer surgery
In this study, HRQOL of breast cancer patients at 6
months postoperatively influenced each HRQOL scale(path coefficient of EQ-5D-5L, 0.66; FACT-B TOTAL,
0.94; FACT-B: TOI, 0.93), postoperative subjective
symptoms (−0.64), and shoulder joint function (0.47),
in that order. On the HRQOL scale, the disease-specificscale of FACT-B was more influential than the comprehensive scale of the EQ-5D-5L, and in the rehabilitationintervention, postoperative subjective symptoms influenced HRQOL more than did shoulder joint function.
The path coefficient from postoperative subjective
symptoms showed that tightness had the highest value
at all of the times. This suggested that in the subjective
symptoms after surgery, tightness affected the decline
in HRQOL by limiting daily activities. The next highest
value was for pain, suggesting that chronic pain at theoperative site derived from surgical invasion interfereswith daily life and also affects the decline in HRQOL. In
addition, it is suggested that any remaining tightness andpain encourage anxiety, thus forming a vicious circle.
There were problems and limitations with this research. In this study, we did not adjust for surgical type,surgical side, pre- and postsurgery adjuvant therapy,
timing of onset (period since onset, first incidence, orrecurrence), and postoperative complications of thebreast cancer patients who underwent rehabilitation.
The postoperative complications of axillary lymphangiectasia syndrome [27] and lymphedema [28] can affectAsian J Occup Ther 15: 1−10, 2019

prognosis, shoulder joint function, and the psychologicalstate. Particularly, temporal changes in the HRQOL
scales can be expected to differ due to shoulder joint
function on the operative side, subjective symptoms
after surgery, surgical type, adjuvant therapy, postoperative complications, and onset time. However, even if
these specific controls are carried out on the subjects,
it is not possible to exclude factors related to shoulder
joint function on the operative side and the influence ofimproving the subjective symptoms after surgery.
In the future it will be desirable to increase thenumber of subjects in whom the above attributes can becompared and to further follow long-term changes overtime.

Conclusion
By using both a breast cancer-specific scale andutility values as comprehensive measures, we could
follow up breast cancer patients until 6 months after surgery to assess the detailed changes in their HRQOL andthe causal relations associated with these changes. Not
only functional aspects but also postoperative subjective
symptoms may affect improvements in the HRQOL ofthese patients. The utility value of breast cancer patientsobtained in this study from the day before surgery to the
6th month after surgery showed the effects of rehabilitation that accumulate in the future and can be a basis
for the future allocation of medical resources. From now
on, by increasing the number of cases and following thelong-term changes over time, methods of rehabilitationintervention can be studied according to different postoperative periods.
Acknowledgements: This research was carried out
under the auspices of the Japanese Association of Occupational Therapists (JSPS) and the Japanese Associationof Occupational Therapists Research Project Grant II.
The authors are grateful to the staff of the rehabilitation
department of Hamamatsu Medical University Medical
College Hospital who cooperated in the study and to thepatients who participated in the study.

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■ORIGINAL ARTICLE

Effect of Adjusting the Challenge-Skill Balance
for Occupational Therapy
in a Recovery Rehabilitation Unit: A Pilot Study
Ippei Yoshida1, 2, Kazuki Hirao3, Ryuji Kobayashi1
1Department of Occupational Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan University
Department of Rehabilitation, Harue Hospital3
Department of Occupational Therapy, Kibi International University Graduate School of Health Sciences
2

Abstract: The primary goal of occupational therapy is to enable people to participate in normal everyday activities. To
understand and support a client’s desired activities, it is necessary to share the meaning of occupation between the therapist and client. One concept that has been used to capture the psychological state for an activity is flow. Therefore, we
devised a process of adjusting the challenge-skill balance for occupational therapy based on flow theory.
In this pilot study, we aimed to verify whether adjusting the challenge-skill balance for occupational therapy improved subjective quality of life in a recovery rehabilitation unit. To inform the future design of randomized controlled
trials, we therefore compared standard occupational therapy with this new approach. Both interventions took place fromrecovery rehabilitation unit entry to discharge, and outcomes (continuous variables) were analyzed using a Bayesian
approach explored with generalized linear mixed modeling.
Among a total of 22 patients, those receiving the new approach showed a significant improvement in Ikigai-9 (qualityof life) compared with those receiving standard occupational therapy. The mean improvement was 4.44 ± 2.17 with a
95% credible interval of 0.104−8.713. The dependence factor, effective sample size, and autocorrelation time were 3.769,
8093, and 6.18, respectively. We conclude that adjusting the challenge-skill balance during occupational therapy could
improve a client’s subjective quality of life.
Keywords: occupational therapy process, flow model, quality of life, recovery rehabilitation unit

(Asian J Occup Ther 15: 11−18, 2019)

Introduction
Occupational therapy is a client-centered profession
concerned with promoting health and well-being throughoccupation. The primary goal of occupational therapy
is to enable people to participate in normal everyday
activities [1]. In occupational therapy, appropriate
activities are typically set based on a comprehensive
assessment of a client’s physical and mental functions,occupational performance, and personal factors, as wellas any relevant environmental factors. Several practicalframeworks exist, including the Occupational Therapy
Received: 17 February 2018, Accepted: 26 December 2018
Corresponding to: Ippei Yoshida, Department of Occupational Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan
University, 7-2-10, Higashiogu, Arakawa-ku, Tokyo, 116-8551, Japane-mail: ippe.i.yoshi@gmail.com©2019 Japanese Association of Occupational Therapists

Practice Framework [2], the Occupational Therapy
Inter­vention Process Model [3], and the Management
Tool for Daily Life Performance [4], together with
important theories, such as the Canadian Model ofOccupational Performance [5] and Model of humanoccupation [6]. However, despite attempts to ensure thatoccupational therapists provide client-centered therapy,
it has been reported that there can be differences in theperception of skill and challenge difficulty between theoccupational therapist and client [7].
To understand and support a client’s desired activities, it is necessary to share the meaning of occupation
between the therapist and client. In other words, subjective assessments about a client’s occupation should beacquired in a way that facilitates easy recognition. One
concept that has been used to capture the psychologicalstate for an activity is “flow” [8]. Csikszentmihalyi
reported that flow occurs when individuals are “so intensely involved in an activity that nothing else seems to12

ADJUSTING THE CHALLENGE-SKILL BALANCE FOR OT

matter; the experience itself is so enjoyable that people
will do it even at great cost, for the sheer sake of doingit” [9]. Flow can contribute to increased happiness,
self-esteem, work productivity, and joy of life [10−13].
Additionally, studies have described the relationship between the experience of flow and everyday life activities[6, 14−16].
According to flow theory, flow can also be defined
operationally according to a challenge–skill balancecalled the “flow model” [8]. This model proposes thatflow occurs when the perceived level of challenge provided by the activity is in balance with the participant’slevel of skill. By contrast, activities in which the individual has high perceived skill relative to the challenge
might lead to boredom, whereas activities in which there
is low perceived skill and high perceived challenge
might lead to anxiety. As research based on the flow
model, there were analyzes targeting activities engaged
by students and occupational therapists. [17−19], whileother analyses have looked at the relationship between
flow and health-related quality of life (QoL) in elderly
people [20−22]. We previously analyzed the activities
supported by occupational therapy among elderly people
in an adult day program and showed a difference inrecognition about the activity, consistent with previous
research [7, 22]. Based on the flow model, we thoughtthat adjusting the challenge–skill balance might facilitate occupational therapy. In a randomized controlled
trial, we examined the effect of occupational therapy
in which the challenge–skill balance was adjusted forelderly people who used an adult day program, and weshowed improvements in health-related QoL [23].
However, since this previous study targeted only
one specific activity in the maintenance rehabilitation
phase, the influence of the intervention period and theeffectiveness of support for multiple activities have notbeen clarified. Therefore, in this study, we conducted
the process adjusting the challenge-skill balance (calledadjusting the challenge–skill balance for occupational
therapy; ACS-OT) in a situation that supports multiple
activities at recovery phase, we examined whether
ACS-OT was more universally effective in occupational
therapy. Our aim was to verify if ACS-OT improved
subjective QoL in a recovery rehabilitation unit.

Method/Design
MethodThis controlled clinical trial was designed to compare the ACS-OT method (experimental group) withstandard occupational therapy (control group). The
primary outcome was change in subjective QoL (ikigai)
for both groups from admission (pre) to discharge (post).

The secondary outcomes were changes in health-related
QoL, flow experience, and ADLs. The study protocol
was approved by the Ethics Review Committee of theHarue hospital (No.29-1).
Inclusion and exclusion criteria
From May 2017 to November 2017, Clients were
included if they were admitted to the recovery rehabilitation unit of Harue hospital with either cerebrovasculardisease or musculoskeletal disease. On admission to therecovery rehabilitation unit, we excluded clients aged
< 50 years and ≥ 100 years, as well as those whose Mini
Mental State Examination scores were ≤ 23 points [24].

ProcedureIntervention
Occupational therapy was provided according to
the guidelines of the American Occupational Therapy
Association [2] in both the experimental and control
groups. All interventions were implemented by occupational therapists experienced (≥ 200 hours) in deliveringclient-centered occupational therapy. In reference to theGraff’s research design [25], the criteria for the amountof experience was set to more than 6 cases (40 minutes,
50 days, 6 cases, total 200 hours). Moreover, all had
received at least 50 hours of training for ACS-OT (30minutes, 50 days, 2 cases, Total 50 hours). Occupational
therapy was conducted individually and was focusedon the performance of activities. The key difference
between groups was whether the evaluation and intervention were conducted based on an assessment of thechallenge–skill balance. Treatment consisted of 40−60
minutes per day, six times in total in a week. The study
period was from admission to discharge from the recovery rehabilitation unit.
Experimental group
The ACS-OT process was implemented in thefollowing way. In the first session, the therapist assessed
the client’s problems in daily living using the Canadian
Occupational Performance Measure [26]. Based on
the problems identified, some activities that could be
supported by occupational therapy were selected. In thesecond session, the client performed the tasks related to
selected activities and evaluated the “challenge level”
and “skill level” as follows: challenge level defined as
the “challenge of the activity” and rated on a seven-point
scale from “very simple” (1) to “very difficult” (7); and“skill level” was defined as “your skills in the activity,”
rated from “not at all skillful” (1) to “very skillful” (7)[18, 27]. The therapist checked with the client why
certain ratings were given.

Yoshida I et al.

Asian J Occup Ther 15: 11−18, 2019

Subsequently, evaluation by the client and therapist
in collaboration helped decide on the factors that madeoccupational performance difficult (i.e., challenge components, such as environment, execution time, and andsize of the location in which the activity is carried out)
and that improved performance (i.e., skill components,
such as frequency, range, distance, accuracy, and dexterity related to activity). The challenge–skill balance fortasks was then changed based on these conclusions. The
criteria for adjusting the challenge–skill balance wasthat the difference in evaluation of the challenge andskill levels between the therapist and client had to be
one or less.
After the client performed the adjusted tasks, thechallenge and skill levels were re-evaluated. If the challenge and skill levels were balanced, therapy was started
to improve performance in those activities. If the challenge and skill levels were not balanced, the tasks were
further adjusted and therapy was only started after they
were balanced. This process was repeated at least oncea week. It should be noted that, activity was changed(added or finished) according to the status of treatment
progress. For example, in the initial session, activities
such as walking and toilets are targeted. Then, the toilet
is achieved (finished), walking tasks are shifted to stairs
and applied walking, bathing and cooking are added.
Control group
The first and second sessions were conductedsimilarly to the experimental group, with the exceptionthat therapists were not allowed to confirm the client’s
subjective perceptions of the challenge posed by, or
skill needed to complete, the activities. From the third
session, therapists assessed the client’s performance andconducted therapy in a typical manner, following thegeneral guidelines for occupational therapy [2].

Outcomes
Subjective QoL
We measured subjective QoL using the Ikigai9 [28], a client’s psychological measure of feeling areason for living (ikigai). It consisted of nine items rated
on 5-point scales (total score, 9−45 points).
Health-related QoL
Health-related QoL was assessed by the EuroQol-5
Dimensions (EQ-5D) [29]. The EQ-5D defines health infive dimensions (i.e., mobility, self-care, usual activities,
pain and discomfort, and anxiety or depression). A
visual analog scale (EQ-VAS) enables self-assessment
on a scale from 0 (worst possible health) to 100 (bestpossible health) per dimension.

13

Flow experience
Flow experience was assessed using the Flow State
Scale for Occupational Tasks [30] developed for clinicalsituations. This consists of 14 items and 3 factors (scores
range from 7 to 98), and its reliability and validity havebeen confirmed [30].
ADL
ADLs were measured by the Functional Independence Measure (FIM) [31]. This comprises 18 items on
7-point scales that uniformly assess the severity of aclient’s disability and functional outcome from medical
rehabilitation (overall score, 7 to 126).

Organization
The primary investigator plans and executes thisresearch and supervises three research assistants. The
research assistants obtained informed consent andperformed procedures, measurements. Data entry andcontrol were conducted by the primary investigator. A
statistician also helped with the data analysis.

Statistical analysis
All statistical analyses were performed using EZR[32] and SAS® (SAS Institute, Sally, NC, USA). Data
were entered in Microsoft Excel 2016 and subsequently
exported into EZR and SAS for analysis. Baseline characteristics were compared by chi-square tests for categorical variables and by independent t-tests and Mann–
Whitney U tests for continuous variables. The comparison of categories of activities targeted in two groups wasanalyzed using Fisher’s exact test.
Each continuous outcome variable was analyzed
using a generalized linear mixed model (GLMM).
Considering the sample size of this study, outcome
analysis adopted a Bayesian method that enables reasonable estimation even when the sample size is small.
We took a Bayesian approach and explored the Markov
chain Monte Carlo (MCMC) [33] fitting of GLMM,
including the following as fixed effects: group allocation(experimental and control groups), time (pre and post),
and the interaction of group and time. Participants were
included as a random effect. MCMC is a method ofgenerating a sample having a distribution characteristic
matching the posterior distribution by Markov chain
using Bayesian method and using it to calculate an estimate value of the objective variable. The convergencecriterion for data in the MCMC fitting was set to adependence factor of 5 for Raftery–Lewis Diagnostics[34]. In addition, autocorrelation time (ACT) andeffective sample size (ESS) are also effective indices for

14

ADJUSTING THE CHALLENGE-SKILL BALANCE FOR OT

the diagnosis of MCMC algorithm. The ACT measuresdependency among Markov chain samples. The ESS estimates how many truly independent samples of a given
parameter the output of the MCMC represents. HighESS or low ACT indicates good mixing of the Markov
chain. Therefore, we also confirmed the ACT and ESS
for MCMC convergence. All credible intervals were
given with a 95% credible interval.
Since the Bayesian method only calculates theestimated value, effect sizes indicating the difference between the two groups with respect to each outcome after
the intervention were calculated to show the magnitudeof the effect in the experimental group.

Results
We included 22 clients (experiment Group; 11, control Group;11) and confirmed that the pre-test characteristics were well matched between the two study groups(Table 1). The total number of activities targeted by bothgroups was 81 (average per client: 3.68), ADL was 54(66.6%), and instrumental ADL was 20 (24.7%). There
was no significant difference in activity between the twogroups (Fig. 1).
The changes from the pre-test to the post-test
characteristics are shown in Table 2. Regarding eachoutcome after intervention, Ikigai-9 was 33.18 ± 7.04 in
the experimental group and 26.64 ± 8.98 in the control

group. EQ-5D was 0.668 ± 0.091 in the experimentalgroup and 0.653 ± 0.122 in the control group, Flow state
scale for occupational task was 82.27 ± 8.90 in the experimental group and 73.27 ± 16.85 in the control group.
FIM total score was 118.73 ± 4.29 in the experimentalgroup and 117.64 ± 8.89 in the control group. The
results analyzed by MCMC for GLMM are shown in
Table 3. The mean improvement in the Ikigai-9 between
the experimental and control groups was 4.44 ± 2.17,
with a 95% credible interval of 0.10−8.71. The difference between the two groups in EQ-5D was 0.061 ±0.089 with a 95% credible interval of −0.115−0.236, inFlow state scale for occupational task was −0.73 ± 5.01
with a 95% credible interval of −10.88−8.94, in FIM
was 3.26 ± 4.88 with a 95% credible interval of −6.37−
12.72. Thus, a significant difference was confirmed in
Ikigai-9. Confirming the information on the convergencesituation of sampling about MCMC analysis for Ikigai-9,
The dependence factor, ACT, and ESS were 3.769,
6.178, and 8093.4, respectively. In addition to the results of dependence factor (less than 5), ESS and ACT,
posterior distribution by sampling data was in a smoothnormal distribution state, indicating that appropriate
sampling was being performed (Fig. 2).
There were no significant differences in the EQ-5D,
Flow State Scale for Occupational Tasks or FIM between the experimental and control groups. Regarding
the FIM, there was a significant difference between the

Table 1. Baseline data.
The results of the baseline data in the experimental and control groups were shown. The pre-test characteristics were
well matched between the two groups.
Experimental Group (n = 11)

Control Group (n = 11)

p value

75.36 (10.51)

73.64 (13.00)

p = 0.742

Sex (n)Male
Female3865p = 0.387

Disease (n)Cerebrovascular
Musculoskeletal

3
8

5
6

p = 0.659

Treatment period: Day (M, SD)

46.27 (18.81)

44.64 (28.41)

p = 0.742

MMSE (M, SD)

25.64 ( 2.16)

26.18 ( 2.99)

p = 0.629

EQ VAS (M, SD)

60.45 (18.64)

63.36 (22.59)

p = 0.745

Flow state scale for Occupational task (M, SD)

79.73 (14.11)

70.00 (20.63)

p = 0.212

Ikigai-9 (M, SD)

31.09 (10.15)

28.00 ( 8.25)

p = 0.442

FIM (M, SD)
Motor
Cognitive
Total

63.36 (14.35)
33.09 ( 2.12)
96.45 (14.69)

65.36 ( 8.66)
33.27 ( 3.90)
98.64 (10.55)

p = 0.696
p = 0.237
p = 0.693

Age (M, SD)

Note. M = mean; SD = standard deviation; EQ-VAS = EuroQol–5 Dimension visual analog scale;
MMSE = Mini Mental State Examination; FIM = Functional Independence Measure.

Yoshida I et al.

Asian J Occup Ther 15: 11−18, 201915

Fig. 1. Activities targeted by experiment group and control group.
In this figure, it showed the classification of the activities that was the target in the experiment group and the control group. As aresult of Fisher’s exact test, there was no significant difference in activity between the two groups.

Table 2. Pre and post data in experimental and control group.
Changes from pretest to post-test characteristics about Ikigai-9, EQ-5D/EQ VAS, Flow state scale for occupational task, and FIM
between the experimental and control groups were shown. Effect sizes between two groups with respect to each outcome after theintervention were also shown.
Observed M (SD)

Observed M (SD)

Effect size [95% CI]

Experimental group (n = 11)

Control group (n = 11)

pre

post

pre

post

Between two groups
after the intervention

Ikigai-9

31.09 (10.15)

33.18 ( 7.04)

28.00 ( 8.25)

26.64 ( 8.98)

0.78 (−0.09 to 1.65)

EQ-5D
EQ VAS

0.497 (0.187)
60.45 (18.64)

0.668 (0.091)
77.09 (15.43)

0.544 (0.243)
63.36 (22.59)

0.653 (0.122)
72.27 (20.42)

0.19 (−0.70 to 0.97)

Flow state scale for occupational task

79.73 (14.11)

82.27 ( 8.90)

70.00 (20.63)

73.27 (16.85)

0.67 (−0.21 to 1.50)

FIM
Total-score
Motor-score
Cognitive-score96.45 (14.69)
63.36 (14.35)
33.09 ( 2.12)

118.73 ( 4.29)
85.27 ( 3.82)
33.45 ( 1.81)

98.64 (10.55)
65.36 ( 8.66)
33.27 ( 3.90)

117.64 ( 8.89)
84.73 ( 5.76)
32.9 ( 5.07)

0.16 (−0.69 to 0.99)

Note. M = mean; SD = standard deviation; CI = confidence interval; EQ-5D = EuroQol–5 Dimension;
EQ-VAS = EuroQol–5 Dimension visual analog scale; FIM = Functional Independence Measure;
Effect sizes between two groups = Calculated as standardized mean differences (Cohen’s d).
Table 3. Results analyzed by MCMC for generalized linear mixed model (GLMM).
The results of each outcome analysis by GLMM using MCMC were shown. There was a significant difference in the subjective QOL (Ikigai-9) between the experimental and control groups.
Time M (SD)Group M (SD)Group*Time M (SD)Ikigai-9−1.36 (1.54)
95%CI [−4.49−1.62]−2.36 (5.16)
95%CI [−12.70−7.49]

4.44 (2.17)
95%CI [0.10−8.71]

EQ-5D

0.110 (0.063)
95%CI [−0.015−0.235]−0.108 (0.150)
95%CI [−0.405−0.188]

0.061 (0.089)
95%CI [−0.115−0.236]

Flow state scale foroccupational task

3.28 (3.53)
95%CI [−3.65−10.33]

10.50 (10.42)
95%CI [−9.17−31.60]−0.73 (5.01)
95%CI [−10.88−8.94]

FIM

18.99 (3.45)
95%CI [11.97−25.57]−5.30 (8.42)
95%CI [−21.98−11.27]

3.26 (4.88)
95%CI [−6.37−12.72]

Note. M = mean; SD = standard deviation; CI = confidence interval; EQ-5D = EuroQol–5 Dimension;
FIM = Functional Independence Measure; Time = pre and post; Group = experimental and control groups.

16

ADJUSTING THE CHALLENGE-SKILL BALANCE FOR OT

Note. B3 = Difference between experimental group and control group in Ikigai-9.
Fig. 2. PROC MCMC procedure about Ikigai-9.
This figure shows mixing of the Markov chain, which has relatively constant mean and variance over iterations. The trace plotshows indication of convergence.

pre-test and post-test results in both groups (18.99 ±
3.45, 95% credible interval: 11.974−25.571).
Analysis by actual measurement values showed
effect sizes (d) and 95% confidence intervals of 0.78(−0.09 to 1.65), 0.19 (−0.70 to 0.97), and 0.67 (−0.21 to1.50) for the Ikigai-9, EQ-5D, and Flow State Scale for
Occupational Tasks, respectively. In addition, all of theclients in both groups were discharged home.

Discussion
To the best of our knowledge, no other study hascompared the outcomes between ACS-OT and standard
occupational therapy in a recovery rehabilitation unit.
When we compared subjective QoL (Ikigai-9) between
the two groups, there was a significant difference in theBayesian GLMM. Although the effect size was moderate(d = 0.78), no significant effect was shown (95% confidence interval, −0.09 to 1.65). In addition, there were no
significant differences in health-related QoL (EQ-5D) or
flow status (Flow State Scale for Occupational Tasks).
Regarding FIM, there was no difference between thetwo groups, though both improved from before to after
the intervention.
The ACS-OT method was based on the flow model,
adjusting the client’s therapy to their perceived skill withthe support of an occupational therapist. The challenge–
skill balance was key to this flow model, requiring thatthe difficulty level of the occupational therapy engaged

in by the client matched the ability of the client; it wastherefore logical that occupational therapy and flow
models should have a very high affinity. Although flow
experiences can be addictive [35], this might relate to alack of opportunity for meaningful chances to develop
the skills needed to perform activities [36]. We believethat our ACS-OT method, by helping to improve skill
by adjusting the challenge level to the patient’s needs,
helped promote the client’s own initiative.
Bayesian estimation by MCMC was used toprovide a statistical framework. In this method, data
were combined with subjective prior information aboutparameter values to derive posterior probabilities of different models or parameter values. MCMC is a Bayesianstatistical technique that samples parameters according
to a stochastic algorithm that converges on the posterior probability distribution of parameters, combining
information from the likelihood and the posterior distributions [37]. By using the prior distribution properly,
this method can give a reasonable estimation even withsmall sample sizes. Adopting this analysis allowed us
to calculate a more accurate estimated value with fewer
samples.
The Ikigai-9 [28] used in this study consisted of
the following three concepts: 1) optimistic and positive
attitude toward present living and life, 2) active andpositive attitude toward the future, and 3) recognitionof the meaning of self-existence. In general, rehabilitation and occupational therapy focus on long-termYoshida I et al.

Asian J Occup Ther 15: 11−18, 2019

goals. Pessimism of goal achievability might therefore
be evidenced by high anxiety if the patient perceives ahigh challenge level and a low skill level. Equally, if theclient judges that the goal has already been achieved (lowchallenge with high skill), he or she may be less likely
to concentrate on an assigned activity. This relates to thepsychological phenomenon of “mind wandering” [38],in which thoughts drift away from the task at hand andonto unrelated thoughts, such as memories, thoughtsof the future, negative emotions, and misfortune [39].
Therefore, because the ACS-OT method focused on activities adjusted to achieve a challenge–skill balance inthis study, it is possible that negative emotions and mind
wandering may have been reduced, increasing being
present or self-esteem. Since there was no significant
difference between the two groups in the comparisonon the contents of the selected activity, and tasks related
to the activities were set taking into consideration theclient’s condition (skill), it is unlikely that the differencein the activities targeted for support affected the outcomes of the two groups. We believe that the use of the
ACS-OT method has made it possible to support clients
more appropriately and has led to positive psychologicalstate.
We noted that the flow scale score did not differ
between the two groups. Given that the ACS-OT method
was based on the flow model, it is possible that clients inthis study did not reach the flow state experienced witha high challenge–skill balance.
Regarding the FIM results, improvement wasobserved for ADL before and after intervention in bothgroups, but no significant difference was found between ACS-OT and normal occupational therapy. Thissuggested that for ADL, it could not be concluded that
ACS-OT intervention was more effective than standard
occupational therapy. The reason for this was that improvement of ADL was one of the main objectives in
the recovery rehabilitation unit, and the improvementof ADL was also shown in conventional occupational
therapy [40−42], it was considered that clear difference
was not reached even with ACS-OT.
A limitation of this research is that it was only acontrolled clinical trial. Therefore, we are planning arandomized controlled trial to obtain more evidence inthe future (UMIN ID: UMIN000029505). Moreover, weused the GLMM to estimate values in this study becauseof the small number of subjects. Although we confirmed
the sampling accuracy, we would like to clarify theeffects of the ACS-OT method, including verificationof the validity of the Bayesian estimate, in a future randomized controlled trial.

17

Conclusion
In conclusion, this study showed that the ACS-OT
method could improve a client’s subjective QoL (i.e.,
ikigai) during recovery in a rehabilitation unit. Combined with the results of previous studies [22, 23], thismethod could have application in different areas ofoccupational therapy.
Acknowledgements: This research was carried out
under the assignment research grant system by the Japan
Occupational Therapist Association in 2017.

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■ORIGINAL ARTICLE

A Qualitative Study on the Practice Structureof Home-Based Occupational Therapy for
the Realisation of Daily Living Activities in the Elderly:
Promoting Co-Operative Constructionof the Life Performance
Seigo Minami1, Ryuji Kobayashi212Faculty of Rehabilitation, Osaka Kawasaki Rehabilitation University
Department of Occupational Therapy, Tokyo Metropolitan University

Abstract: We aimed to clarify intervention processes for facilitating patients’ living activities by understanding thepractical structure of home-based occupational therapy (OT). Study participants were occupational therapists with atleast three years of home-based OT experience. Data analysis was based on the grounded theory. For categorisation,
MAXQDA 10 was used to conduct continuous comparative analysis. Analysis resulted in the following categories: 1,572
text segments, 195 labels, 40 small categories, 15 medium categories and 6 large categories. The large categories were(a) identifying unique living activities, (b) analysing and predicting living activities, (c) employing practices to confront
living activities, (d) creating an environment that fosters living activities, (e) implementing independent living activitiesand (f) co-operating to realise living activities. Occupational therapists used patients’ living spaces to support them interms of independently performing living activities, accumulating living activity experience in familiar homes and com­munities.
Keywords: home-based occupational therapy, life performance, quality of life

(Asian J Occup Ther 15: 19−25, 2019)

Introduction
Comprehensive community care systems are being
promoted in Japan to help elderly people live in familiar
communities for as long as possible [1]. The main ob­
jectives of comprehensive community care of the elderly
are to expand support for elderly people from a multi­
disciplinary, professional perspective that ensures thecontinuity of elderly people’s unique lives throughimprovements to social infrastructure. Occupational
therapists can contribute to sustainable community lifeof the elderly by providing well-balanced approaches
to activities, opportunities to participate in the environ­
Received: 22 March 2018, Accepted: 27 January 2019
Corresponding to: Seigo Minami, Faculty of Rehabilitation, Osaka
Kawasaki Rehabilitation University, 158, Mizuma, Kaizuka, Osaka,567-0104, Japane-mail: seigo.minami@gmail.com©2019 Japanese Association of Occupational Therapists

ment, and supporting mental and physical functions [2].
In light of these circumstances, the Japanese As­
sociation of Occupational Therapists has proposed theManagement Tool for Daily Life Performance (MTDLP)
to the public as one approach that occupational ther­
apists can use in comprehensive community care [3].
Activities of daily living, work, hobbies and leisureactivities are designed to maintain self-care [4, 5]. The
MTDLP is a process tool for occupational therapiststhat is intended to improve living activities of elderly
individuals living in the community.
Home-based occupational therapy (OT) contributes
to improving living activities at home and specificallyprovides services that are congruent with a patient’s
lifestyle. The reported outcomes of home-based OT
are improvement of patients’ practical functions andreduction of carer burden [6−8], as well as increasedsocial participation through interventions congruent withpatients’ interests and concerns [9, 10].
Home-based OT is therefore considered to be effec­

20

PRACTICE STRUCTURE OF HOME-BASED OTtive at improving living activities [9]. Accordingly, ourobjective in this study was to analyse the intervention
processes employed to enable patients in fulfilling living
activities by gaining an understanding of the practicalstructure of home-based OT. We referred reference tothe theoretical framework of MTDLP to identify the
purpose of the intervention process. We expect ourfindings to help standardise the process of facilitating
patients’ daily living activities and further expand thescope of patient activities and participation.

Materials and Methods
Study Design
We used a qualitative design for this study. We
conducted interviews with experienced occupational
therapists and created a structural diagram—aiming topresent home-based OT as a storyline—that depicts the
co-operative building of daily living activity goals as
related to home-based OT.
Participant and Procedure Selection
This study’s participants were experienced occu­
pational therapists involved in home-based OT. They
were selected by requesting the names of occupational
therapists from the Japan Association of Home-Visit
Rehabilitation (in Japanese), and snowball sampling was
employed to select participants whenever a referral was
obtained from a director of OT. The participants were
occupational therapists with at least eight years’ experi­ence after obtaining their therapist’s licences and at least
three years’ experience in home-based OT. The sample
size of a qualitative study varies depending on whether
or not theoretical saturation has been reached; thus, we
did not identify the sample size needed in this study [11,12].
We created an interview survey and conductedsemi-structured interviews. To create a supportive
environment for the interviews, we informed the par­ticipants of the study objectives and ensured them that
their stories would be confidential. To protect privacy,
we clarified in writing that the participants’ rights would
be respected. Translation from Japanese to English was
performed by experts in the translation of rehabilitation
information after generation of categories. Subsequently,
reverse translation from English to Japanese was per­formed using translation software (MED-Trancer V12),and transparency was confirmed. Backward translation
was repeated with healthcare professionals until thecorrect meaning was obtained. The interviews involved
listening carefully to the participants’ answers to a list of
open-ended questions (Table 1), which was distributed
in advance, asking participants to freely answer. The

Table 1. Questions Included in the Semi-structured Interview.
1 Practice of home-based rehabilitation and unique viewpoint ofhome-based OT□ Please tell me the specific content that directly interfered withthe target person during the home-based OT.
□ Please tell me anything specific to OT.
□ Please tell us a unique perspective of home-based OT.
□ Any other practices of home-based OT
2 Intervention of OT with respect to the subjects□ Please tell me about actual environmental adjustment and intro­
duction of welfare equipment.
□ Please tell me specifically whether there is a point of viewunique to home-based OT.
□ Please tell me the role of home-based OT.
□ Any other approach of home-based OT

items in the interview list included (1) the participants’unique viewpoints on home-based rehabilitation, (2)outcomes of home-based OT, (3) environmental adjust­ments and (4) open-ended questions. With the partic­
ipants’ consent, interview data were recorded using a
digital voice recorder. The recorded interview content
was transcribed verbatim.
Data analysis was conducted using the Grounded
Theory Approach [13]. In Japan, there are few empirical
data from previous studies on the subject of this study
and there is no hypothesis about it. Therefore, to clarify
the occupation structure, we first adopted a qualitative
research design. Labels were generated using the Steps
for Coding and Theorization (SCAT) [14], and coding
and continuous comparative analysis were conductedsequentially, in conjunction with experienced instructors
in the field of health sciences, until opinions matched.
The labels obtained from SCAT were categorised ac­
cording to similarities; however, coding in this study
differed from that done in broad integration, such as in
SCAT, in that labels were assigned to each line. Labels
were named with gerunds, as recommended by Charmaz(2014) [15].The study used the qualitative data analysis
software MAXQDA 10 (VERBI, GmbH, Berlin, Germa­ny). The raw data were referred to, and the labels wererevised many times during their generation.
The Schnabel method was adopted for measuring
theoretical saturation [11]. This method can show thecapture rate from a rational perspective. Toyoda et al.
used the data capture rate as an indicator of the degreeof saturation [12]. To determine if theoretical sampling
had been achieved, the capture rate was calculated andevaluated at the point when almost no new findings wereseen. Schnabel method evaluations were determinedon the basis of the relationship between the overall
labels obtained from SCAT and the labels obtained
from the last case. Category reliability was examined by
calculating the concordance rate, using Scott’s pi [16],Minami S et al.

Asian J Occup Ther 15: 19−25, 201921

Table 2. Characteristics of the nine interviewed occupational therapists.
Subject

No. 1

No. 2

No. 3

No. 4

No. 5

No. 6

No. 7

No. 8

No. 9

GenderAge (y)Mean OT experience (y)Mean home-based OT experience (y)Mean number of weekly home visitsInterview time (min)

M
40s
19
16
20
48

M
30s
15
14
20
112

F
30s
12
9
8
50

M
30s
8
7
22
74

F
30s
16
4
24
60

M
30s
11
11
2
79

F
40s
16
6
23
91

M
40s
14
7
20
84

M
50s
30
20
1
60

M: male; F: female; OT: occupational therapy

which can verify the concordance rate corrected for con­cordance arising from coincidence. A concordance rateof 70% was deemed to ensure reliability in accordancewith a previous study [17].
Once the reliability of categorisation was con­firmed, we created a structural diagram depicting therelationship between categories. The structural diagram
was then used to create a storyline for the support pro­
cess of home-based OT.

research. There were three third parties. They worked
in practical research in the field of OT and had morethan 8 years of experience in community medical care.
They included two men and one woman with a mean
age of 37 (SD, ±6.4) years and mean home-based OT
experience of 14 (SD, ±4.9) years. The concordance rateaccording to Scott’s pi was at least 78.3% in all threeparties, which was deemed to indicate ensured reliability[18].

Results

Generation of categories for the process of realisinghome-based OT
Categories were generated by conducting a con­tinuous comparative analysis until opinions matchedthose of experienced instructors in the field of healthsciences. The categories were coded by the researchers
who compared codes. Analysis generated the following
categories: 1,572 text segments, 195 labels, 40 small
categories, 15 medium categories and six large catego­ries. The large categories consisted of (a) identifying
unique living activities, (b) analysing and predicting
living activities, (c) employing practices to confront
living activities, (d) creating an environment that fosters
living activities, (e) implementing independent living
activities and (f) co-operating to realise living activities.
When the large categories were classified by type forthe realisation of living activities, they formed the (A)co-operative building of living activity goals (a, b);(B) practical building of living activities (c, d); and (C)autonomous building of living activities (e, f) (Fig. 1).

Theoretical saturation of data and establishment of
reliability
Two researchers were involved in data analysis.
First, we individually created the code and then com­pared the codes to reach a consensus. The researchers
conducted the analysis with university faculty members
who have conducted doctoral programs in the field ofhealth care. In the interviews, from the seventh partici­
pant onwards, the interview content appeared to repeat
the same narrative. We therefore examined theoreticalsaturation using the Schnabel method. We verified reli­ability by confirming the capture rate with the Schnabel
method up to the ninth participant, who had 30 labels,
28 of which were the same as the overall labels and twoof which qualified as newly obtained labels, yielding acapture rate of 94.5%. Since the capture rate exceeded
90%, theoretical saturation was deemed to be achieved[16]. The nine participants comprised six men and three
women with a mean age of 35 (SD, ±6.8) years, mean
OT experience of 15 (SD, ±5.9) years, mean homebased OT experience of 10.4 (SD, ±4.9) years and amean of 15.5 (SD, ±8.6) for number of weekly home
visits (Table 2).
The reliability of categories was verified using
Scott’s pi. Third parties were shown small categories
and asked to identify the middle category in which theywould place these small categories to confirm the con­cordance rate with the analysts. The third parties includ­
ed a professor in health sciences, a qualitative researcher
and an occupational therapist not involved in qualitative

Storylines of supportive techniques in co-operativebuilding of living activity goals
In the process of realising living activities in thisstudy, the category for the co-operative building ofliving activity goals included (a) identifying uniquedaily living activities and (b) analysing and predicting
daily living activities (Fig. 2). These practices were sup­portive techniques forming the foundation for the prac­
tical building of daily living activities. The storylines ofeach supportive technique are indicated as follows by[…] for large categories, á…ñ for middle categories, “…”22

PRACTICE STRUCTURE OF HOME-BASED OTC) Autonomous building of living activitiesf) Cooperating to realise living
activitiese) Implementing independent
living activities

B) Practical building of living activitiesc) Employing practices to confront living
activitiesd) Creating an environment that
fosters living activities

A) Co-operative building of living activity goalsa) Identifying unique living activities

Fig. 1.

b) Analysing and predicting living
activities

Practical structural diagram of home-based occupational therapy for the realisation of living activities.

(iii) Intervening in a way that
respects patients’ life roles

Supporting living activities inwhich patients are interested② Intervening in a way that respects theseunique habits and roles(iv) Intervening in a waythat respects patients’living habits① Providing support to realise
unique living activities(a) Identifying unique living activities(v) Encouraging patients’unique aspects③ Encouraging a unique way of living

Supporting living activities
that maintain patients’ uniqueaspects(vi) Encouraging patients in living alife that feels unique to them(vii) Judging the degree of
patients’ awareness of
their own capabilities(viii) Judging the degree of patients’suspension of living activities④ Evaluating patients’ self-awareness of living
activities(ix) Judging living tasks thatpatients had not noticed(b) Analysing and predicting living activities(x) Analysing behaviour so that patientscan engage in their lifestyle⑤

Analysing patients’ adaptability to living
activities(xii) Analysing the work that isuseful for patients toperform in their lifestyle(xi) Analysing the environment sothat the patient can engage intheir lifestyle・ 'Unique' is regarded as a person's unique world feeling. In this research, we were aware of the existence of a person's unique lifestyle and regard it as a breakthrough for a new life.
・ 'Autonomous' is regarded as the authority to make his/her own decisions independently. This research considers the person to have authority to independently decide to challenge life.
・ 'Adaptability' is regarded as the quality required in a constantly changing environment. This research observes the extent of ability recognised in a person's daily activities.

Fig. 2.

Co-operative building of living activity goals set by occupational therapists and patients.

for small categories and ‘…’ for raw data.
a) Storyline for identifying unique living activities[Identifying unique living activities] involved á(1)providing support to realise unique living activitiesñ
to encourage living activities in which patients areinterested and to ensure that interest can be maintained.
Occupational therapists also gained an understandingof life roles and habits followed by á(2) intervening ina way that respects these unique habits and rolesñ. Fur­thermore, occupational therapists gained an understand­ing of the living situations of patients and encouraged

patients to embrace the feeling of living in that situation
so as to á(3) encourage a unique way of livingñ.
In á(1) providing support to realise unique living
activitiesñ, occupational therapists supported patients in
actualising their own living activities by “(i) supporting
living activities in which patients are interested” while“(ii) supporting living activities that maintain patients’unique aspects”. For example, an occupational therapist
responsible for a patient who was a Japanese danceteacher focused on daily living activities in which the
bedridden patient was interested, thereby revealing thatpatient’s unique lifestyle. In their story, the occupational

Minami S et al.

Asian J Occup Ther 15: 19−25, 2019

therapist described how ‘the patient talked about creat­
ing a form of Japanese dance that could be done sitting
down and actually created this form of dance’. This
‘greatly changed the patient’s lifestyle’.
In á(2) intervening in a way that respects theseunique habits and rolesñ, occupational therapists sup­ported patients in experiencing a unique lifestyle by“(iii) intervening in a way that respects patients’ liferoles” while also “(iv) intervening in a way that respects
patients’ living habits”. For example, an occupational
therapist of a patient with incomplete tetraplegia froma neck tumour supported the patient in living activities
tailored to his lifestyle. In their story, the occupational
therapist described how they ‘walked together, during
working hours, covering the 800-m distance from thepatient’s workplace to his house’.
In á(3) encouraging a unique way of livingñ,
occupational therapists supported patients through inter­
vention by “(v) encouraging patients’ unique aspects”
more at home and “(vi) encouraging patients in living alife that feels unique to them”. This involved supporting
patients so that they could perform their own individual
routines and live unique lifestyles in their familiar
homes. Occupational therapists intervened by surmising
how beneficial it is for the patient to live in his/herhome. In one of the stories, an occupational therapist
described how ‘it is natural to intervene in a way thatallows one to feel that the person is living’.
b) Storyline for analysing and predicting living activities[Analysing and predicting living activities] in­volved á(4) evaluating patients’ self-awareness of living
activitiesñ to gain an understanding of their awarenessof their own capabilities while á(5) analysing patients’adaptability to living activitiesñ to ascertain the degreeof engagement in living activities and predict patients’future living activities.
In á(4) evaluating patients’ self-awareness of living
activitiesñ, occupational therapists used “(vii) judging
the degree of patients’ awareness of their own capabil­ities” to gain an understanding of patients’ self-aware­ness of their own capabilities and used “(viii) judging
the degree of patients’ suspension of living activities”
to ascertain the living activities from which patientswere turning away. Occupational therapists also used“(ix) judging living tasks that patients had not noticed
to analyse living activities that patients were unable torecognise. Occupational therapists evaluated patients’adaptability to living activities. In one of the stories, anoccupational therapist described how ‘patients play alarge role in identifying needs of which they are not yetaware’.
In á(5) analysing patients’ adaptability to living ac­

23

tivitiesñ in home-based OT, occupational therapists used“(x) analysing behaviour so that patients can engage intheir lifestyle” to gain an understanding of the patient’s
lifestyle and used “(xi) analysing the environment sothat patients can engage in their lifestyle” to ascertain
the patient’s situation. Occupational therapists also
used “(xii) analysing work that is useful for patients toperform in their lifestyle” to analyse activities that cancontribute to maintaining their lifestyle. Occupational
therapists therefore analysed patients’ adaptability to adifferent lifestyle. In one of the stories, an occupational
therapist remarked, ‘If a patient in a wheelchair wishes
to visit a golf course and grasps and swings a golf club, I
would check the balance and swing, taking into accountthe environment of the golf course’. This was linked to
the next step, ‘I was able to listen to the patient’s stories
about where they went and what they did the week
before’.

Discussion“Identifying unique living activities” and “Analys­ing and predicting living activities” were based on the
co-operative building of living activity goals. Practising
support for patients in confronting living activities
identified a structure in which patients carry the ability
to autonomously lead their own lives. Occupational
therapists used patients’ living spaces to support themin performing their own living activities, accumulating
living activity experience, and engaging in living activi­
ties independently.
Christiansen (1999) [19] argued that occupation
expresses and identifies an individual’s identity. In otherwords, it is estimated that a lot of personal experiences
are accumulated in the living activities at home. In thecurrent report, “identifying unique living activities” isunderstood in the context of co-operative building ofdaily activity goals in home-based OT, and intervention
appears to focus on encouraging patient uniqueness andtheir sense of living a unique lifestyle. Furthermore, in“identifying unique living activities” in home-based OT,
occupational therapists directly intervene in patients’lifestyles, which indicates an interventional structure
wherein evaluation and support take place simultaneous­
ly in OT.
Meanwhile, when patients lack experience in en­
gaging in daily living activities because of an illness or
disorder, they have no opportunities to recognise theirown capabilities and may stop performing living activi­
ties at home [20]. Home-based OT involves “analysing
and predicting living activities” to gain an understandingof patients’ self-awareness of living activities, which
may serve to prevent the suspension of living activities.

24

PRACTICE STRUCTURE OF HOME-BASED OT

Furthermore, occupational therapists evaluated patients’
self-awareness of living activities to analyse and predictpatients’ adaptability to living activities. This suggeststhat occupational therapists predict patients’ futureliving activities on the basis of the degree of living ac­
tivity recognition and adaptability of patients.
In addition, occupational therapists promote
occupational engagement of patients [2, 21]. This ispresumed to be a challenge for patients themselves. This
involves “identifying unique living activities” and “ana­lysing and predicting living activities” to analyse adapt­ability to living activities and encourage motivation inpatients. In the practice of home-based OT, conventional
behavioural and environmental analyses and analyses ofwork that is useful to patients’ lifestyles are conducted
to examine opportunities to motivate patients. Patientsare consequently thought to willingly engage in living
activities.
The MTDLP includes confirmation, analysis andprognosis of living behaviour. Our findings indicatedthat providing support to realise unique living activities,
intervening in a manner that respects these unique habits
and roles and encouraging a unique way of living are in­fluential factors in the identification of living activities.
Evaluating patients’ self-awareness of living activities
and analysing their adaptability to living activities wereidentified to affect the analysis and prediction.
In other words, home-based OT has no fixed way as
many personal experiences of patients are accumulated.
Occupational therapists suggested that it is important tocollaboratively explore the patient’s unique living activ­
ities.

Conclusions
The process of facilitating daily living activities inelderly individuals living in the community is supported
by home based occupational therapists. Therefore, thepractices of experienced occupational therapists respect
the uniqueness of patients, and the process of cooper­
atively building goals with occupational therapists ap­
pears to allow patients to autonomously perform living
activities.
By this research, interventions for occupational
therapists working in elderly people and communities
to maintain and improve daily living functions make thecurrent state of their daily activities visible, and show
the daily activities to be tackled along with their abili­ties. In other words, it is inferred that it is adapting theliving act within the range that the elderly knows.
In this study, the viewpoint of occupational therapy
realised the living behaviour of the patient. However,
we could not judge whether we responded to our own

emotions and feelings in this research nor show the rela­tionship with patient intention.
In the future, according to the process of thisresearch, we need to develop a questionnaire and achecklist as indicators and examine the viewpoint ofoccupational therapy.
Acknowledgements: We would like to give our sincere
thanks to the occupational therapists who generously
agreed to participate in this study. Finally, we are grate­
ful to the referees for useful comments on earlier versionof this paper.

Conflicts of Interest
The authors declare that there is no conflict of inter­est regarding the publication of this article.

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■ORIGINAL ARTICLE

Clinical Indicators and Thresholds
for Determining Discharge Destinationfrom Acute Stroke Ward
Kazuaki Iokawa, OTR, PhD1, Toshimasa Sone, OTR, PhD2,
Takaaki Fujita, OTR, PhD2, Tetsu Tsukada, OTR, PhD3,Mariko Kaneda, OTR3, Keiichi Hasegawa, OTR, MS3
1

Preparing section for New Faculty of Medical Science, Fukushima Medical University, Fukushima, Japan
Department of Rehabilitation, Faculty of Health Science, Tohoku Fukushi University, Sendai, Japan3
Department of Rehabilitation, Takeda General Hospital, Aizuwakamatsu, Japan
2

Abstract: Objective: The present study aimed to investigate the complex interaction of factors affecting discharge destination after the acute phase of stroke.
Methods: In 304 patients with stroke who required rehabilitation, we focused on three discharge destinations (i.e.,home, convalescent rehabilitation ward, and other facility). Sociodemographic, medical, and acute symptoms data,
within the first week of stroke onset and discharge destination, were collected from acute stroke wards. The complex
interaction of factors relating to discharge destination from an acute stroke ward was investigated by classification andregression tree analysis.
Results: Patients with a total Functional Independence Measure (FIM) score > 35, a Brunnstrom recovery stage of thelower limb > V, and a comprehension FIM score > 5 had a 91.7% chance of home discharge. By contrast, patients witha total FIM score ≤ 35, age ≤ 79.5 years, and > 2.5 family members had an 80% chance of discharge to a convalescentrehabilitation ward. Finally, patients with a total FIM score ≤ 35, age > 79.5 years, and an expression FIM score ≤ 3 had
a 78.6% chance of discharge to other facilities.
Conclusion: The interaction of independence on FIM, function of the paralyzed lower limb, age, number of family
members, and comprehension or expression function affect the choice of discharge destination from acute stroke wards.
Keywords: rehabilitation, stroke, prediction, discharge destination, classification and regression tree

(Asian J Occup Ther 15: 27−35, 2019)

Introduction
Discharge planning is important for patients after
acute stroke to ensure that medical resources are usedeffectively through appropriate rehabilitation planning[1, 2]. Acute care hospitals typically determine discharge
destinations on the basis of a patient's initial status at
hospitalization, with home, convalescent rehabilitation
ward, other hospital, or long-term care facility being
Received: 10 April 2018, Accepted: 24 February 2019
Corresponding to: Kazuaki Iokawa, Preparing section for New Facultyof Medical Science, Fukushima Medical University, 1 Hikarigaoka,
Fukushima City, Fukushima, 960-1295, Japane-mail: iokawa@fmu.ac.jp©2019 Japanese Association of Occupational Therapists

the main options. Prediction of discharge destination at
an early stage is necessary for implementing effective
occupational therapy for patients with acute stroke. A
previous study has reported that improved prediction ofdischarge destination could shorten acute stays, improveoutcomes, and reduce treatment costs [3]. Therefore,a patient’s discharge destination should be consideredsoon after admission [2, 4].
The rehabilitation team plays a key role in evaluating activity limitations and rehabilitation tolerance, andthey are therefore important for determining discharge
destinations [5]. Especially, occupational therapists are
required to be involved in determining discharge destinations in the rehabilitation team because they are
responsible for supporting patients’ activities and social
participation. In general, stroke rehabilitation in Japan

28

CLINICAL INDICATORS AND THRESHOLDS AFFECTING DISCHARGE DESTINATION

is delivered in acute, convalescent, and maintenancephases [6]. During the acute phase in acute care settings,
rehabilitation aims to encourage compensatory functionsin the cerebrum to restore the functional impairment
while preventing disuse syndromes [6]. Once this phasehas passed, patients enter the convalescent phase. Iffurther improvement of function can be expected, thesepatients undergo intensive rehabilitation in convalescentrehabilitation wards until they are discharged from
hospital [6]. The main purpose of rehabilitation in themaintenance phase is to maintain the acquired functions,activities, and social participation for as long as possible. In the maintenance phase, patients use home-visit
rehabilitation or facility services, such as the welfare
facilities for the elderly requiring long-term care, inlong-term care insurance system. However, patients areoften discharged to their homes after using the rehabilitation of facility service in the health care facilities forthe elderly requiring long-term care.
Discharge destination after acute stroke has beenreported to be predicted by many factors, including
age, race, gender, medical complications/comorbidities,
neurological complications, and environmental andsocioeconomic factors [4]. In particular, younger age
has been identified as a significant factor for being
discharged home [7−9]. High scores on Functional Independence Measures (FIM) of activities of daily living(ADL) at admission have also been associated withhome discharge versus discharge to other settings [10].
Indeed, functional dependence of ADL on admission isconsidered the most important determinant of discharge
destination by some researchers [7, 11, 12], though thenumber of family members and the marital status havealso been associated with better chances of being discharged home [11, 13]. Thus, the choice of discharge
destination is influenced, not by a single factor, but by
a combination of factors [2], that has yet to be clarified.
This is further confounded by the fact that many previous studies on discharge destination after acute strokes
have used dichotomous categories (i.e., home versus
other facilities) [2, 9, 13−15], limiting their usefulness.
That is, the dichotomous categories of discharge destination can predict patients who are likely to be discharged
home, but cannot predict patients who are likely to betransferred to convalescent rehabilitation ward.
In Japan, there is a need to develop appropriate
decision-making policies for discharge planning to convalescent rehabilitation wards, other hospitals, or longterm care facilities. Moreover, this needs to be applicable in the acute phase of stroke. Therefore, we aimed
to investigate the complex interaction of factors that
influence discharge destination after acute stroke, focusing specifically on discharge to home, convalescentrehabilitation wards, or other facilities. Furthermore,
we aimed to analyze the combinations of related factorsof discharge destination in clinically useful method(decision tree analysis). This information could be usedby not only professionals in acute stroke ward, such as
medical doctor, occupational therapists and physicaltherapists, but also patients and family members tofacilitate discharge planning as early as possible duringhospitalization. Furthermore, by being able to predict
discharge destination, the problems of ADL of patientsand the needs of patients and their families will become
concrete, and the goal of occupational therapy can be set
more clearly. In other words, the prediction of discharge
destination enables more effective occupational therapy
program and environment adjustment (including welfare
equipment) of the living situation in the acute phase of
stroke. Moreover, by the early decision of the discharge
destination, collaboration between acute care ward
and post-discharge institution becomes possible fromthe early stage; therefore, occupational therapists canadjust necessary service contents and support system forpatients, and seamlessly provide necessary occupational
therapy to patients after discharge.

Materials and Methods
We enrolled patients admitted to the Takeda
General Hospital with a diagnosis of stroke who wereprescribed rehabilitation therapy between July 2014 andJune 2016. For inclusion, patients were required to beaged ≥20 years and to have their initial rehabilitationassessment conducted within 1 week of symptom onset.
We excluded patients who died or had missing data.
All enrolled patients were required to provide writtenconsent for participation and were given an opportunity
to refuse to participate in the study.
Takeda General Hospital is a certified Aizu Community-Based Rehabilitation Center in the Fukushima
prefecture that has 897 hospital beds and offers multidisciplinary care for cerebrovascular disease [16]. The
rehabilitation team consisted of a neurologist, a rehabilitation physician, an occupational therapist, a physiotherapist, a speech therapist, a nurse, and a social worker.
Multidisciplinary team meetings were conducted weekly
to discuss rehabilitation and discharge planning (including destination). During these meetings, the occupational therapists were asked by the doctors about the ADL
goal based on functional prognosis. Furthermore, basedon the results of the initial evaluation and the needs ofpatients and their families, occupational therapists wereasked for opinions on the place of transference and therequired services when performing patient’s acute postrehabilitation. Based on the information collected at

Iokawa K et al.

Asian J Occup Ther 15: 27−35, 2019

these meetings, the support staff creates a patient’s discharge plan.
This study protocol was reviewed and approvedby the Ethics Committee of Tohoku Fukushi University(RS14071106).
Occupational therapists collected all sociodemographic and medical data, such as age, sex, numberof family members, dominant hand, type of stroke,affected side, and the history of illness. Furthermore,
occupational therapists assessed the acute symptomsof stroke patients within the first week of symptom
onset, as follows: consciousness [Japan Coma Scale(JCS) score] [17], upper limb function [Brunnstrom
recovery stage (BRS) for the upper limb] [18], lower
limb function (BRS for the lower limb) [18], sensationin the upper and lower limbs, upper and lower limb joint
range of motion, limb and trunk ataxia, agnosia, apraxia,
aphasia, hemianopia, trunk control test [19], Functional
Ambulation Categories classification [20], cognitive
function [Hasegawa Dementia Scale—Revised (HDS-R)
score] [21], and ADL (using the FIM) [22]. Moreover,evaluation in case of severe consciousness disorder was
objectively evaluated based on the fact that it was confirmed by each test of the acute symptoms in principle.
However, in particular, those with a consciousness levelof 100−300 in JCS were rated as 0 in HDS-R. BRS wasevaluated based on reactions that could be confirmed bypalpation and observation scenes, and the sensation was
mainly evaluated through a response by pain stimulus.
Finally, we identified the discharge destination from theacute care ward.
Statistical analysis
Subjects were divided into three groups basedon discharge destination (i.e., home, convalescentrehabilitation ward, or other facilities). Differences insocio­demo­graphic profiles, medical profiles, and acutesymp­toms were tested among these groups by one-way
analysis of variance for continuous variables or by the
Kruskal–Wallis and chi-squared test for categoricalvariables. All statistical analyses were performed using
the IBM SPSS Version 25.0 (IBM Corp., Armonk, NY,
USA). The level of statistical significance was set at
a p-value of < 0.05. Descriptive data are presented as
numbers (percentages) or as means ± standard deviations (SDs).
Classification and regression tree (CART) analysis
was used to investigate the complex interaction offactors related to discharge destination in the previous
analyses. Binary trees were used to split predictor
variables recursively with yes/no questions about eachvariable [23]. The CART algorithm produced a tree fromthe root by selecting the best predictor variable, defined29

as that with the lowest Gini index value as an internal
node [24]. We specified a growing depth of three withthe parent node having at least 10 subjects and a childnode having at least three subjects [25]. The partitioning process was recursively applied until the stopping
criteria were fulfilled or splitting was impossible [24].
Additionally, we performed a 10-fold cross-validationin which we randomly divided data into 10 groups (nineused to build and one used to validate the model) [26].
The sample size of this study was based on the previous
study that used a CART analysis [27] because it is difficult to determine the number of samples required fora study on the interaction of factors affecting discharge
destination after the acute phase of stroke using CART
analysis.

Results
In total, 414 patients were enrolled during the study
period, from which we excluded 110 patients (12 diedand 98 had missing data). Consequently, our final analysis included 304 patients. The mean time to assessment
from symptom onset was 1.4 ± 1.2 days. The mean age
was 78.5 ± 11.7 years, and the male to female distribution was similar (154 men and 150 women). Approximately 75% of patients had suffered cerebral infarctions.
Histories of stroke and hypertension were present in
36.2% and 62.8%, respectively, and approximately 60%
of patients had a history of circulatory disease. The
mean HDS-R score was 12.8 ± 11.4, and the mean FIM
score was 44.0 ± 25.2. The clinical characteristics ofthe patients are summarized by discharge destination in
Table 1.
Among the 304 patients, 102 (33.6%) were dis­charged home, 107 (35.2%) were transferred to aconvalescent rehabilitation ward, and 95 (31.3%) weretransferred to other facilities. Concerning the socio­
demo­graphic and medical profiles, there were significant
differences in the age, sex, number of family numbers,
and history of mental and behavioral disorders amonggroups based on discharge destination. There were alsosignificant differences in all acute symptoms except fortrunk ataxia, apraxia, and hemianopia. Finally, significant differences were present for all FIM scores, except
for stair climbing (Table 2).
In the CART analysis, the total FIM score (> 35or ≤ 35) was identified as the single best discriminatorof discharge destination (Fig. 1). Patients with a total
FIM score > 35, a BRS of the lower limb > V, and an
FIM comprehension score > 5 had a 91.7% probabilityof home discharge. Moreover, patients with a total FIM
score > 35, a BRS of the lower limb ≤ V, and an FIM
motor score > 44 had an 81.2% probability of home

30

CLINICAL INDICATORS AND THRESHOLDS AFFECTING DISCHARGE DESTINATION

Table 1. Characteristics of the study subjects (n = 304)
Discharge destination from acute care ward
VariablesHome(n = 102)

Convalescentrehabilitation ward(n = 107)

Other facilities(n = 95)

P value

Age, years, mean ± SD
Female, n (%)
Number of family members, mean ± SD
Dominant hand side (right), n (%)
Type of stroke (ischemic/ hemorrhage), n (%)
Paralyzed side (right), n (%)
History of illness, n (%)
StrokeHypertension
Heart disease
Hyperlipidemia
Diabetes mellitus
Japan Coma Scale, n (%)
Grade 0, Normal
Grade 1, Single digit
Grade 2, Double digits
Grade 3, Triple digits
BRS of the upper limb, n (%)
I
II
III
IV
V
VI
BRS of the lower limb, n (%)
I
II
III
IV
V
VI
Sensation of the upper limb, n (%)
DeficitSensation of the lower limb, n (%)
Deficit
ROM of the upper limb, n (%)
Deficit
ROM of the lower limb, n (%)
DeficitAtaxia of limbs, n (%)
Presence
Ataxia of trunk, n (%)
Presence
Agnosia, n (%)
Presence
Apraxia, n (%)
Presence
Aphasia, n (%)
Presence
Hemianopia, n (%)
Presence
Trunk control test, mean ± SD
Functional Ambulation Categories, mean ± SD/median (range)
HDS–R scores, mean ± SD

75.4 ± 12.1
47 (46.1)
3.2 ± 1.8102 (100)
84 (82.4)/18 (17.6)
45 (44.1)

75.3 ± 10.7
46 (43.0)
2.8 ± 1.7
105 (98.1)
74 (69.2)/33 (30.8)
59 (55.1)

85.6 ± 9.3
57 (60.0)
2.4 ± 1.8
94 (98.9)
69 (72.6)/26 (27.4)
58 (61.1)< .001
.039
.007
.392
.165
.052

34 (33.3)
62 (60.8)
29 (28.4)
15 (14.7)
24 (23.5)

39 (36.4)
67 (62.6)
32 (29.9)21 (19.6)
32 (29.9)37 (38.9)
62 (65.3)
33 (34.7)
13 (13.7)
17 (17.9)

.713
.808
.608
.463
.135

59 (57.8)
37 (36.3)
6 (5.9)0 (0)26 (24.3)
61 (57.0)
17 (15.9)
3 (2.8)6 (6.3)47 (49.5)
30 (31.6)
12 (12.6)< .0012 (2.0)4 (3.9)6 (5.9)11 (10.8)
26 (25.5)
53 (52.0)

6 (5.6)28 (26.2)
18 (16.8)
20 (18.7)
22 (20.6)
13 (12.1)

16 (16.8)
28 (29.5)
15 (15.8)
16 (16.8)
12 (12.6)
8 (8.4)< .0013 (2.9)3 (2.9)5 (4.9)5 (4.9)32 (31.4)
54 (52.9)

4 (3.7)22 (20.6)
13 (12.1)
24 (22.4)
33 (30.8)
11 (10.3)

13 (13.7)
25 (26.3)
14 (14.7)
19 (20.0)
16 (16.8)8 (8.4)< .00136 (35.3)

54 (50.5)

55 (57.9).006

30 (29.4)

53 (49.5)

53 (55.8)< .0016 (5.9)11 (10.3)

21 (22.1).002

7 (6.9)9 (8.4)18 (18.9).014

5 (4.9)14 (13.1)

3 (3.2).013

2 (2.0)7 (6.5)

1 (1.1).060

4 (3.9)15 (14.0)

16 (16.8).011

2 (2.0)6 (5.6)4 (4.2).395

11 (10.8)

25 (23.4)

31 (32.6).001

9 (8.8)69.2 ± 37.0
1.6 ± 1.6/2.0 (0−3)
19.3 ± 9.9

7 (6.5)33.4 ± 37.9
0.3 ± 0.8/0.0 (0−0)
14.3 ± 10.8

11 (11.6)
12.7 ± 26.2
0.2 ± 0.6/0.0 (0−0)
4.2 ± 7.5.454
< .001< .001< .001

BRS: Brunnstrom recovery stage; ROM: Range of motion; HDS–R: Hasegawa Dementia Scale–Revised; SD: standard deviation.

Iokawa K et al.

Asian J Occup Ther 15: 27−35, 201931

Table 2. The Functional Independence Measure scores by discharge destination
Discharge destination from acute care ward
VariablesHome(n = 102)

Convalescentrehabilitation ward(n = 107)

Other facilities(n = 95)

P value

Eating, mean ± SD/median (range)
Grooming, mean ± SD/median (range)
Bathing, mean ± SD/median (range)
Dressing upper body, mean ± SD/median (range)
Dressing lower body, mean ± SD/median (range)
Toileting, mean ± SD/median (range)
Bladder management, mean ± SD/median (range)
Bowel management, mean ± SD/median (range)
Transfers to bed/chair/wheelchair, mean ± SD/median (range)
Transfers to toilet, mean ± SD/median (range)
Transfer to tub/shower, mean ± SD/median (range)
Walking or wheelchair propulsion, mean ± SD/median (range)
Stair climbing, mean ± SD/median (range)
Comprehension, mean ± SD/median (range)
Expression, mean ± SD/median (range)
Social interaction, mean ± SD/median (range)
Problem solving, mean ± SD/median (range)
Memory, mean ± SD/median (range)
Motor FIM Score, mean ± SD/median (range)

4.3 ± 2.2/5 (1−6)
3.1 ± 2.1/3 (1−5)
2.2 ± 1.7/1 (1−4)
2.3 ± 1.5/1 (1−4)
2.5 ± 1.8/1 (1−4)
3.3 ± 2.3/4 (1−5)
3.9 ± 2.8/3.5 (1−7)
3.9 ± 2.8/4 (1−7)
3.4 ± 2.1/4 (1−5)
3.4 ± 2.1/4 (1−5)
1.2 ± 0.9/1 (1−1)
2.1 ± 1.7/1 (1−4)
1.0 ± 0.1/1 (1−1)
5.6 ± 1.8/7 (5−7)
5.7 ± 1.8/6 (5−7)
5.7 ± 2.2/7 (6−7)
4.7 ± 2.6/6 (1−7)
5.0 ± 2.2/6 (3−7)
36.7 ± 19.9/36.5(16−56)26.7 ± 9.7/32(18.8−35.0)
63.4 ± 27.3/64.5(38.8−89.0)

2.6 ± 2.0/1 (1−5)
1.5 ± 1.2/1 (1−1)
1.2 ± 0.6/1 (1−1)
1.4 ± 0.8/1 (1−1)
1.4 ± 0.9/1 (1−1)
1.6 ± 1.3/1 (1−1)
1.9 ± 1.7/1 (1−2)
2.1 ± 2.0/1 (1−2)
1.7 ± 1.3/1 (1−2)
1.7 ± 1.3/1 (1−1)
1.0 ± 0.3/1 (1−1)
1.1 ± 0.6/1 (1−1)
1.0 ± 0.0/1 (1−1)
4.7 ± 2.0/5 (3−6)
4.5 ± 2.1/5 (3−6)
4.9 ± 2.6/6 (1−7)
3.3 ± 2.5/1 (1−5)
4.0 ± 2.2/3 (2−6)
20.1 ± 10.9/14(13−24)21.3 ± 9.6/22(14−30)41.3 ± 17.1/39(27−51)

1.5 ± 1.4/1 (1−1)
1.2 ± 0.8/1 (1−1)
1.1 ± 0.5/1 (1−1)
1.1 ± 0.5/1 (1−1)
1.1 ± 0.5/1 (1−1)
1.2 ± 0.8/1 (1−1)
1.2 ± 1.1/1 (1−1)
1.2 ± 1.1/1 (1−1)
1.2 ± 0.8/1 (1−1)
1.2 ± 0.9/1 (1−1)
1.0 ± 0.0/1 (1−1)
1.1 ± 0.6/1 (1−1)
1.0 ± 0.0/1 (1−1)
2.5 ± 1.7/2 (1−4)
2.4 ± 1.8/2 (1−3)
2.6 ± 2.5/1 (1−5)
1.7 ± 1.6/1 (1−1)
1.9 ± 1.6/1 (1−2)
15.0 ± 7.9/13(13−13)11.0 ± 7.7/8(5−14)
26.1 ± 13.3/21(18−27)< .001< .001< .001< .001< .001< .001< .001< .001< .001< .001.029< .001.372< .001< .001< .001< .001< .001

Cognitive FIM score, mean ± SD/median (range)
Total FIM score, mean ± SD/median (range)< .001< .001< .001

FIM: Functional Independence Measure; SD: standard deviation.

discharge, whereas those with a total FIM score ≤ 35,
age ≤ 79.5 years, and with > 2.5 family members had
an 80% probability of discharge to a convalescent rehabilitation ward. Finally, patients with a total FIM score≤ 35, age > 79.5 years, and FIM expression score ≤ 3
had a 78.6% probability of discharge to other facilities(e.g., long-term care). The 10-fold cross-validation
showed that the outcomes of 61.5% of the patients werecorrectly predicted by the CART analysis.

Discussion
CART analysis indicated that functional ADL status,
lower limb function, and comprehension ability at
admission were most strongly associated with homedischarge. Of note, the total FIM score at admission(> 35 or ≤ 35) was the best predictor of discharge destination. A total FIM score of 35 points is almost at thelevel of total or maximal ADL assistance, indicating thatcomplete dependence of ADLs (i.e., a total FIM score≤ 35) at the initial assessment within 1 week of stroke
onset made home discharge very unlikely. By contrast,
when patients with a total FIM score > 35 had retained

lower limb function (BRS of the lower limbs > V) andcomprehension (FIM comprehension score > 5), homedischarge was more likely. Therefore, we recommendthat occupational therapists use these results as clinicalindicators and thresholds for determining discharge destination.
A BRS of the lower limb of VI implies normal
muscle tone and control [28], and an FIM comprehension score > 5 implies independence level [29].
After a stroke, patients are usually forced to rest in
bed for medical treatment despite having functional
ability. However, under conditions where ADLs wererestricted, home discharge was the most likely, in ourcohort, in case of BRS of the lower limbs > V and FIM
comprehension score > 5. Home discharge was also
highly probable if patients with a total FIM score > 35
and a BRS of the lower limb ≤ V (i.e., apparent motor
paralysis) had an FIM motor score > 44. Despite thepoor BRS, patients with an FIM motor score > 44 can be
expected to have relatively mild motor paralysis of thelower limbs because the average FIM motor score was
36.7 ± 19.9 in the home discharge group.
When the FIM motor score reaches the 40-point

32

CLINICAL INDICATORS AND THRESHOLDS AFFECTING DISCHARGE DESTINATIONBRS: Brunnstrom recovery stage; FIM: Functional Independence Measure; Rehabilitation ward: Convalescent rehabilitation ward.
Fig. 1. Classification and regression tree for discharge destination after the acute phase of stroke
Patients with a total FIM score > 35, a BRS of the lower limb > V, and an FIM comprehension score > 5 had a 91.7%
probability of home discharge. Patients with a total FIM score > 35, a BRS of the lower limb ≤ V, and an FIM motorscore > 44 had an 81.2% probability of home discharge, whereas those with a total FIM score ≤ 35, age ≤ 79.5 years,
and with > 2.5 family members had an 80% probability of discharge to a convalescent rehabilitation ward. Patients witha total FIM score ≤ 35, age > 79.5 years, and FIM expression score ≤ 3 had a 78.6% probability of discharge to otherfacilities (e.g., long-term care).

level, it has been reported that other items of the motor
FIM indicate less than moderate assistance, except foritems related to bathing (bathing and transfer to tub/shower) and locomotion (walk or wheelchair) [30].
Eating, bladder management, and bowel management
are considered the easiest of the FIM motor items,
whereas walking or wheelchair use, tub/shower transfer,using stairs, and bathing are the most difficult [31]. The
results of the present study are consistent with thesestudies [30, 31]. On the other hand, bathing-related
activity and locomotion are highly likely to reduce theamount of assistance needed through welfare equipment
and social resources [30]. Therefore, patients with 40 or
more FIM motor points are likely to be discharged home[30]. Occupational therapists should conduct a detailed
assessment of each activity of ADL, and it is importantto carry out environmental interventions using assistive
devices or welfare equipment from the acute stage.
Additionally, if necessary, various services and social

resources should be utilized.
When patients had a total FIM score ≤ 35, wereaged ≤ 79.5 years, and had > 2.5 family members, thechance of discharge to a convalescent rehabilitation
ward increased. This suggested that, even if the ADL atstroke onset indicated the need for full assistance, there
remained a high probability of transfer to a convalescentrehabilitation ward if the patient was younger than 79.5
years and had three or more family members. Patientsare expected to improve further when admitted to aconvalescent rehabilitation ward [6]. Previous studies
have also shown that a patient’s age and the number offamily members were related to home discharge [7−9].
Our data indicate that transfer to a convalescent rehabilitation ward may be more appropriate in this group,with the ultimate goal being home discharge. Moreover,patients with a total FIM score > 35, a BRS of the lower
limb ≤ V, and an FIM motor score ≤ 44 had approximately a 70% chance of discharge to a convalescentAsian J Occup Ther 15: 27−35, 2019rehabilitation ward. Requiring moderate to maximal assistance in the total FIM at stroke onset, excluding items
related to bathing and locomotion, may predict recovery
in future rehabilitation.
Factors associated with discharge to other facilities,
such as other hospitals or long-term care facilities,
were near-total assistance on the ADL assessment, age
80 years or over, and the need for more than moderateassistance with expression. This suggests that not only
motor function but also cognitive function must be
severely impaired for patients to be discharged to otherfacilities. In clinical practice, even if there is severe
dysfunction at onset, patients can recover function in
the future, and patients with family support at home areoften first transferred to a convalescent rehabilitation
ward. Although severe disability makes home discharge
difficult, there are cases in which it may remain possible, such as when there is adequate support from family
and welfare services. The results of this study wereconsistent with those of previous studies [11].
Several studies have been done using regression
analysis to predict discharge destinations after stroke[7−11, 13], but few have used CART analysis. For example, Falconer et al. used CART analysis to show thatindependence in toilet management, bladder management, and toilet transfer, as well as adequacy of financial
resources, affected the outcomes of patients after stroke[27]. Furthermore, El-Solh et al. reported that several
variables predicted the discharge destination of stroke
patients in post-acute geriatric rehabilitation units. These
were as follows: age; preadmission living environment;
nursing severity index; cardiac, musculoskeletal–integument, and lower gastrointestinal symptoms; toiletingtransfer; and toilet management [32]. By using signal
detection analysis, Miyamoto et al. also showed that
ADLs, key person preference, age, gender, route taken
to hospitalization, residence before hospitalization, anddiagnosis of dementia were significant predictors of discharge destination [2]. Even though there are differencesin the methods of analysis, the variables associatedwith discharge destination tend to be the same in thesestudies. However, because CART analysis can provide amodel diagram (e.g., Fig. 1) of the complex interactionof factors relating discharge destination, it provides
more useful information for clinical reasoning comparedwith logistic regression analysis. Furthermore, this study
showed multiple clinical indicators in the acute phaseof patients, who were expected long-term recovery andeventually would be discharged to their home by placing
convalescent rehabilitation ward in the category of discharge destination.
We believe that the present study would provide
useful information for occupational therapy practice

Iokawa K et al.

33

in the acute phase of stroke. First, occupational therapists will be able to concretely examine the priority ofpatients’ daily life problems in the acute phase with along-term perspective, by using these clinical indicators
to make discharge predictions. Second, occupational
therapists will be able to more accurately conceptualize
the occupational therapy goals under discharge prediction, taking into consideration the needs of patients andtheir families, and as a result, it would be possible tointroduce interventions, not only viewpoints of physicaland cognitive functions but also activities, occupations
or environment adjustment in the acute phase. We believe that the goals of occupational therapy according topatients’ future life are definitely reflected in the goals of
the acute rehabilitation team. Third, occupational therapists will be able to communicate patients’ problems,particularly with respect to the next stage after the acutephase; i.e., occupational therapists are required to coordinate service contents and support systems necessary
for patients in post-discharge institution, and the resultsof this study are considered to be useful as appropriate
discharge plan in acute stroke patients. American Occupational Therapy Association (AOTA) recommends
that occupational therapy’s holistic approach should
focus on patient’s goals and integrate occupation-based
activities into the rehabilitation process of acute care[33]. Moreover, AOTA also recommends that occupational therapists collaborate closely with other healthcare professionals to create an interdisciplinary plan ofcare and a coordinated and appropriate discharge plan[33]. Therefore, the present study is believed to further
promote occupational therapists’ practices in the acutephase of stroke.
Study Limitations
This study has several limitations. First, we only
included patients from one acute care ward, making it
is difficult to generalize our findings and making multicenter collaboration necessary in the future. Second,previous studies have reported that it is desirable toconsider a patient's discharge destination soon after
symptom onset to screen for further interventions [2, 7].
However, predicting discharge as a short-term outcome
is not necessarily synonymous with predicting optimal
rehabilitation and long-term outcomes [34]. Given thatit has also been reported that outcomes should not be
predicted before day seven after a stroke [35], there
remains a need to confirm the optimal time at which
outcomes should be predicted. Third, we did not include
key background factors, such as household income,housing conditions, and local community resources,that are known to be important when making discharge
decisions. Verification of the role of these is needed in

34

CLINICAL INDICATORS AND THRESHOLDS AFFECTING DISCHARGE DESTINATION

future research, aiming to determine whether their inclusion produces different decision trees in CART analysis.
Finally, with regard to statistical analysis, because
there are many items to consider in this study, there areconcerns about the problem of multiple testing. Thus,
further verification is necessary in the future.

Conclusion
The findings of this study suggested that degreeof independence on the FIM, function of the paralyzed
lower limb, age, number of family members, and comprehension or expression function influence the choiceof discharge destination for patients from acute stroke
wards. However, further studies are needed to clarify
the clinical indicators that determine the likely discharge
destination from acute stroke wards. This is becauseintervention of occupational therapists based on accurate
prognostic prediction in acute stroke rehabilitation isextremely important for supporting patients’ activities
and social participation.

Conflicts of Interest
The authors have no conflicts of interest to declare.
Acknowledgments: The authors would like to thank all
the study patients.

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■ORIGINAL ARTICLE

The Influence of Physical Function
on Drawing Performance and Drawing Motionin Clumsy Children
Chisa Ikeda1, Sonomi Nakajima2, Toshio Ohyanagi3, Yuji Nakamura2,
Yasuhito Sengoku2
1

Special Needs Education Course, Hokkaido University of Education, Japan
Department of Occupational Therapy, School of Health Sciences, Sapporo Medical University, Japan3
Department of Liberal Arts and Sciences, Center for Medical Education, Sapporo Medical University, Japan
2

Abstract: Background: Children with developmental disorders who require occupational therapy often show clumsiness in handwriting (hereafter referred to as clumsy children). The quality of handwriting has been reported to be deteriorated in children who had physical function-related issues for using handwriting tools. However, to date there has notbeen any clinical research to investigate the types and severity of deficits in physical function that influence the using
handwriting tools. Similarly, how the trends and the severity of problems in physical function affect the characteristicsof the results of handwriting task was previously unaddressed.
Objective: This study investigated the influence of characteristics of physical function on drawing performance anddrawing motion in clumsy children.
Method: Participants were healthy children and clumsy children enrolled in grades 2–6 of elementary school. The participants’ drawing performance was evaluated using the triangle drawing task on a tablet personal computer. The participants’ drawing motion was evaluated using the two-dimensional movement analysis device. The physical function ofclumsy children was evaluated using the clinical observational assessment.
Results: The largest stray distance, the range of speed and the difference of speed for the healthy child group by gradeand each clumsy child. The sway length ratio of the clumsy children differed from those of the healthy children group.
Clumsy children who exhibited poor drawing skills also had problems in posture maintenance, muscle condition, upper
limb coordination, and eye movement.
Conclusion: We found the influence of poor physical function on poor drawing and drawing motion in clumsy children.
Keywords: developmental disabilities, clumsy children, drawing performance, drawing motion, physical function(Asian J Occup Ther 15: 37−44, 2019)

Introduction
Children with developmental disorders who require
occupational therapy often show clumsiness in writing
and drawing (hereafter referred to as clumsy children)[1].
Previous studies have examined the accuracy ofReceived: 26 February 2018, Accepted: 29 January 2019
Corresponding to: Chisa Ikeda, Special Needs Education Course,
Hokkaido University of Education, 5-3, Ainosato, Kita-ku, Sapporo,
Hokkaido, 002-8501, Japane-mail: nikonikochisa57@gmail.com©2019 Japanese Association of Occupational Therapists

drawing tasks using PC tablets to measure changes in
speed and pen pressure while drawing figures. Thesestudies have reported that clumsy children exhibit alower level of accuracy in drawing and show patterns ofdrawing speed changes that are different from those ofchildren with typical development (hereafter referred toas healthy children) [2–4]. These studies also noted that
accuracy and speed changes both differ greatly between
individual clumsy children. However, clumsy children
who present with problems associated with using a
pen are uniformly assessed as having poor handwriting
skills, then clinical support based on individual problems has not been examined.
Previous reports have identified numerous factors

38

INFLUENCE OF PHYSICAL FUNCTION ON DRAWING IN CLUMSY CHILDREN

that affect the test results of children assessed as having
poor handwriting skills in using a pen. These factors
include problems in physical function, such as decreased
cooperativeness and manual dexterity of the upper limbs,
difficulty in maintaining posture, controlling muscle
tone and poor eye movements. Additionally, the qualityof handwriting has been reported to be deteriorated inchildren who had physical function related issues forusing handwriting tools [5–9]. However, to date there
has not been any clinical research to investigate thetypes and the severity of deficits in physical functionthat influence the using of handwriting tools. Similarly,
how the trends and the severity of problems in physicalfunction affect the characteristics of the results of handwriting task was previously unaddressed.
In this study, we clarified the relationship between
drawing performance and drawing motion in clumsy
children as compared to that in healthy children byanalyzing the results of a drawing task and their drawing
motions while doing the task. Additionally, by analyzing
physical function we also elucidated how characteristicsof physical function influence drawing performance anddrawing motion in clumsy children.
The hypotheses of this study were as follows.
1) The clumsy children were different from the healthy
children in the accomplishment result of drawing
motion in the drawing task.
2) The accomplishment result and the campaign fordrawing motion in the drawing task of the clumsy
children were related to characteristic of physicalfunction.

Methods
Research Design
A cross-sectional design was used to study the
relationship between drawing performance and drawing motion in clumsy children, and to determine how
characteristics of physical function influence drawing
performance and drawing motion in clumsy children.
Each clumsy and healthy child was asked to perform adrawing task, and each clumsy child was asked to perform an additional physical function test. This study wasapproved by the institutional review board at Sapporo
Medical University. Parents were informed of the study
and given a right to remove their child from this study.
Subjects
The clumsy child group comprised 10 boys who
had received a diagnosis of developmental disorders
by a doctor, and who showed difficulty in handwriting.
There is not an evaluation scale of clumsiness standardized in Japan. Therefore, in this study, the clumsy child

was defined as judged to be weak in writing comparedto each grade children by occupational therapists andparents. This group included 2 second grade students, 3
third grade students, 1 fourth grade student, 2 fifth gradestudents, and 2 sixth grade students.
The healthy child group comprised 54 boys who
did not have any apparent physical or learning disabilities. We classify them in 2–6 grade by age. The healthy
child group included 8 second grade students (7–8 years
old), 10 third grade students (8–9 years old), 12 fourth
grade students (9–10 years old), 12 fifth grade students(10–11 years old), and 12 sixth grade students (11–12
years old),. All subjects normally used their right hand
to handwrite.
Instrument
Drawing Performance and Drawing Motion
A tablet personal computer (Sony VAIO Duo 11;
hereafter referred to as PC tablet), a stylus to draw
directly on the screen, and software developed for theassessment of upper limb function in handwriting tasks[10] were used for the drawing task. Microsoft Visual
Basic 2012 was used to create the figures used for assessing upper limb function. During the drawing task,changes in the positioning of the stylus and elapsed time
were recorded using a sampling frequency of 133 Hz.
Subjects were seated with both feet placed on thefloor and with their forearms on the table. The PC tablet
was placed 12.5 cm from the front edge of the desk, andsubjects held the stylus with their right hand. Their left
hand was placed on the bottom left of the tablet. Videocameras were placed above and to the right of the subjects to record the drawing motion. Based on a previous
study [1], markers were placed on the right acromion,lateral epicondyle of the right humerus, right radialstyloid process, and stylus to serve as indicators for the
analysis of motions.
The drawing task was to draw a line between two
concentric equilateral triangles displayed on the PC
tablet, spaced 3 mm apart, the side length of the outerequilateral triangle was 10 cm. The subjects drew aline in a counterclockwise direction, starting from the
top point. Subjects were instructed to draw accurately,
to try to not write outside the lines, and to not lift up
the stylus from the screen while drawing. The drawing
task was performed three times after the subjects hadpracticed using the PC tablet and stylus and after they
were accustomed to the necessary movements. Based on
the position coordinates of the stylus on the PC tablet,
the distance that the stylus strayed outside of the parallellines (hereafter referred to as stray distance) and the
speed of the stylus movement (hereafter referred to as
speed) were calculated.

Ikeda C et al.

Asian J Occup Ther 15: 37−44, 201939

Fig. 1. Environment Configuration of Drawing Motion Analysis.
Note. Video cameras were placed above and to the right of the subjects to record the drawing motion, and markers wereplaced on the right acromion, the lateral epicondyle of the right humerus, right radial styloid process, and stylus to serve
as indicators for the analysis of actions.

Dartfish 4.0 (Dartfish Company) was used to analyze the movements of each marker recorded by thecameras placed above and to the right of the subjects.
The markers attached to the right acromion, lateralepicondyle of the right humerus, right radial styloid
process, and stylus during the drawing tasks indicatedmovements of the body, shoulder joint, elbow joint, andfingers, respectively (Fig. 1). We calculated the trace
length for each marker (hereafter referred to as sway
length) and the total trace length (hereafter referred to
as total sway length) while performing the drawing task.
The ratio of the sway length for each marker was calculated by setting the total sway length of each marker to100%.
Physical Function
Twenty-six tasks were selected from the clinicalobservational assessment items of the Japanese Academy of Sensory Integration: three tasks were related
to the postural reflex, three tasks were related to theresidual primitive reflexes, four tasks were related to themuscle tone condition, two tasks were related to posture
maintenance, four tasks were related to cooperativenessof the upper limbs, six tasks were related to compound
motions and four tasks were related to eye movements.
The tasks were conducted by occupational therapists inaccordance with the procedures in the manual, and somesubjects were filmed during the tests when the subjects
and their parents gave consent.
The result of each task was classified into one ofthree categories: poor, moderately poor, or normal.
Based on these results, the occupational therapist responsible for the experiment and a second occupational
therapist with at least 5 years of clinical experience
confirmed the scores while checking the recordings. In
cases where subjects were not filmed, the second occu-

pational therapist re-evaluated the clinical observations
and, if the scores did not match, the two assessors discussed the results and confirmed the scores. The resultsof the clinical observations were quantified as follows:
poor, 2 points; moderately poor, 1 point; and normal, 0
points. Total points for the seven categories and all tasks
were then calculated.

Data Analysis
Drawing Performance
For healthy children, we calculated the largest straydistance in three times of the drawing task, the speedof the trial with the largest sway length, the difference
between the fastest and the slowest speed (hereafterreferred to as the range of speed) for each school grade,and the difference between the fastest and slowest speedof each healthy children (hereafter referred to as the difference of speed). For clumsy children, the largest straydistance, the range of speed, and the difference of speed
were calculated and then compared with those of healthy
children of the same grade. Clumsy children who had alarger stray distance than the largest stray distance of thehealthy children of their grade were considered to havea drawing problem. Clumsy children who had a faster
speed than the fastest speed of the healthy child groupof each grade were defined as having a fast drawing
speed. Similarly, those who had a slower speed than theslowest speed of the healthy child group of each gradewere defined as having a slow drawing speed. Clumsy
children who had a larger range of speed than the largest
range of speed of the healthy child group of each gradewere considered to have a varied drawing.
Drawing Motion
In regards to drawing motion in the healthy child

40

INFLUENCE OF PHYSICAL FUNCTION ON DRAWING IN CLUMSY CHILDREN

group, we calculated the mean and standard deviation(SD) of both the sway length and the total sway lengthfor each marker for each grade. Subjects who had asway length of greater than the mean value +1SD of thehealthy child group were defined as having a large sway
length, and those who had a sway length of less than themean value −1SD were defined as having a little sway
length. We concluded that the clumsy children had different drawing motion than healthy children when theirsway length was qualified as large or little.
Further, we calculated the mean ratio of the sway
length for each marker for each grade. A goodness-offit test was used to analyze the ratio of sway length. The
mean ratio value of the healthy child group for each
grade was defined as the expected value and the mean
ratio of the each clumsy child in each grade was definedas the actual measurements. When the ratio of sway
length for each marker in the healthy child group andthe clumsy child did not match, we concluded that thedrawing motion differed between healthy child groupand the clumsy child.
IBM SPSS statistical software version 16.0 J for
Windows (IBM Global Services Japan Solution andServices Company) was used for statistical analysis andp < 0.05 was used to determine statistical significance.

Physical Function
The physical function tasks were measured using
the assessment scores of each area of the clinical observations and converted to a score with a possible total of
100 points. In the present study, subjects who had highassessment scores and high total points were determined
as having a physical function problem.
Finally, clumsy children who had any problem indrawing performance or drawing motion were classified
and analyzed according to trends noted in their physicaldysfunction.

Results
Drawing Performance
The largest stray distance, the range of speed andthe difference of speed for the healthy child group by
grade and each clumsy child are shown in Table 1.
Clumsy children were classified into two groups according to the largest stray distance: 6 children in GroupI (Case A, B, G, H, I and J) had a drawing problem; 4children in Group II (Case C, D, E and F) did not havea drawing problem. In clumsy children from Group I,
they had a tendency for larger mean stray distance andgreater speed variability than the healthy child group,
when categorized by grade.

Table 1. Drawing performance for healthy and clumsy children.
Grade (age)Healthy children

2 (7−8)3 (8−9)4 (9−10)
5 (10−11)
6 (11−12)grade

the trial of the largest
stray distancesway length

speed

2.39
2.32
1.80
1.34
0.20

2.13
2.44
2.69
2.22
1.74

the trial of the largest
stray distance

range of speed
1.36−3.28
0.95−4.10
0.96−3.11
0.88−3.59
1.20−2.67

difference of speed
min

max

0.16
0.24
0.03
0.14
0.05

1.32
1.97
0.85
1.37
0.76

range of speed

difference of speed

4.79*
2.15*
2.65*
1.30
3.84*
7.26*

2.10−4.79
1.96−2.72
1.10−2.65
0.91−2.63
2.48−3.84
3.93−7.26

2.69*
0.76
1.55*
1.72*
1.36*
3.33*

2.43
3.07*
1.03
1.09

1.95−2.81
3.07−4.57
1.03−2.94
1.09−1.39

0.86
1.50
1.91
0.30

sway length

speedGroup I
with drawing problem

A (2)
B (2)
G (5)
H (5)
I (6)
J (6)

3.70*
2.94*
5.18*
1.54*
1.58*
13.76*

Group II
without drawing problem

C (3)
D (3)
E (3)
F (4)

0.27
1.94
2.18
0.34

Stray distance; cm, Speed; cm/sec, *; above the standard of the healthy child group of each gradeNote. In clumsy children from Group I, they had a tendency for longer mean stray distance and greater
speed variability than the healthy child group, when categorized by grade.

Ikeda C et al.

Asian J Occup Ther 15: 37−44, 2019

Drawing Motion
The mean sway length and total sway length ofeach marker for the healthy child group and the clumsy
children were classified into two groups according to
drawing performance are shown in Table 2. The sway
length and total sway length of each marker for clumsy
children were defined as being large when the sway
length deviated above the normal range of movement asmeasured by one of the cameras monitoring the subject.
The sway length was defined as little than the normal
range when the sway length deviated below the normal
range as measured by either camera monitoring the
subject.
We then compared the trends in the drawing motion
between the two drawing performance groups are shownin Table 3. In clumsy children from Group I, most markers deviated from the normal range. In clumsy children
from Group II, most markers remain within the normal
range. Further, body sway length in all Group II subjects
was within the normal range.
The goodness-of-fit test results for the ratio of sway
length and total sway length for the healthy and clumsy
children were classified into two groups are shown in
Table 3. When the goodness-of-fit test revealed that thesway length ratio of the clumsy children differed fromthose of the healthy children group. And then there weredifferences in normal range of movement as measured
by either camera monitoring the subject, the sway length
ratio for each marker was determined not to be a fit.

41

Therefore, we compared the trends in drawing motion
between the two groups from the results of the drawing
performance tests. All children in Group I had differing
ratios when compared with individuals in the healthy
child group, and were therefore determined not to fit.
Physical Function
The clinical observations of drawing performancefor each of the two groups of clumsy children are shownin Fig. 2. The results revealed numerous problems,
including residual primitive reflexes, muscle tone condition, posture maintenance, cooperativeness of the upper
limbs, and eye movement in both groups. However, atendency for greater severity of problems was observedin Group I than that in Group II. Furthermore, a tendency for increased severity of problems related to posturalreflex was noted in Group I. The total point scorerevealed that subjects in Group II tended to have fewer
problems related to physical function characteristics.

Discussion
Drawing Performance and Drawing Motion
We found that some clumsy children who had poor
drawing skill tended to have large motion of the bodyand shoulder joint for all drawing tasks, as comparedto healthy children. On the other hand some clumsy
children who tended to use finger movements to draw
and exhibit a small handwriting motion, as compared

Table 2. The mean sway length and total sway length of each for healthy and clumsy children.

Healthy children

sway length (above)sway length (right side)

Grade
(age)

body

shoulderelbow

finger

total

body

shoulderelbow

fingertotal

2 (7−8)3 (8−9)4 (9−10)
5 (10−11)
6 (11−12)

1.47 (0.77)
1.01 (0.63)
0.86 (0.62)
0.73 (0.57)
0.60 (0.41)

0.74 (0.38)
0.74 (0.44)
0.59 (0.37)
0.67 (0.38)
0.48 (0.40)

0.96 (0.59)
1.10 (0.63)
0.92 (0.48)
1.14 (0.56)
0.96 (0.72)

2.22 (1.06)
2.09 (0.87)
1.83 (0.58)
2.38 (1.09)
2.02 (0.62)

5.37 (2.00)
4.91 (1.92)
4.19 (1.53)
4.93 (1.99)
4.08 (1.63)

1.44 (0.86)
0.90 (0.57)
0.74 (0.55)
0.67 (0.45)
0.64 (0.46)

0.82 (0.38)
0.91 (0.53)
0.55 (0.38)
0.67 (0.38)
0.75 (0.44)

0.81 (0.37)
0.57 (0.45)
0.55 (0.48)
0.64 (0.46)
0.66 (0.64)

1.65 (0.88)
1.05 (0.71)
0.87 (0.56)
1.05 (0.71)
1.33 (0.56)

4.70 (1.48)
3.39 (1.69)
2.72 (1.53)
3.02 (1.63)
3.38 (1.37)

grade

trace length (above)trace length (right side)bodyshoulderelbow

finger

total

body

shoulderelbow

fingertotal

Group I
with drawing
problem

A (2)
B (2)
G (5)
H (5)
I (6)
J (6)

17.46
28.73
15.68
45.71
2.24
4.01

22.17
28.64
14.52
28.54
2.00
3.15

24.39
36.44
17.67
29.32
16.00
14.43

30.13
37.76
21.37
41.46
21.16
19.05

94.15
131.5769.24
145.03
41.40
40.65

9.40
20.04
10.97
25.19
1.51
2.61

22.03
30.02
10.46
33.82
2.09
4.93

16.19
16.43
7.64
19.87
5.79
9.59

16.27
19.99
11.11
36.69
8.57
10.74

63.89
86.49
40.18
115.5717.96
27.86

Group II
without drawing
problem

C (3)
D (3)
E (3)
F (4)

15.56
10.13
8.05
15.30

22.66
20.06
10.72
12.25

36.18
31.00
18.97
20.37

34.83
29.72
23.64
30.22

109.23
90.92
61.38
78.15

6.47
5.71
3.43
5.33

19.37
20.88
5.88
8.67

11.67
14.90
11.18
7.87

14.26
14.01
12.19
12.71

51.78
55.51
32.67
34.57

Trace length : cm
Note. The mean sway length and total sway length of each marker for the healthy child group and the clumsy children were classified into two groups according to drawing performance.

42

INFLUENCE OF PHYSICAL FUNCTION ON DRAWING IN CLUMSY CHILDREN

Table 3. Drawing motion by mean sway length and total sway length in clumsy children.
sway length judgment
child(grade)body

sholderGroup I
with drawing
problem

A (2)
B (2)
G (5)
H (5)
I (6)
J (6)

large
large
large
large
littlelittle

large
large

Group II
without drawing
problem

C (3)
D (3)
E (3)
F (4)

large
littlelittleelbow

littlelittlelittlefinger

total

large

large
large

large
littlelittlelarge
littlelittlelarge
littlelittlegoodness of fit test

large
littlelittle

above
2

df

7.710713.1850
14.751044.781020.9390
10.7470
1.13780.67310.88707.6320X

right side

judgment

p valueX2df

p value

3
3
3
3
3
3

 0.05< 0.01< 0.01< 0.01< 0.01< 0.052.262312.9190
17.1680
8.706334.0620
16.3830

3
3
3
3
3
3

0.52
< 0.01< 0.01< 0.05< 0.01< 0.01

non fitnon fitnon fitnon fitnon fitnon fit

3
3
3
3

0.77
0.88
0.83
 0.051.47872.044511.67104.4216

3
3
3
3

0.69
0.56
< 0.01
0.22

non fitnon fitNote. A goodness of fit test was used to analyze the ratio of sway length. The mean value of the healthy child group scores for each grade were
defined as the expected values and the ratio of sway length of each clumsy child in each grade were defined as the actual measurements.

Fig. 2. The Physical Function in Clumsy Children.
Note. A tendency for increased severity of problems related to postural reflex was noted in Group I. The total point scorerevealed that subjects in Group II tended to have fewer problems related to physical function characteristics.

to healthy children. In either case, the drawings were
inaccurate due to drawing problems, the mechanism bywhich these drawing problem manifest are not uniform.
The drawing tasks used in the present study contained an equilateral triangle with 10 cm sides. Tasks
such as this that involve drawing large lines require
movements of the shoulder and elbow joints [11, 12].
Therefore, inaccurate drawings may be associatedwith instability of the body or scapula, or decreased
cooperativeness of the upper limbs. When the drawing
motion was generally large, movements of the bodyand shoulder joints also tended to become larger due
to posture instability. This is similar to the results ofprevious studies [13] and may be due to the influenceof problems in maintaining continued muscle tone [7].
Children who have decreased muscle tone and problems
in maintaining continued muscle tension often stabilize
or immobilize another part of the body for increased
support [14]. Subjects who used small drawing motions

to draw the 10 cm triangle placed their upper limbs on
the desk to obtain support for handwriting, allowing
them to compensate for the instability in posture andproblems in maintaining continued muscle tension.
Physical Function
The results of the clinical observations revealed thatwhen drawings were inaccurate, there were problems
with postural reflexes, posture maintenance, or cooperativeness of the upper limbs. However, based on the results of the clinical observations, the trends observed forcharacteristics of physical function problems in clumsy
children whose drawings were inaccurate appeared to be
similar, but the severity of the problems was unclear.
Each clumsy child used a different strategy whenusing the writing tools to cope with their individual
deficits in physical function, which may have led todifferences in drawing motion. However, the strategies
used by clumsy children did not seem to be appropriate,Ikeda C et al.

Asian J Occup Ther 15: 37−44, 2019

and the subjects could not control the writing tools accurately.
Moreover, body stability appeared to have the mostinfluence on drawing accuracy in clumsy children who
had no problems in drawing, and had similar drawing
motion as healthy children. This was based on the factthat these subjects tended to show no problems in posture reflexes, posture maintenance, or performance ofcomposite movements.
Study Limitation
It may be inappropriate to apply the results of thisresearch to females, because this research was performed exclusively in male subjects. The figure in thisdrawing task was a triangle; hence, these results may
not apply directly to other drawing tasks. A problem ofhandwriting indicated by daily life is that it includes
writing as well as drawing. The drawing task performedin this study can generate a quantitative result, but
handwriting evaluation is inevitably subjective to somedegree. We can’t evaluate three-dimensional movement
enough because this study analyzed drawing motion of
two dimensions movement analysis software.
Implication for Occupational Therapy Practice
The results of our study have the following implications for occupational therapy practice:• The evaluation of physical function is necessary to asupported occasion for a problem of drawing, and wehave to confirm the muscle tone condition, posture
maintenance, cooperativeness of the upper limbs andeye movement in particular• Children with drawing problems exhibit different
drawing motion than healthy children, and it is necessary to support it in drawing motion as well as thephysical function.

Conclusion
From our findings, clumsy children with developmental disorders seem to present with difficulty inphysical functions. Limitations in drawing and drawing
motion are influenced primarily by body stability. Moreover, although we originally thought that the severityof problems in muscle tone and cooperativeness of theupper limbs had an influence on the ability to control
writing tools, in some cases, subjects could neverthelesscontrol the tools accurately depending on the method ofdrawing.
When providing support to children who haveproblems in writing or drawing, improvements may begained by teaching them the strategies that are uniquely
used by healthy children. However, it is possible that43

changing strategies may decrease drawing ability
in clumsy children. In order to examine methods ofsupport for the physical function of individual clumsy
children, it is necessary to not only evaluate the drawing
performance and physical function of subjects but also
to assess the methods of drawing.
Acknowledgements: This study received a grant from
Sapporo Medical University, Japan. This study was apart of the first author’s thesis for a doctorate.

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■ORIGINAL ARTICLE

A Mixed Methods Study Exploring Difficulties
in Child Care Among Japanese Motherswith Depression
Aiko Hoshino1, 2, Mami Suwa2
12

Department of Physical and Occupational Therapy, Graduate School of Medicine, Nagoya University, Japan
Mental Clinic Anser, Medical Corporation Seiseikai, Japan

Abstract: Background: Depression causes mothers to experience difficulties in child care and increases stress, which
can influence the development of the child. Japan currently has insufficient support for mothers with depression.
Objectives: We aimed to reveal the difficulties in child care and related factors of three Japanese mothers with depression by examining their narratives.
Methods: A mixed method design was applied. We conducted in-depth, semi-structured interviews with mothers withdepression and analyzed the data using both the grounded theory approach and text mining software (KH Coder).
Results: As a result of focus coding, 11 focus codes were extracted. In addition, as a result of multi-dimensional scaling, two codes (“Physical burden caused by family and child care” and “The mother coping with difficulties by herself”) were in close proximity and formed a unit. Another two codes (“Anxiety over not having complete control overchild care” and “One-sided coping methods”) were in close proximity, creating a second unit.
Conclusion: This study suggested the following: 1) in spite of being aware of their excessive burden, mothers withdepression believed that they should take care of their children by themselves; 2) because of the desire to be a perfectmother, mothers with depression tended to have extremes in their child care. We need further research based this result
for the developing support systems.
Keywords: depression, mother, support, narrative, text-mining(Asian J Occup Ther 15: 45−52, 2019)

Having a role to play is one of the most importantfactors for occupational therapy clients to reconstructtheir daily lives. Their roles allow them to engage inactivities and social interactions, and contribute totheir self-esteem and identity [1]. For women, motheris one of the most typical roles. Since the 1990s, manystudies in the field of occupational therapy have focusedon the role of the mother and parental behavior [2].
Additionally, the parental consciousness of women havebeen reported to be higher than that of men [3]. Whenmothers have difficulty in parenting activities, they tend
to have more stress than fathers. Previous reports haveinvestigated the disruption of mothering activities due
Received: 28 November 2018, Accepted: 19 March 2019
Corresponding to: Aiko Hoshino, Department of Physical and Occupational Therapy, Graduate School of Medicine, Nagoya University, 1-120 Daiko-Minami, Higashi-ku, Nagoya City, Aichi 461-0047, Japane-mail: hoshino@met.nagoya-u.ac.jp©2019 Japanese Association of Occupational Therapists

to illness. Vallido, Wilkes, Carter and Jackson (2010)[4] suggested the following themes in their systematic
review of women’s experiences of mothering disrupted
by illness: mechanism of disruption, reframing themother’s role, experiencing guilt or shame, protecting
the children, experiences with health care professionals,
living to mother, and mothering to live. Additionally,
they mentioned that we should consider these themes
when developing intervention and support programs.
Depression is an illness that disrupts mothering.
The lifetime prevalence of depression in women is twicethat in men. This difference is attributed to changes in
the hormonal balance or changes in life stages throughout women’s lives [5, 6]. Women are reported to havea high prevalence of depression in the postpartum andmenopausal periods. Postpartum depression develops
within 1 year after childbirth [7, 8, 9], and is a notabletopic in women’s health. About 10% to 15% of new
mothers worldwide develop depression [10]. Moreover,symptoms can continue depending on the severity of

46

EXPLORING DIFFICULTIES IN MOTHER WITH DEPRESSION

depression for some years [8, 11].
In 2009, The National Research Council and Institution of Medicine [12] recommended a coordinatedapproach that combines treating the mother’s depression
and training mothers on parenting skills. Goodman andGarber [13] suggested the necessity of integrated intervention that reduces mothers’ depression and promotes
mothers’ parenting behavior. The United States has
introduced several interventions to improve parenting
by mothers of infants and young children, such as home
visiting programs (HVP), including in-home Cognitive
Behavioral Therapy (CBT) and the Positive Parenting
Program, also known as Triple P. In these programs, theevidence for improving parenting and effectively reducing depression in mothers is strong [14−16]. However,in Japan, we have no outreach services equivalent to
HVP. Therefore, Japanese mothers with depression havelittle support available. Furthermore, this topic is not
given sufficient attention in Japan, and previous reports
in this area have been limited to investigations of the experiences of mothers with infants; for example, infants
under the age of 1 year [17]. Therefore, there are notenough reports to serve as a basis for the developmentof support systems for Japanese mothers. Since parental
behavior and child care are influenced by the culture ofmothers, it is necessary to investigate the situations ofJapanese mothers with depression in order to develop a
support system in Japan.
As a first step of the basis for the development of
support system, in this study, we aimed to obtain clues
for revealing the difficulties in child care and related
factors of Japanese mothers with depression by examining their narratives. We focused on three Japanesemothers, who are serve as a prime examples supported
in the future, of preschool children to investigate postpartum depression in particular. Qualitative Analysis
based on their narratives can make clear their characteristics based on their individualities. On the other hand,
we have necessity of revealing common factors among
mothers, because aim of this study is the first investigation for the development of support. Therefore, addition
to usual qualitative analyses, we used the text mining
which is one of the quantitative analyses.

MethodDesignThe approach in this study was a mixed methods
design through semi-structured interviews.
Participants
The study participants were recruited from threeprivate psychiatric clinics in Aichi Prefecture, Japan.

The inclusion criteria were as follows: women aged 20
to 50 years old; living in Japan in a household with morethan two family members, including a preschool child;being responsible for the majority of the housework andchild care; psychiatry clinic outpatients receiving treatment including psychotherapy and pharmacology for
major depression diagnosed by an attending psychiatrist
according to the Diagnostic and Statistical Manual of
Mental Disorders-4 Text Revision (DSM-4); and scoringover 16 points on the Center for Epidemiologic Studies
Depression (CES-D) scale.
The CES-D is a self-assessment questionnaire with
20 items scored on a four-point scale; it was designed
to quantify the level of depressive symptoms during thepast week, with a cut-off point of 16 to discriminate thedepressive state [18]. Therefore, all participants in thepresent study were in a depressive state at time of theinterview. The validity and reliability of the Japaneseversion of the CES-D have been confirmed [19, 20].
Semi-structured interviews
In-depth, semi-structured interviews were conducted by the first author. The interviews lasted for 1 hour
and were conducted in a private room (e.g., a room inthe participant’s workplace or psychiatry clinic). A monetary reward (1000 Japanese yen per 1 hour) was given
to the participants. An interview guide was used, and thecontents of the interviews were recorded. The interview
guide included open-ended questions that explored theparticipants’ experiences with difficulties in child careand housework (e.g., when did you experience difficulties in child care or housework, could you tell me abouta child care or housework situation that you felt wasvery difficult). Basic information (e.g., family structure,
participant’s age, age of their child(ren), and contentsof child care and housework that the participants
undertook) was collected at the start of the interview.
Then, the interviews explored the participants’ concrete
experiences with housework and/or child care situations
that they found difficult, their thoughts about these situations, and the ways they managed them.
Analyses
Data were analyzed using a conversion mixed
design following Teddlie and Tashakkori [21]. In thismethod, a correlational approach was used together
with a dictionary-based approach. Application of a conversion mixed design enables the visualization of datafrom both processing language computer analysis andthe interpretations of researchers. In this study, we useda mixed conversion approach [22] that included both atext mining approach and a grounded theory approach(GTA).

Hoshino A et al.

Asian J Occup Ther 15: 45−52, 201947

Table 1. Participants’ remarks, initial codes and focus codes
Initial code
Participant

RemarkParticipant A“My baby is so inflexible and he never moves
when he does not want to.”Baby is inflexible

inflexible

The child does not act
as the mother expected.

Participant B“They don’t really listen to me.”Children don’t listen to me.

don’t listen

The child does not act
as the mother expected.

Participant C“For example, after I make him breakfast, he
has so many requests and complaints for me;
he is so selfish. I know he is a little boy, but I
am so tired.”

The child does not act as themother expected.

selfishThe child does not act
as the mother expected.

Name of code

First, recorded interview data were transcribed verbatim into text data. After that, the text data were read
repeatedly and checked for accuracy in Japanese wording and expression. In cases of transcription mistakes
or a lack of uniformity of expression, the data were
carefully modified. This process was conducted in order
to avoid misinterpretation in the subsequent computer
analyses. Second, the data for each participant weresectioned at every remark and coded as initial coding. In
this process, we also extracted one word that was related
to the purpose of this study and made in vivo code foreach word. Third, we conducted focus coding in order toorganize these codes (Table 1). Focus coding enables theinterpreted data to be integrated into one code depending
on meaning of the code. These analyses were based on
the GTA [23] and the results were examined by researchcolleagues with experience in qualitative researchbased on GTA. The qualitative data analysis software
MAXQDA (VERBI GmbH, Germany) was used in thisprocess.
After completing the GTA process, analyses basedon text mining were conducted. Text mining clarifies
the characteristics and tendencies of text data throughnatural language processing based on morphologicalanalysis. In this study, we used KH Coder (Ritsumeikan
University, Japan) which is a free software tool for text
mining and text analyses that can handle six languages,
including English and Japanese, and has been recently
used by several researchers [24−26]. Using KH Coder, it
is possible to make a table of the frequency words, andextract words that co-occur with certain words throughmorphological analysis. It also has functions to allow
visualization of co-occurrence networks or the resultsof multivariate analysis. Moreover, with KH Coder,
we could define results of “in vivo code in each word”
and “focused coding” as a coding rule, and perform
multivariate analysis based on this rule. These results or
the relationships between codes could then be visualizedusing a multidimensional scale (MDS) method. MDS is

In vivo code(one word)

Focus codea visualizing method based on similarities between data.
Namely, data that have high similarities are positioned
near each other, and those with low similarities are positioned far from each other.
In this study, we defined “in vivo code in eachword” as the coding file in each “focused coding”. After
that, the results of the analyses were visualized withcoding functions and multivariate analysis using KH
Coder.
Ethical considerations
All procedures were approved by the Research
Ethics Committee of the Graduate School of Medicine,
Nagoya University, Japan (authorization number: 20160015), and all participants provided informed writtenconsent.

Results
Participants
Three participants (Participant A, B, C) were enroll­
ed in this study. All three were in their thirties or forties
and the ages of their preschool children were 11 months(son), 3 years old (son) and 6 years old (son). All family
members including their children they lived with were
healthy, and no one had any illness and disability. Participant B and Participant C were both employed fulltime whereas Participant A was a stay-at-home mother.
Participant B had a clerical position at a medium-sizedcompany and Participant C was a care worker at a nursing home. Both Participant B and Participant C had twochildren (a preschool child and an elementary school
child, respectively). All of their households were nuclear
families. Participant C was divorced and her household
consisted of only herself and her children. All threeparticipants talked about receiving support from theirhusbands or ex-husband. The mean score of CES-D inthree patients was 24.6 ± 5.0. Detailed information on
the participants’ basic information is provided in Table 2.

48

EXPLORING DIFFICULTIES IN MOTHER WITH DEPRESSION

Table 2. Participants’ basic information

Age (years)

Participant A

Participant B

Participant C

33

46

38

Family structure(living together)

Husband
One son (11 months)

Husband
Two sons (9 years old/3 years old)

One daughter (9 years old)
One son (6 years old)

Ordinary contents ofchild care and housework

Child care and housework
except preparing meals

Everything

Everything

Employment status

Unemployed

Full-time clerical work

Full-time care worker

Support they received(name of supporter(s)/frequency)

Preparing meals(husband/every day)Child care(maternal grandmother/once a week)

General support(husband/
when the participant works overtime)
Picking up sons from nursing home
(paternal grandmother/everyday)

General support(ex-husband/
about once a week or dependingon the husband’s convenience)

Results of focus coding
As a result of focus coding, 11 focus codes wereextracted.
Positive feelings for the child’s father who supports the mother. The mothers expressed grateful feelings towards their husband or ex-husband who provided
support.
“He makes food for us, so I thank him.” (Participant A)
Negative feelings about the support that thechild’s father gives. On the other hand, they also complained about the kind of support that the father gives.
“My ex-husband helps me only when it is convenient forhim. Convenient time for him means that he is free, orthat he wants to eat dinner with the children. It is not
usual daily life.” (Participant C)
The child does not act as the mother expected.
The mothers’ expectations differed depending on themental and physical development of their children.
However, they experienced difficulty when their children’s behaviors and actions were contrary to their
expectations and intentions.
“My baby didn’t act as I expected.” (Participant A)“I always think, ‘you are so slow, please hurry up!’”(Participant C)
The child’s characteristics. The participants talked
about the characteristics of their children.
“Mischievous.” (Participant B)
The mothers had difficulties with not only theirchildren’s characteristics, but in situations caused bytheir children’s characteristics.
One-sided coping methods.
“When I use gas to cook, I am always afraid of my baby

getting burned because he is always around me. So, now
I eat only food that doesn’t need to be cooked on thestove.” (Participant A)
These narratives illustrate ways of dealing with or
avoiding difficult situations caused by child care. The
mothers’ methods were limited and were “one-sided”
in that they placed too much priority on merely copingwith children rather than actually addressing the real
problems.
The mother coping with difficulties by herself.
“There is no one except me.” (Participant A)“I have always done everything.” (Participant C)
These narratives illustrate that the mothers seemedto think that they always have to solve any and all problems.
The mother does not want to use support systems.
“I think that I am spoiling myself whenever I use support
systems.” (Participant C)
The mothers talked about their negative feelings
towards using support systems. They not only worried
about leaving their child in someone else’s care, but also
experienced a sense of guilt.
Anxiety over not having complete control overchild care.
“When I’m sleeping, I am afraid that something badwill happen to my baby. So, I am too scared to sleep.”(Participant A)“I should take perfect care of my child, but I cannot.”(Participant C)
The mothers seemed to believe that they shouldhave complete control over child care and the impossibility of being perfect caused them a great deal of stressand anxiety.

Hoshino A et al.

Asian J Occup Ther 15: 45−52, 201949

Fig. 1. Visualized similarity map based on MDS with KH Coder.

Overdoing child care during the appearance ofsymptoms.
“Even if I had heavy symptoms, I had to go about myroutine as usual.” (Participant C)
Regardless of the severity of their symptoms, themothers still had to engage in child care and housework.
At such times, they felt their situation was difficult.
Physical burden caused by family and child care.
“I desperately try to finish my tasks in the morning,for example, making breakfast, brushing my child’s
teeth, etc. After finishing those tasks, I go to work at thenursing home. But by the time I get there, I am alreadyexhausted.” (Participant C)
These narratives show that the mothers experiencea physical burden from the quantity of tasks they haveto perform.
Impatience and panic.
“I felt more and more impatient and I was in a panic.
What should I do? I am scared.” (Participant C)
These narratives illustrate that impatience brought

the mothers a high degree of stress.
Relationships among codes analyzed by MDS.
Data were visualized based on MDS analysis
through a coding file. Based on the similarity map, we
could visualize the structure of our data (Fig. 1).
Two codes (“Physical burden caused by family andchild care” and “The mother coping with difficulties
by herself”) were in close proximity and formed a unit.
Another two codes (“Anxiety over not having complete
control over child care” and “One-sided coping methods”) were in close proximity, creating a second unit.

Discussion
Japanese mothers’ consciousness of their role as a motherand the influence of depression
The MDS results showed that two codes (“Themother coping with difficulties by herself” and “Physicalburden caused by family and child care”) were in close
proximity. We can infer that the participants had to copewith their situation regardless of their awareness of their

50

EXPLORING DIFFICULTIES IN MOTHER WITH DEPRESSION

excessive burden. In our previous study, we showedthat the amount of support that women with depression
receive is lower than that of healthy women [27]. Similarly, the result of this study showed that the participantsalso could not get support when they need.
One of the closest supporters of the participants
seemed to have been their husband or ex-husband. The
participants had positive and negative opinions about
the support they received from their child’s father. However, in both the positive and negative comments, theyused the word “help” to express their husband’s support.
From this viewpoint, they seemed to have the idea that
all child care was basically the mother’s responsibility.
In Japanese mother, compared with European counties,
they were found to have a lower quality of life due togender roles and to receive less support [28]. Also, Moricompared mothering between two Asian countries,
China and Japan, and found that Japanese mothers had
a firmer belief that children should be reared by theirmother than Chinese mothers [29]. Additionally, in an
investigation by the Japanese Cabinet Office in 2018,that examined adults aged 20−49 years old in five countries (the United States, South Korea, Sweden, France
and Japan) [30], 66.9% of Japanese respondents selected“Child care should be always done by the mother” or“Mainly the mother should rear a child, and the father
should help sometimes.” On the other hand, in similar
surveys in Sweden, the United States and France,over 50% of respondents selected “Both the motherand father should care for their child.” Based on theseresults, Japan has a culture of child care being provided
mainly by the mother. In addition, mothers in the present
study, who were in a depressive state, noted that they
were strongly aware of their responsibilities and experienced guilt. Combining this pathological mindset andthe strong consciousness of a mother’s role in Japaneseculture, serious situations might result for mothers withdepression. This result gave us worthy viewpoint, butthat point were limited in three Japanese mother withdepression in this study. Therefore, we need more investigation in many participants.
Necessity of considering strong anxiety and self-esteem
related to child care
The code “Anxiety over not being able to completely control child care” showed mothers’ desire tohave complete control over child care and be a perfectmother, and strong anxiety when that desire was not fulfilled. As a result, they tended to select extreme methodsof child care to cope with difficult situations, such as“avoiding cooking with gas”. Also, the code “Mothers
do not want to use support systems” was located in
proximity to the previously mentioned code. Therefore,

background of those behavior might be their wish which
they should be a perfect mother. In other word, theirwish of being perfect mother might prevent from using
support, because being perfect mother based might berelated to their self-esteem and their identity in Japaneseculture.
In Japan, one of the general methods for treating
outpatients with depression is to enlist the help of a
grandparent or another close relative or friend in childcare activities to lighten the parents’ burden and to allow
them a short break from their role as a parent. However,speaking of three participants in this study alone, thismight increase anxiety and decrease the self-esteem ofmothers. Like in outreach services, mothers caring fortheir children together with the help of others would be
ideal.

Limitations
There are some limitations of the present study.
First, the amount of basic information collected forthe participants was insufficient. Housework and childrearing might be influenced by several factors such as
economic status, employment status, and degree of support provided by family members. Addition to those, we
needed to have collected more basic information aboutmother’s depression, for example amount of medicine
they had, timing of their onsets and duration of illness.
Therefore, we should have conducted a more in-depth
investigation of the mothers’ backgrounds. Second,
we had possibilities which participants were not primeexamples strictly. This investigation was limited to threeparticipants, further research with a larger number ofparticipants is required to verify the results.

Conclusion
This study suggested the following: 1) in spiteof being aware of their excessive burden, participants
believed that they should take care of their children
by themselves; 2) because of the desire to be a perfectmother, they tended to have extremes in their child care.
Japan has few support systems for mothers withdepression and their children, we believe it is necessary
to further research this topic to develop effective meansof support.

Conflicts of Interest
The authors declare that there are no conflicts ofinterest regarding the publication of this paper.

Asian J Occup Ther 15: 45−52, 2019

Funding statement
This study was supported by JSPS KAKENHI
Grant Number JP26750184. The sponsor had no control
over the interpretation, writing, or publication of thisstudy. Apart from this grant, we have no financial relationships to disclose.
Acknowledgement: We would like to thank the participants and doctors involved for their help in the datacollection.

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■ORIGINAL ARTICLE

Wearing a Ball Vest in Everyday Activities:
Experiences from Adolescents with Neuropsychiatric
Disorders, their Parents and Teachers
Ingrid Breivik1, Staffan Josephsson2, Helene Lidström3
1Children and Youth Habilitation Centre, Östersund Hospital, Östersund, Sweden
Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
3
Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden
2

Abstract: Background: Children with neuropsychiatric disorders may have a limited participation in everyday activities. It is common that they tend to avoid engaging in activities due to a decreased ability to interpret sensory information. To increase these children’s’ activity performance ball vests are provided and prescribed as an intervention. The
aim of this study was to explore the use of a ball vest in everyday activities from the perspective of adolescents withneuropsychiatric disorders, their parents and teachers.
Method: A qualitative method, where six adolescents with neuropsychiatric disorders, their parents and teachers wereinterviewed concerning experiences of the adolescents’ use of a ball vest for eight weeks. A qualitative content analysis
approach was used.
Results: The analysis identified four themes. The adolescents with neuropsychiatric disorders, their parents and teachers portrayed different aspects of the use of the vest which all were mainly positive. The adolescents experienced that
their high activity level was influenced by using the ball vest in activities. A slightly delayed calming effect was also
described which influenced the adolescents plan when to use of the ball vest during the day.
Conclusion: This study identifies a positive though limited hypothesis regarding how a ball vest can be experienced inrelation to everyday activities at home and in the school setting for adolescents with high activity levels and neuropsychiatric disorders.
Keywords: ADHD, autism, leisure activities, qualitative research, weighted vest

(Asian J Occup Ther 15: 53−62, 2019)

INTRODUCTION
Through performing everyday activities at home
and in the school setting, children develop abilities andskills [1]. Which activities are chosen and how they are
performed are influenced by the context, and the performance of an activity builds one’s motivation, routine andabilities. Children and adolescents with attention deficit
hyperactivity disorder (ADHD) display developmental
difficulties concerning inattention, hyperactivity, impulsivity and social interaction, which bring difficulties in
Received: 20 November 2018, Accepted: 2 April 2019
Corresponding to: Helene Lidström Reg. OT, MSc, PhD, Department
of Social and Welfare Studies, Division of Occupational Therapy,
Linköping University, 601 74 Norrköping, Sweden
e-mail: helene.lidstrom@liu.se©2019 Japanese Association of Occupational Therapists

activities in everyday life [2−5]. The symptoms diminish as the children grow up, but at least 50% percent of
the children still have impairing symptoms in adulthood.
Autism spectrum disorder (ASD) is the behavioral expression of a neurological disturbance which is triggeredin different ways and in different stages of development[5−7]. Children with autism have difficulties within theareas of verbal and nonverbal communication, understanding of social codes, image ability and play [6−8].
They may have difficulties with social interaction indifferent ways and limited opportunities to initiate activities. An updated literature review indicates that many
symptoms overlap between ADHD and ASD in children
and adolescents and that comorbidity between the two
diagnoses is common [9].
Children with ADHD and ASD [10] often show
sensory processing challenges [11−13]. These children
often raise their activity levels when they are exposed to54

WEARING A BALL VEST IN EVERYDAY ACTIVITIES

sensory input (hearing and visual) and have difficulties
lowering it again and therefore easily become stressed[2, 7]. Research show that there are similarities between children with ADHD and ASD regarding sensory
processing patterns and behavior strategies to manage
sensory stimuli [14]. A decreased ability to interpretsensory information often leads to evasion of participation in activities [15], and restricted participation indaily activities decreases children’s opportunities foreveryday learning [16, 17].
In summary, children with neuropsychiatric disorders are at risk of having limited participation in everyday activities and it is of great importance to examine
new interventions which may enable increased activity
performance. A common intervention in children with
ADHD is stimulant medication [18, 19]. To improvefunctioning and lower risks for future disabilities, it isimportant to combine stimulant medication with otherinterventions such as psychosocial treatments, parenting
interventions and child psychological therapy [3, 4, 18].
Common intervention approaches for children with
autism are psychosocial and educational interventions
such as the Treatment and Education of Autistic andCommunication Handicapped Children (TEACCH) program [20], which uses structured teaching procedures,and Applied Behavior Analysis [21]. There is also a
general increase of psychotropic medications amongchildren and especially among children with autism[22, 23].
Occupational therapy provides Sensory Integration
Therapy (SI) to this group of children [24, 25]. SI was
designed by A. Jean Ayres [25] when she studied thequestion of a relationship between learning difficulties
among children and a decreased ability to interpretsensory input. SI is defined as the neurological process
which organizes sensory input from the context andmakes it possible to use the body effectively [24, 25].
The integrative functions are normally activated at engagement in an activity and the ability to process andintegrate sensory information is of vital importance tomaintain balance and encourage health and wellbeing[26]. Sensory Integration difficulties are labelled Sensory
Processing Disorder (SPD), which can worsen the impairment that the diagnosis of ASD brings the child [27].
Ayres [25] observed that children with ADHD and ASD
were calmed by deep pressure stimulation when rolled
up in a gym mat. For the purpose of enabling activity
participation interventions are developed that use deeppressure to calm down [15, 24, 28]. One example is to
use the weight of a ball blanket, which supports the bodyto feel its boundaries [29]. A case control study which
explored this method found that children with ADHD
benefitted from a ball blanket to fall asleep and to sleep

well during the night. Participants in this study were 21
children with ADHD and 21 typical developing children
during 28 nights. All children slept 14 nights with a ballblanket and 14 nights without. Results showed that thetime it took to fall asleep when using the ball blanket
was the same for the children with ADHD and the typical children. Inattention and hyperactivity were rated byboth parents and teachers at the end of both periods andalso after 7 nights after the use of the blanket. The children with ADHD were observed by their teachers rated
to improve their activity function in the school setting
even after the period the ball blanket was used. Their
activity levels were lowered and their attention spans increased according to the measurement using the ADHD
rating scale [30]. Fertel-Daly, Bedell and Hinojousa [31]studied deep pressure intervention for preeschool children with ASD who used weighted vests during daytime
while performing activities. The participating children
increased focus and attention and showed less distractibility when they wore weighted vests. Follow-up
showed that the gains in behavior were partly enduring,suggesting that the intervention had some lasting effect.
Occupational therapists who participated in a survey
reported that the use of weighted vest intervention increased focus on tasks and extended attention spans
when used on preschool children with autism, ADHD
and delayed development [32]. Students with ADHD
showed increased focus in a study when they wore
weighted vests, and three of the four students wanted
to wear the vests on occasions other than wearing vest
for the study [33]. A randomized two-period crossoverdesign with children with ADHD resulted in significant
improvements in attention, less talking, decreased fidgeting and leaving their seats while wearing a weighted
vest, compared to wearing a vest without weights [34].
In addition to the positive result above, another study
found that weighted vests did not decrease stereotyped
behaviors or support arousal for the six participated children with autism performing table-top activities in theschool setting [35]. Davis et al. [36] examined the effects
of weighed vests on aggressive and self-injurious behavior of a young boy with autism and their result found noeffect on the behaviors that were analyzed.
A weighted vest and a ball vest are similar to eachother. The weighted vest has pockets in front, back andon top of shoulders where weights are inserted, and thisvest is supposed to give deep touch pressure to the bodyof the wearer [34]. A ball vest is tighter on the body andhas canals on front and back filled with heavy plasticballs. The balls are supposed to give pointwise deep
touch pressure to the skin and body and are also supposed to stimulate the kinesthetic sense of the muscle
joints. Accordingly, both vests are supposed to give deep

Asian J Occup Ther 15: 53−62, 2019pressure and a ball vest also to give stimulation of thesensory system of the body.
In a literature review Morrison [37] observed that,among occupational therapists weighted vests are perceived as beneficial but the evidence to support thepositive effect is restricted. There is a similar case withball vests that research reflecting the use of these vests
is limited although they have become a more common
intervention. Consequently, there is a need to investigate
the usefulness of a ball vest for the wearer. Because thecontext influences activity performance which is a dynamic interplay between the performer and the environment [1] we decided to address observations of parents
and teachers in this study. The current study addresses
questions on how the adolescents with neuropsychiatricdisorders and the adults in their context experienced theuse of a ball vest in various activities and daily situations. Furthermore, this study seeks to contribute knowledge that facilitates the performance of daily activities
for children and adolescents with neuropsychiatricdiagnoses. The aim of this study was to explore the useof a ball vest in everyday activities from the perspectiveof adolescents with neuropsychiatric disorders, theirparents and teachers.

METHODS
DesignA qualitative descriptive approach was used [38].
Interviews were conducted after the participants had
used a ball vest for a period of eight weeks.
Procedures
A secretary sent out cover letters with informationand consent forms on the study, and an enquiry to participate to parents of adolescents who met the inclusion
criteria (n = 40). The adolescents got an easy-read letterwith consent form that was especially addressed to them.
Seven adolescents and their parents accepted and wereinvited to an information meeting, where ball vests wereon loan. What was important to think of during the introduction was given by the first author, and the families
were given opportunity to ask questions. Information
was given about the time range of the loan and that interviews would be conducted subsequently. Because of
the qualitative design of the study there were no further
instructions given on the use of the ball vest.
Participants
Inclusion criteria were adolescents in mainstream
schools with ADHD, ASD or both diagnoses in ages
9 to 14 years, their parents and teachers. Adolescentswith intellectual disability were excluded, because

Breivik I et al.

55

they were expected to have difficulties carrying out aninterview and developing their answers. Participants
were recruited from both Neuropsychiatric Teams of theChildren’s and Youth habilitation Centre (CYHC) in anorthern county of Sweden. Seven out of forty enquiries
were returned with an agreement to participate and theremaining thirty-three did not respond. The two female
teachers of the participants who wore the ball vests
regularly in the school setting were also asked to participate, and they agreed.
After a month one family discontinued their participation. Thus six adolescents, five boys and one girl, six
parents (four mothers and two fathers), and two teachers
participated in the study. Two of the adolescents had an
ADHD diagnosis, two had an ASD diagnosis and two
had both diagnoses.
Materials
The participating adolescents were invited to try
wearing a ball vest to get the opportunity to discoverwhat experiences they could have from wearing it intheir daily life. The vest was in most cases handled by
the adolescents, but sometimes parents or teachers asked
them to wear it. A ball vest in junior size weighs 2.5 kg
and is manufactured with an elastic fabric that fits tightto the body. On the front and back there are channels
filled with heavy plastic balls. The vest is closed witha zipper and has a simple system of strings on the backand at the sides which makes it easier to adjust individually. The vest is portable and the wearer can choose touse it in different activities and contexts.

https://www.komikapp.se
Data collection
The first author collected the data by semi-structured
interviews with a focus on the participants’ experiencesof using the ball vest in everyday activities [38, 39]. Interviews were booked and carried out individually withall participants directly after the vests were returned.
The participants chose the surroundings where the interviews took place; some chose the school setting, andsome chose the premises of the CYHC. The interviews
lasted between 30 to 45 minutes.
The interviews followed an interview guide with
open-ended questions to facilitate supplementary inquiry. Examples of questions were: Give an example of
how it was for you to wear the ball vest at home. Tell

56

WEARING A BALL VEST IN EVERYDAY ACTIVITIESme about a usual situation when you wore the vest. Tellme about how it was to use it in the beginning. Describe
what situations make you wear it. Give an example of
how it was for you to wear the ball vest in school.
Data analysis
The interviews were written out verbatim anddata were analyzed by the first author using qualitative
content analysis following guidelines by Graneheim andLundman [39]. At first the transcripts representing eachof all fourteen interviews were read through a couple oftimes to receive an overview of the data. The transcripts
were compared to discover and identify similarities
and differences in experiences, outlining the substanceof the data. Patterns concerning the use of the ball vest
at home and in the school setting were identified. In
a second step each interview was reread and meaning
units which seized the use of the ball vest and the experiences of wearing it in various activities were identified.
The captured meaning units were condensed so that thecore of the meaning in each unit was recognized. These
condensed meaning units were abstracted into codes andcategories regarding the adolescents’ and their networks’experiences of the ball vest. In the third stage the codesand categories were compared concerning differences
and similarities and sorted into four themes of which
two also were divided into subthemes. The content of
the meaning units were foundation to what themes andsubthemes that were chosen. In the fourth stage, the content of the themes and the subthemes were compared tothe original text, and it was confirmed that they reflected
the content of the interviews. Throughout performing
the analysis, emerging findings were discussed with theco- authors.
Every theme and subtheme that the analysis identified described different aspects of the experiences ofwearing a ball vest and how it was used. Table 1 shows
an example of the qualitative content analysis process inwhich the theme The ball vest as mind and body helper
emerged. Table 2 shows one example of the qualitative
content analysis process in which the subtheme Possibilities to be active and participate in school setting
emerged.
Ethical aspects
The fact that the recipients of the enquiry letterswere families who had contact with the CYHC could
have made it difficult to decline. However, the letter
clearly informed that the decision of participation or not
would not influence the further contact with the CYHC.
The participating adolescents belong to a groupwhich may have difficulties expressing themselves verbally. This circumstance put demand on the interviewer

to be extra attentive in order to fulfil ethical standards.
The interviewer had to be considerably conscious about
the balance of power between adults and adolescentsand to create a comfortable situation while questioning[40]. The questions had to be put in a substantiallynatural, attentive and simultaneously distinct way. In the
result, pseudonyms are used for the adolescents’ names.
The Regional Ethics Board in Umeå, Sweden approved
the study, study code 2014-92-31M.

RESULTSThe result of the analysis is presented in four
themes, of which two themes were sorted into three subthemes that each described the experiences of wearing
a ball vest and how it was used. The four themes are:
1. A desire to relive an earlier experienced feeling;
2. The ball vest as mind and body helper with three subcategories; 3.The Ball Vest as an Activity Friend withthree subcategories and 4. Attitudes of people influenced
the use of the ball vest.
A desire to relive an earlier experienced feeling
The analysis showed that most adolescents had
earlier tried a ball blanket which was remembered ascozy to wind down with and hoped that the ball vest
would bring the same sensation. Oscar, nine years old,said: “Directly when we got the letter about the vest I
thought I should try it because the ball blanket had been
so calming and maybe this also would feel real nice”.
In the beginning of the period of wearing the vest
for the study, a calming feeling was experienced, whichbrought a desire and a longing to experience this positive feeling again. Patrick, 10 years old, said: “I actually
can buy a vest, if we have the money. I would like to,because I could concentrate better, and it was really
comfortable to wear. I thought that it reminded me of theball blanket, it felt almost the same. It felt good when
the balls squeezed ”.
The ball vest as mind and body helper
A great sense of comfort and fatigue made life brighter
The analysis revealed that the ball vest provided apleasant feeling of fatigue and comfort. The vest gave
heaviness on the body described as a pleasant hug and afeeling of being safe and brought a need to yawn. Agnes’
father explained: “She likes to wear it, and that provesthat something happens in her body. I think there issomething with the balls that makes her feel calmer andsafer that gives her body a nice feeling on the whole,that gives a kind of massage on her back and both sidesof her body. Otherwise you could wear any vest at all ”.
The vest brought a confident feeling and was worn

Breivik I et al.

Asian J Occup Ther 15: 53−62, 2019

Table 1.

57

Examples of the qualitative content analysis process in which the theme The ball vest as mind and body helper emerged

Identified meaning unit

Condensed meaning unit

Code, underlying meaning

Subcategory

Category

Well, when we got the letterI thought that it would feelrather nice like, and that I
should become calmer of it,of having it.

… got the letter, thought
it would feel nice, become
calmer.

Had an expectation thatthe vest would feel niceand bring composure.

Had an expectation thatthe vest would feel niceand to bring composure.

Had an expectation thatthe vest would feel niceand to bring composure.

It has been rather heavy touse, but has been calming inthe same time. Thus I havebecome calmer; I have notbeen that stressful.

Become calmer, haven’t
been that stressful.

Become calmer, haven’t
been that stressful.

Used as shelter in theafternoon when messy
at home when the family
gathered.

I used in the afternoon when
it was pretty messy at home,when everyone came homeand hurried round.

Used in the afternoon
when it was messy athome, when everyone
came home

Used as shelter in theafternoon when messy
at home when everyone
came home

Winded down by the vest.
Calmer, not stressful. The
vest gave a nice heavy
feeling. Used as shelterin the afternoon whenmessy at home.

When I was very excitedand became calmer when I
put the vest on and so.

I was very excited andbecame calmer when I put
the vest on

Winded down by the vest

Winded down by the vest.
Became calmer wasn’t
that stressful.

It felt very nice to wear it, inthe same time a little heavy
in a nice way the balls gavea nice feeling.

It felt very nice to wear it,in the same time a little
heavy in a nice way, theballs gave a nice feeling.

The vest was very nice towear, it was a little heavy
in a nice way, the balls
gave a nice feeling.

The vest was very nice towear, gave a nice heavy
feeling.

Table 2. Examples of the qualitative content analysis process in which the subtheme Possibilities to be active and participate in school setting
emerged
Identified meaning unit

Condensed meaning unit

Code, underlying meaning

Subcategory

I have used the vest every
day since I got it. It has felt
good to use the ball vest. It
feels important

Used the vest every day
since I got it. Feels good,
important

The vest was usedevery day, felt good andimportant

Used the vest vey day
since I got it. It feels
important

I had it mostly in school
during lessons, took it off
during breaks and lunch.

Mostly in school during
lessons, off during breaks
and lunch.

The vest was worn inschool during lessons, notbreaks and lunch.

It has been good when I had
it on in the classroom, thelesson went better.

It has been good when I
had it on in the classroom

Wearing the vest felt good.

The vest was worn during
lessons in school because
it brought calm and madeit easier to listen.

I had the vest on during
Swedish, English classes
and reading. All was better;
I was calmer and listened
better.

Wore the vest during
Swedish, English classes
and reading. All was
better; I was calmer andlistened better.

Wore the vest during
Swedish, English classes
and reading. All was
better; I was calmer andlistened better.

I put it on when I want,when I feel for it, it can bethat I feel I will not be able
to sit in the classroom for solong, not the whole lesson.
Then I put the vest on.

Put it on when I want, canbe that I feel I will not beable to sit in the classroom
the whole lesson.

Put it on when I want, canbe that I feel I will not beable to sit in the classroom
the whole lesson.

Wear it whenever theneed, can be a feelingnot being able to sit in
the classroom the whole
lesson.

It feels good to have it on I
like the balls.

Feels good to have it on I
like the balls.

The vest feels good towear and the balls are nice

The vest feels good towear

Category
The vest was worn
during lessons in school
whenever the needwas. Felt good, brought
calmness, made it easier
to listen and to sit longer
time.

58

WEARING A BALL VEST IN EVERYDAY ACTIVITIES

to be able to perform an activity or to be able to relax
and calm down in stressful moments. Andrew liked thatthe vest made him relax so well that he fell asleep when
he was sitting on the couch and had nothing to occupy
himself with. Ben’s mother stated that when her son
tried the vest for the very first time, he after 10 minutes
uttered: “Mum, it feels in my body like I’m going toburst into laughter!” Ben then looked very pleased andshe recognized a positive feeling in him that sort ofpoured through his body. He was very calm and looked
like he had received a kick of endorphins. During thefollowing intervention period he took the initiative towear it himself on half of the occasions, saying: “Well,
now mum I have to have the vest. Now I must have it.
Mum, I use the vest for a while”.
Lucas’ mother noticed he had the strongest need towear the ball vest in the afternoon, when the effect of thestimulant medication disappeared. Patrick discoveredthat the vest gave massage on the back and shoulders
when he pulled his shoulders up and down and thought
it was comfortable to do this now and then to become
more aware of his body.
Loosened up to be able to socialize
The analysis revealed that the vest brought a soothing effect on mood and temper and contributed to theability to endure sounds, light and smells better. During
the afternoons after school the adolescents often got
irritated because they experienced this time as messy.
At this time of day the adolescents could get very edgy
if someone touched them, or when they stood close
together with their siblings or sat at the table during
dinner. Some participants experienced that wearing thevest could reduce such incidences and make it possible
to handle the teasing of younger siblings without getting
tantrums. Wearing the vest made it easier to loosen up
and focus on what parents and siblings said and handle
the situation in a proper way. The vest was also used towind down all on their own when contact with others
was unwanted. One of the boys put it on deliberately forhalf an hour afterwards to be able to meet and socialize
with family and friends for a long while in a balanced
way. Andrew, 13 years old, explains: “The ball vest was
comfortable to wear. It made thus I did not get so fast
angry with my brother”.
Lucas, 13 years old, explained that when he wore
the vest while playing computer games, he did not get
as upset as he used to when the keys got stuck. He said:“Well, then I can lose in certain games. When I had thevest on I could just simply start from the beginning and I
did not get so enraged either”. When he had discovered
this, he began to put the vest on before he started playing.

The ball vest as a friend and pet
The ball vest brought a feeling of comfort whenthings were strenuous both in school and at home. In
general, the vest helped to hold one together and supported the adolescents when they were sad or missed
someone. The vest was handled gently and protected
and sheltered from other students in school and fromyounger siblings at home. It was described as a friendthat could make the adolescents calm down when they
were angry and support them to feel better when they
were sad. Lucas said: “Yes, it feels like someone is there
to hug you all the time. You need to have a little, well…
if you feel alone, maybe miss someone or so. Well, I
missed my cat, and then I put the vest on and then it felt
much better”.
The vest was experienced as hugging and consolingby the adolescents, and when hurting themselves theysaid they were less distressed. Giving the ball vest backafter the loan was described by one participant as similar
to have to leave a dog or a cat with a new owner because
not being able to take care of it.
The ball vest as an activity friend
Easier to think of what to do and keep it in mind
Several participants described that the vest made iteasier to be concentrated on activities they wanted to do.
The vest also enabled to perform activities they did notwant to do, such as tidying up the room, doing homework, and writing, doing math’s, and making a snack.
Andrew explained that he could walk wildly around notknowing what to do but when he put on the vest, on it
became easier to do activities that were planned. He uttered: “I concentrate when I wear the vest because thenI am calm, I can think of what I have to do and keep it in
my mind – do not think of other things, and I finish what
I have to do. Then I do those things first. If I don’t wear
it I don’t concentrate as well. I can sit and write or dosomething, and then whoop – start to do something elseand immediately stop doing what I have to, for example
write. Instead I fetch and build with Lego, because thatis one of the most fun things I can do, I think, actually”.
Possibilities to be active and participate in the school
setting
The two adolescents who brought the vest to school
regularly wore it during lessons containing exposition,
instruction and individual school work. Wearing the vest
brought an ability to pull together and participate andstay in the classroom during a whole lesson performing
school activities. Oscar was calm and listened better
when he used the vest during academics. His teacher
observed him being proud wearing the vest and that thevest gave him gravity, as if he felt, Here I am! Patrick,Breivik I et al.

Asian J Occup Ther 15: 53−62, 201911 years old, thought that the best time to wear the vest
was when his teacher gave instructions and information,
which then were easier to receive. Agnes explained thatduring the two days she wore the ball vest in the school
setting, she relaxed more than she used to. Because ofnegative attention from other students, she discontinued
bringing it but wore it at home at breakfast before goingto school, and then had a calming feeling of still wearing
it when she entered school.
Satisfaction with performing interesting and funny
activities
The analysis showed that it was common to switch
between activities such as building with Lego andwatching a film, without finishing any of these activities.
The vest brought the capacity to view a whole film without a break in the middle and made it possible to follow
the storyline in a TV series you wanted to see. Lucas
explained that if he wondered what to do, he sat downon his bed, put the vest on and then had an idea of what
to do. He then could use his iPad, watch TV, play Minecraft, play cards or use his smartphone. Patrick said: “Ihave watched TV with it too, yes. It is comfortable to sit
calm and nice and concentrate to watch a little… without walking away directly and think… nooooo, boring,kind of. Then I can stay and watch a while, to see what
it is all about and think yes, this was pretty enjoyable
after all, in spite of starting dull ”.
Wearing the vest made it possible to build morecreative and advanced constructions of Legos and othermaterials and it was deliberately worn to get imaginativeand funny ideas. It also gave the opportunity to implement ideas for activities and how to use the vest could
be arranged. When Ben got an idea of an advanced
building project, he put the vest on in advance because
he had discovered he had to wear it to be able to sit
calmly and concentrate to carry the plan out. He thought
the vest had a disadvantage in that it was clumsy and, inthe way, when he sat on the floor building Legos, but heused it anyway because it made him relax.
Attitudes of people influenced the use of the ball vest
The analysis revealed that all six adolescents usedthe vest at home and that two of them also used it regularly in school. Another two wanted to wear it in schooland brought it there for a couple of days and felt comforted by it but discontinued the use because of otherpupils’ teasing. The adolescents who wore the ball vest
regularly in school were younger and their teachers were
engaged in the use. The vest was accepted by everyone intheir school context and they got questions but not teasing. The older adolescents felt uncomfortable to wear
the ball vest in school despite its benefits. They who

59

attended upper secondary school felt deviant and stigmatized because of all the questions from other students
who did not understand the purpose of wearing it.

DISCUSSION
This qualitative study brought an insight into how
wearing a ball vest while performing everyday activities
could be experienced by adolescents’, their parents andteachers. The theme “The ball vest as an activity friend”
indicate that the ball vest may be an enabler to increase
activity performance both at home and in the school
setting among adolescents with neuropsychiatric disorders. This is illuminating because the ability to focus onand concentrate to perform an activity is a known issue
among this group of adolescents [2−4, 6, 7, 18]. Regarding children with ADHD this result can be compared
to another study where researchers found that weighted
vests showed improvement in attention, responding
and processing speed, executive management and ontask behavior [34]. Their study showed no significant
improvement in impulse control and automatic vocalizations in a randomized, two-period crossover design, but
the study supported the use of weighted vests to increase
attention to task problems of children with ADHD.
In the present study, the adolescents reported anincreased ability to perform various activities whichmeans that this was essential to them. This condition
supports earlier findings where students with disabilities
communicated that to them the most important element
was to be active and to be seen participating with othersin their context [41]. That adolescents with disabilities
emphasize the need to prioritize mainstream solutions
were also found in other studies [42, 43]. In the Modelof Human Occupation (MOHO) [1], participation is
acknowledged as an important aspect of activity performance, and is perceived as engagement in play, workor daily activities, which are part of our socioculturalcontext and are desirable or necessary to our wellbeing.
That the adolescents in the present study found that theball vest brought possibilities to perform interesting andfunny activities corresponds with how Kielhofner [1]describes pleasure as an important aspect of creating anactive life.
The vest was useful at home but not all adolescentsfelt comfortable to wear it in the school setting. The
subtheme “Attitudes of people influenced the use of theball vest” indicate that the social context in the upper
secondary school influenced negatively on the possibilities of using the ball vest. This finding supports earlier
research that found the social context more important
to students’ deciding to use or abandon their assistive
technology than the benefits they received from the

60

WEARING A BALL VEST IN EVERYDAY ACTIVITIES

devices [42]. However, this study also shows that theadolescents who used the ball vest in the school setting
had teachers who were positive. The success of the useof assistive technology devices may depend on teachers’
encouragement [44].
Another finding in the theme “A desire relieve an
earlier experienced feeling” is that the majority of theparticipating adolescents earlier had tried a ball blanket
and felt the need to experience the same sensation thatthe ball blanket had given them. That they felt a needto relive an earlier experienced feeling indicates theimportance of opportunities for children and adolescentsto try and experience new assistive technology devices.
This finding also supports earlier research that foundthat children and adolescents need to have their own
experiences to know whether a device is useful or not[42, 45]. Associated with this result, one could discuss
what impact the fact that the majority of the adolescents
had a positive experience of trying a ball blanket before
had on how they experienced the ball vest. That theadolescents associated the ball blanket with the ball vest
suggests that children and adolescents should get the opportunity to try a ball blanket before they try a ball vest.
An implication could be to try a ball blanket before prescription. This also suggests further studies with moreparticipants to get answers about if there is a correlation
between these two interventions.
An interesting finding is that a delayed effect was
discovered which was made use of preventively. One
example is that the vest was worn during breakfast at
home, to be able to enter school in a calm mood. Other
examples are that the vest was worn for half an hour inthe afternoons to prepare to socialize with the family
and in advance of building a complicated Lego project
to be able to carry the building plan out. A delayed effectof deep pressure treatment goes in line with earlier studies [29, 31]. This finding suggests that clinicians should
inform ball vest users to try to wear the vest ahead of
performing an important activity where they have toconcentrate. Overall, it should be recommended thatball vest users themselves decide when and where to use
their vest.
The present study supplies knowledge of how aball vest can be useful to adolescents that need to relax
to be able to focus and stay engaged in an activity. This
supports earlier research on calming down using deeppressure which earlier was given by holding, stroking,hugging and swaddling [45]. The results revealed thatthe ball vest gave a feeling of confidence and was worn
during stressful moments or to make one able to perform
an activity or to just relax and calm down. The ball vest
was described as giving a pleasant feeling and provided
comfort when the balls squeezed, phrased as a kind of

massage on the body. This finding shows that a ballvest can be an alternative to techniques used for stress
reduction such as mindfulness meditation, which is used
to find relaxation through cognitive and intention-based
self-regulation [46]. Morrison [37] found in her review
that the results of the articles were questionable or positive and concluded that the effectiveness of the weighted
vests was limited, and further research using larger samples using standardized protocol and less homogenous
groups is needed. The present study has a qualitative
approach, and does not meet any of these proposals, but
can serve as an important guide forward.
Limitations
The findings can be utilized as a guide to understanding what might occur in other situations and samples. Despite this, the following limitations need to betaken into account. This study sought insights into theadolescents’ experiences of using a ball vest in everyday
activities, but it is common that when interviewing
children, data is not as exhaustive as one intends [40].
Addressing the adolescents themselves to gather data
was significant for the study. To also address their parents and teachers increased the trustworthiness. Anotherlimitation was the eight-week-long period of using theball vest, which means that the long-term outcome has
not been studied. In this matter this study can be viewed
as a pilot study.

CONCLUSION AND IMPLICATIONThis qualitative study identifies an interesting hypothesis regarding how a ball vest can be experienced
in relation to the performance of everyday activities athome and in the school setting for students with highactivity levels and neuropsychiatric disorders. This
study suggests that the participating adolescents themselves were conscious about the importance of theirown activity performance and activity participation.
An implication for practice and further use of ball vest
includes that detailed information from the occupational
therapist to the teacher and the school class should begiven to create a friendlier climate for ball vest use.
There is a need of structural information to the children
and adolescents themselves. The occupational therapist
and the teacher should also give more time for information and adaptation in the school setting.
In addition, the adolescents need to wear the ballvest in different contexts and activities to get experiences in which settings it was most useful, which seems to
be of importance for the experience of benefit. Further
research is needed to explain what factors are importantand to influence the decision to wear a ball vest or not inAsian J Occup Ther 15: 53−62, 2019the school setting.
Acknowledgement: The authors would like to thank theparticipating families and teachers who were involved inthis study.
Declaration of Interest: The ball vests used in thisstudy were loaned from Komikapp AB. The company
had however no affiliation with the development, or
execution of this research. The authors alone are responsible for the content and writing of the article.

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■ORIGINAL ARTICLE

Difficulties in Everyday Technology Use of the People
with Acquired Brain Injury Living at Home
Osamu Nakata, OTR, PhD1, Rumi Tanemura, OTR, PhD2,
Toru Nagao, OTR, PhD2, Kazue Noda, OTR, PhD2, Jiro Sagawa, Engineer, PhD3
1

Kobe Co-medical College Department of Occupational Therapy
Kobe University, Graduate School of Health Sciences
3
Kobe Design University, Graduate School of Arts and Design
2

Abstract: Everyday technology (ET) has become central to modern life, but its use poses challenges to those with cog­
nitive impairments. We sought to describe the level of perceived difficulties in using ET by people with Acquired Brain
Injury (ABI) and to assess the correlation between perceived level of difficulty and cognitive impairment. The Every­
day Technology Use Questionnaire revised Japanese version (ETUQ-Japan) was used to assess perceived difficulties in
ET use for twenty-two participants with ABI. A trend of negative correlation was observed between the ratio of ET usedwith assistance of someone else and all neuropsychological test results. In particular, strong negative correlation wasobserved between the executive function (Behavioral Assessment of the Dysexecutive Syndrome, BADS) and the useof ET with assistance. It is likely that impairments to executive function are associated with difficulties in using ET use
and patients with ABI living at home will require aid to address these problems.
Keywords: acquired brain injury, everyday technology, executive function(Asian J Occup Ther 15: 63−68, 2019)

1. Introduction
The daily life of people with acquired brain injury(ABI) is influenced by their cognitive impairments
including memory disorder, attention disorder, andexecutive dysfunction [1]. Wilson and her colleagues
have reported the challenges for their patients with ABIin their daily lives, including forgetting where they haveplaced objects or parked their cars and being unable
to manage money or leave the house alone [2]. Others
reported that people with ABI have limitations to theirlevel of activity [3] and social adaptation [4]. Many
young persons with ABI who live at home need services
and supports in their environments [5]. In addition to
the inconveniences faced by persons with ABI them­selves, there is also extensive burden placed upon care­givers [6, 7]. Cognitive impairment is associated with
Received: 5 September 2016, Accepted: 27 June 2019
Corresponding to: Osamu Nakata, Kobe Co-medical College Depart­
ment of Occupational Therapy, 7-1-21, Tomogaoka, Suma-ku, Kobe,
Hyogo 654-0142, Japane-mail: hind3999@yahoo.co.jp©2019 Japanese Association of Occupational Therapists

the loss of social autonomy and an inability to return towork after ABI [8].
For people with ABI to live comfortably at home, it
is important to have abilities to handle many everyday
technologies (ET). ET has been defined to include avariety of technical, electronic, and mechanical equip­
ment, including both recently developed devices andwell-known technology and services [9]. Not only does
the use of ET contribute to an improved lifestyle [10],it has also become an integral part of most tasks athome and in society, including the workplace in recent
decades [11]. However, the use of ET, even by people
without cognitive impairments, can be difficult at times[12], and the benefits that people with ABI, who havevarious types of cognitive impairment, can gain fromET are even more limited than those without cognitive
impairment [13].
Multiple studies have evaluated the relationships
between people with ABI and their ET use in everyday
life. Lindén and her colleagues have demonstrated thatpeople with ABI have difficulties using everyday tech­
nology, in particular, advanced technology such as com­puters, telephones, and other electronic systems which
require the use of cognitive functions [14]. Fallahpour

64

DIFFICULTIES OF THE PEOPLE WITH ACQUIRED BRAIN INJURY

and her colleagues have revealed that perceived diffi­
culty in ET use is significantly increased among people
with ABI, with severe to moderate disability, comparedwith controls [15]. Malinowsky and Lund have de­scribed the relationship between the perceived difficulty
and the observed ability of ET use in people with ABI of
working age [16].
Although there are a few studies that evaluated dif­ferent aspects of ET use in people with ABI, to the bestof our knowledge, there have been no studies regarding
the relationship between the difficulties using ET andvarious types of cognitive impairments. Therefore, ourstudy sought to explore the level of the difficulties inusing ET among people with ABI and to assess how thelevel of difficulties is associated with cognitive impair­ment in people with ABI. Lund et al. also emphasized
the need for occupational therapists to evaluate theextent to which people with ABI experience difficulties
while using ET as a result of cognitive impairment [17],and occupational therapists need knowledge about therelationship between the difficulties experienced bypeople with ABI during ET use and their cognitive im­pairments.
In conclusion, this study aimed to clarify the relation­
ship between various cognitive functional impairmentsin people with ABI living at home and their perceived
level of difficulty of ET use.

2. Participants
Inclusion criteria required that participants in thisstudy (i) had a diagnosis of cognitive impairment causedby acquired brain injury and, (ii) lived at home and,(iii) either had no physical dysfunction or only limited
physical dysfunction that scarcely affected their ET use
in daily life. Exclusion criteria included (i) a diagnosisof cognitive impairment with no clear cause, (ii) a diag­nosis made by someone other than a physician and (iii)
those who lacked the communicative ability to undergointerviews. Upon commencing research, requests for re­search cooperation were sent to eight general hospitals,
clinics, community workshops specialized in cognitive
disorders and ABI Patient-Family Associations in the
Kansai area and Okayama prefecture. People from these
institutions and organizations introduced the research
to potential participants using written explanations.
Twenty-two participants who met the criteria wereenrolled (Table 1). The participants, of which 17 weremen and five were women, were aged from 20 to 62
years with a mean age of 41.3 ± 13.4 years. Causes ofhead injuries included head trauma (15 participants),
cerebrovascular accident (five participants) and hypoxic
encephalopathy (two participants). Two participants

Table 1.

Characteristics of 22 participants in the study

Age (years)

Mean (SD)
Range

Gender (n)Living situation (n)Employment Status (n)41.3 (13.4)
20−62

male
female17
5with family
alone

20
2

not employment
assisted employment
regular employment

1093

TraumaStrokehypoxia15
52Type of ABI (n)lived alone and 20 participants lived with their families.
Three participants were in regular employment, nine
participants were in assisted employment at welfare
facilities, and 10 participants were unemployed (includ­ing retirees, housewives and students).
This study proposal was approved by the EthicalCommittee of Kobe University Graduate School of
Health Sciences. All participants provided written in­formed consent before data collection.

3. Materials and Methods
Data-collection tools
For collecting information of perceived difficultyin ET use by the participants with ABI, the Everyday
Technology Use Questionnaire revised Japanese version(ETUQ-Japan) was used. The original ETUQ is a semistructured standardized interview questionnaire, devel­
oped to investigate perceived difficulties among elderly
people with cognitive deficits living at home [9, 12].
The original ETUQ is composed of 93 ET-items orga­
nized into 8 domains, namely: household activities (e.g.,
micro­wave oven and vacuum cleaner), activities at home(e.g., TV and DVD), personal care (e.g., thermometerand hair dryer), power tools (e.g., lawnmower andelectric screwdriver), accessibility (e.g., elevator and in­tercom), data and telecommunications (e.g., push-button
telephone and PC), economy and shopping (e.g., credit
card and the Internet banking), transportation (e.g., anautomatic turnstile and automatic ticket machine). The
ETUQ-Japan was composed of 101 items in the same 8
domains [18−20].
For evaluating cognitive functions of the people with

Nakata O et al.

Asian J Occup Ther 15: 63−68, 2019

Table 2.

Neuropsychological test results of ABI patients
WMS-R

Mean
SD
Median65

WAIS-III

BADS

verbal memory

visual memory

total memory

VIQ

PIQ

FIQ

BADS score

70.9
14.9
68.5

75.1
19.2
81

68.5
16.1
67

85.7
20.8
85.5

75.5
15.9
75

78.5
17.6
77

79.0
22.8
80.5

ABI, we used the Wechsler Adult Intelligence ScaleThird Edition (WAIS-III) for Intelligence, the Wechsler
Memory Scale-Revised (WMS-R) for memory functions,and the Behavioral Assessment of the Dysexecutive
Syndrome (BADS) for executive function. These cogni­
tive functions were evaluated in the participant’s home,and some was submitted from the cooperating facility
with consent.
Data collection methods
Interviews regarding perceived difficulty in ET use
were obtained by conducting the ETUQ-Japan in theparticipant’s home. These interviews were done by firstauthor. He, as well as the members of the research team,
had extensive knowledge about the ETUQ obtained
from a workshop on the original ETUQ and work on
developing the ETUQ-Japan [20].
In the ETUQ interviews participants were first asked
if each ET was “relevant” or “not relevant” for them.
If an ET was relevant, then they were asked regarding
ease or difficulty of use, which was scored according to
the level of perceived difficulty in using it. There were
three scoring categories: (i) “use independently without
difficulty,” (ii) “use independently with difficulty,” or(iii) “use with assistance of someone else.”
Data analysis
In each participant, a value was obtained by dividing
the number of ET included in each category (i, ii, andiii) by the total number of relevant ET. These threevalues and the number of using ET (relevant ET) were
defined as “condition of using ET”.
The condition of using ET and the results of neuro­
psychological tests (“performance intelligence quotient(PIQ),” “verbal intelligence quotient (VIQ),” “full scale
intelligence quotient (FIQ)” of WAIS-III, “verbal
memory,” “visual memory,” “total memory” of WMS-R,
and BADS score) were analyzed with the Spearman’srank correlation coefficient in order to clarify the
relationship between the various measured cognitive
functions and use of ET. All risk ratios were consideredsignificant with scores below 5% based on the two-sided
test. For data analysis, the SPSS version 20.0 for win­
dows was used for this study.

4. Results
The relationship between various cognitive and executive functional impairments and perceived level of difficulty of ET use
The mean ± standard deviation for ET used in people
with ABI was 34.7 ± 8.3, out of a total of 101 items of
the ETUQ-Japan. Neuropsychological test results for
subject with ABI are shown in Table 2.
The coefficient ratio of each neuropsychological test
and the condition of using ET are shown in Table 3. A
positive correlation was observed between “the numberof using ET” and the BADS score (r = 0.466, p < 0.05).
A positive correlation was also observed between “useindependently without difficulty” and the BADS score(r = 0.430, p < 0.05). A negative correlation was ob­
served between “use with assistance of someone else”
and verbal intelligence following WAIS-III “VIQ” score(r = −0.479, p < 0.05). A negative correlation was also
observed between “use with assistance of someone else”
and WMS-R “verbal memory” (r = −0.570, p < 0.01),“visual memory” (r = −0.561, p < 0.01), “total memory”(r = −0.568, p < 0.01), WAIS-III performance intel­
ligence “PIQ” score (r = −0.613, p < 0.01), full scale
intelligence “FIQ” score (r = −0.598, p < 0.01), andexecutive function BADS score (r = −0.843, p < 0.01).
No significant correlation was observed between “useindependently with difficulty” and neuropsychologicalscores.

5. Discussion
A trend of negative correlation was observed between
the ratio of ET “used with assistance of someone else”
and all of neuropsychological test results. In particular, astrong negative correlation was observed with the BADS
score. On the other hand, there was a positive correla­tion between the BADS score “the number of using ET”
and “use independently without difficulty” categories,
but no correlations were observed for the condition of
ET use and the other neuropsychological tests results,
except for the “use with assistance of someone else”
category. Therefore, it is believed that the BADS scorereflects the condition of ET use and everyday quality of

66

DIFFICULTIES OF THE PEOPLE WITH ACQUIRED BRAIN INJURY

Table 3. Relationship between the states of ET use and each score of neuropsychological test (Spearman’s rank cor­
relation coefficient)
Types of neuro­
psychological test

the number ofusing ET (rs)use independently
without difficulty (rs)use independently
with difficulty (rs)use with assistanceof someone else (rs)verbal memory
visual memory
total memory
VIQ
PIQ
FIQ
BADS

0.364
0.409
0.416
0.281
0.271
0.342
0.466*

0.411
0.195
0.355
0.360
0.382
0.397
0.430*

0.167
0.339
0.214
0.162
0.197
0.204
0.371

−0.570**−0.561**−0.568**−0.479*−0.613**−0.598**−0.843***p < 0.05, ** p < 0.01.

life of patients with ABI. Furthermore, there is a greater
likelihood of requiring assistance, especially when the
BADS score is low. BADS was developed by Wilson
and her colleagues as a standardized battery for evalu­
ating executive dysfunction [21] and was thought to bean effective tool for evaluating the ability to perform
an action independently and efficiently [22]. Executivefunctions are the controlling mechanisms of the brain
and include the processes of planning, initiation, organi­zation, inhibition, problem solving, self-monitoring anderror correction [23]. People with executive dysfunc­tion lack the ability to create ideas and build practicalstrategies, have difficulties in starting and maintaining
actions, as well as taking independent actions [1, 22]. In
conclusion, occupational therapists should heed BADS
scores as indicating the possible existence of difficulties
with using ET.
No previous research makes explicit reference to therelationship between ET use and executive dysfunction;
but several studies have suggested the relationship.
Organizing or sequencing steps and actions in a logicalorder may affect using ET in daily activities [24]. Also,
Larsson and colleagues reported one of the response
actions while using ET being random and inflexible
repeating [17]. Kassberg et al identified that people with
ABI require varied support to identify their problems
and goals related to ET use [25]. In a recent research
we conducted, we characterized the difficulties faced bypeople with ABI in daily life, by classifying the encoun­
tered difficulties [26]. According to that research, vari­
ous types of level of perceived difficulties among people
with ABI were identified, such as, “pressing the buttons
of DVD player at random, due to having difficulty inrecording” or “being unable to distinguish the difference
between the ways of cooking on the rice cooker.” Thesedifficulties are classified as “cannot correct one’s error
when using ET” and “inflexible in changing one’s corre­
spondence according to each device.” These difficulties
are thought to be caused by executive dysfunction.

Therefore, when these people perceive any difficulties
at the time of ET use, they tend to give up or dependon others, rather than trying to solve the problems bythemselves through trial and error. This is thought to be
characteristic of “use with assistance.” Furthermore, inthat study there were some problems, such as “spend a
day without adjusting the air conditioner according to
the room temperature” or “often use the hair dryer whenreminded by the caregiver and get told that the time
for drying is not enough.” The present study’s results
support the notion that for people with executive dys­function, difficulties arise when they start or continue
operating ET, and then it is necessary for someone towatch and tell them what to do at the time of their ET
use.
Regarding these problems that he/she cannot start orcontinue operating ET, the use of assistive technologythat prompt his/her actions is thought to be effective. The
paging system designed by Wilson and her colleagues
is an assistive technology for memory impair­ment,
but can also be used to give cues regarding initiat­ing
actions [27]. As for a trial to replace caregivers withassistive technology, Tanemura and her colleagues havedeveloped a daily life management application named“Arata,” which achieved good results [28].
In a study of mental health and related factors, Suzuki
and his colleagues indicated that memory disorder wasless related to mental health, and it was executive dys­function and social behavior disorder that were associat­
ed with mental health [29]. In addition, they pointed outthat the number of prompting and time spend watchingover a person with executive dysfunction required foreach occupational performance process in everyday life
may affect the mental health of caregivers. Based on
the results of that study and the present study, it seems
that with executive dysfunction increasing so does thetendency to depend on others when using ET, and as aresult the burden on caregivers is increasing. Decreasing
the need for prompting and watching over required forNakata O et al.

Asian J Occup Ther 15: 63−68, 2019each occupational performance process in everyday life
might result the reduction of caregiver burden. Also,
assistive technology that prompts the actions of people
with executive dysfunction instead of caregivers isuseful for the reduction of caregiver burden.
Executive dysfunction is also said to have a mutual
relation with social participation [30]. Executive func­tion is associated to the abilities of planning efficiently
to do daily routines skillfully and to adjust well with thesurrounding people to solve social problems [31]. The
result of this study indicated that there is a relationshipbetween ET use and executive dysfunction. We have tofocus both on the situation of using ET and the level ofexecutive dysfunction to understand the daily life of thepeople with ABI from their ADL to social integration.

Study limitations
We looked at the influence of cognitive impairment,
however there are many other influences. It is known
that personal identification and environmental factors
affect the difficulty of ET use [33]. Considering thesefactors is necessary when providing interventions forpeople with ABI.
The surveyed area of this study was limited in the
Kansai region and Okayama prefecture. Accordingly
this study’s findings might not reflect geographicaldifferences that might influence the use of ET and therelationship between client and caregiver.
Even though the participants did not have difficultywith physical function, it is well-known that people
with ABI have additional problems, not only withmemory disorder and executive function, but also withmotivation and personality. Taking such problems into
consideration might lead to different findings regarding
cognitive impairment and conditions of ET use. For
instance, there is a possibility that motivation and per­sonality are more important than executive function.

Conclusions
The level of perceived difficulties in ET use by people
with ABI were explored and revealed. The results sug­gest that the quality of executive function influence theability of an individual to use ET. People with ABI have
many difficulties in ET use, and they might have a needfor support from others in many cases. Consequently,
difficulties of using ET not only impedes the use of ET
in clients, but also hinders their participation in society
and places burdens on caregivers. It is necessary foroccupational therapists who are involved in the home
life of patients with ABI to pay attention to the patient’s
ability to use ET as well as their executive dysfunction.

67

Acknowledgements: We would like to thank all clientsand their caregivers who participated in this study.
Also, we would like to thank general hospitals, clinics,
regional workshops specializing in cognitive disorders
and patient–family associations which gave us theircooperation when we were recruiting participants.
Declaration of interest: The authors indicated no po­
tential conflicts of interest.

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■ORIGINAL ARTICLE

A Comparative Study of Adjustability of Grasping Forcebetween Young People and Elderly Individuals
Tatsuya Kaneno1, Muku Ito2, Naoto Kiguchi1, Akihiro Sato1,
Kazunori Akizuki3, Jun Yabuki4, Yuki Echizenya5, Satoshi Shibata6
1

Department of Occupational Therapy, Mejiro University
Harajuku Rehabilitation Hospital3
Department of Physical Therapy, Kobe International University
4
Ibaraki Prefectural University of Health Sciences Hospital
5
Saitama Rehabilitation Center
6
Department of Sports R&D Core, University of Tsukuba
2

Abstract: Purpose: This study aimed to compare adjustability of grasping force (AGF) between people belonging toyoung and elderly age-groups.
Methods: Twenty young people and 20 elderly people, with no previous pathology involving the hands and fingers,
were included in the study, and an AGF assessment was performed for all the subjects using an iWakka. Subjects
adjusted the grasping force according to the target value displayed on the monitor by opening or closing the iWakka.
Results: The assessment of AGF was performed separately from that of the gripping force, and the latter was found to
be comparable between the two groups. The mean AGF was found to be 8.9 ± 4.0 g and 7.6 ± 2.8 g for the dominant
and the non-dominant hand, respectively, in the elderly group, as compared to the mean AGF for the dominant and thenon-dominant hand of 4.4 ± 1.2 g and 4.4 ± 0.6 g, respectively estimated in the young age-group. A t-test conducted
after controlling the disparate factors (sex, handedness, gripping force) between the subjects of the two groups, showedthat there was a significant difference in AGF between the young and the elderly groups for both the dominant ( p = 0.03)
and the non-dominant hand ( p = 0.02), indicating that the AGF of the elderly people was significantly lower than thatof the young study-subjects.
Conclusions: Our findings suggest that AGF decreases with aging and that it is necessary to assess AGF separatelyfrom the gripping force, to make a precise comparison.
Keywords: adjustability of grasping force, iWakka, elderly people, gripping force(Asian J Occup Ther 15: 69−75, 2019)

1. Introduction
The functions of hands and fingers involve making
grabbing, gripping, pinching, hooking, scooping, andpressing movements, which play an important role inperforming daily activities [1]. Therefore, in many instances, rehabilitation centers have developed interventional programs for training patients to resume activities
of daily living (ADL), based on the results of functional
Received: 21 April 2019, Accepted: 14 August 2019
Corresponding to: Tatsuya Kaneno, Department of Occupational Therapy, Mejiro University, 320 Ukiya, Iwatsuki-ku, Saitama-shi, Saitama339-8501, Japane-mail: kaneno@mejiro.ac.jp©2019 Japanese Association of Occupational Therapists

assessment of their hand and finger movements. Currently, an assessment of gripping force, the Purdue Pegboard Test [2], the O’Connor Finger Dexterity Test [3, 4],
the Jebsen-Taylor Hand Function Test [5], and an examination of the physical capacity of hand-related skills[6], are utilized widely for assessing the hand and finger
functions. Since these tests depend on an evaluation ofboth the time taken to complete a task and the degree towhich the task is achieved, they can assess the maximum
functional output while attempting to complete a task.
However, while performing ADL, though there are tasks
for which maximum force output is indicated, there arealso those which require the capability of adjusting theexertional force, both chronologically and spatially, in acontinuous manner and at a level below the maximum,
without dropping a grasped object, further defined by its

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A COMPARATIVE STUDY OF AGF BETWEEN YOUNG PEOPLE AND ELDERLY INDIVIDUALS

shape, weight, and type of material. This capability isreferred to as the adjustability of grasping force (AGF).
A specialized device, called an iWakka, has beendeveloped for the purpose of measuring AGF. Assessments performed using this device allow insights into
the patient’s actual AGF capability, which other existing
modalities cannot evaluate [7−9]. Kaneno et al. [10]verified the reliability of an AGF-assessment method inyoung adults using an iWakka. Kaneno et al. [11] also
verified the reliability of using this device for AGF evaluation in elderly individuals. These studies reported that
AGF assessments performed using an iWakka provide
reliable data on the AGF of people belonging to both theyoung and elderly age-groups.
Studies have reported that compared to young
subjects, the elderly ones tend to have reduced hand andfinger functions, indicated by evaluating various parameters including gripping force and fine motor skills [12,13]. Conversely, with respect to certain mental skills
such as comprehending a story from the context and forrecall related to prospective memories [14, 15], elderly
people demonstrate a capability equivalent to that observed in young subjects. These insights about the typesof abilities that elderly individuals need assistance canhelp provide targeted preventive assistance. However,there have been no reports on a comparison of AGF
between young and elderly individuals, and no data are
available on whether elderly individuals have a reduced
AGF as compared to the young age-group. Therefore,
this study aims to compare AGF between people belonging to young and elderly age-groups.

2. Methods
2.1 Subjects
The eligibility criteria for the young subjects included in the study were 20 ≤ age < 30 years and being
affiliated to the Faculty of Health Sciences, Mejiro
University, in Japan. Exclusion criteria were having
an experience of carrying out tasks similar to thoserequired to be performed for this study, or having acurrent or past (history of) orthopedic or neurologicaldisease of the hands and fingers that impacted ADL. The
eligibility criteria for elderly individuals subjects wereage ≥ 65 years, those living in their own homes (mainplace of residence), and those able to ambulate without
a walking-aid and able to travel to the study venue bythemselves. The exclusion criteria for the latter groupwere having an experience of carrying out tasks similar
to those required to be performed for this study, having
a current or past (history of) an orthopedic or neurological disease of the hands and fingers that impacted ADL,
or scoring ≤ 23 on the Mini-Mental State Examination(MMSE).
In order to estimate the sample size required for thisstudy, we conducted a pilot survey of a small group (n= 10) consisting of 5 young people and elderly people,
respectively. The results showed that the effect size of
the AGF value (the main outcome of this study) for thissmall-sized sample was 1.17. We estimated the size ofthe study-sample required for the study, from the effectsize of AGF value on the test group, using software
G*Power [16] at a setting of α = 0.05 and β = 0.20,
which showed that an evaluation of at least 10 subjects
in each group would be necessary to obtain statistically
viable results. In order to adjust for confounding factors
arising from matching of subjects, we recruited 20 subjects each for the young and elderly study groups.
All subjects received written and verbal explanationof the objectives and the study protocol in advance.
All subjects included in the study provided written,
informed consent for participation. The study protocol
was approved by the research ethics review board of theMejiro University (Approval number: 17-007).
2.2 Outcome measures
2.2.1 AGF assessment
In this study, we used the device iWakka (AimuCo., Ltd.) for assessing the AGF of the study subjects.
The device has a cylindrical shape with an 80-mm
height and a 65-mm diameter. It consists of attachedhinges for fixation to one of the edges of the cut- vinyl
chloride pipe, and plate springs are placed within thepipe in such a manner that they cross each other [7, 8](Fig. 1). Opening or closing the iWakka causes the plate
springs to distort. We measured the level of distortion
with a gauge and used a computerized analysis to createa real-time graph indicating the variability of the grasping force (in grams) over time (in seconds). Subjects
were instructed to adjust the grasping force according
to the target value displayed on the monitor. The maximum target value used was 400 g. The target value waschanged in a stepwise manner at certain time intervals.
The displayed values moved from right to left on thegraph, with the passage of time. Quantitative evaluationis possible by calculating the absolute value of error,
between the target value and the measured value ofgrasping force as AGF. A smaller the absolute values
were indicative of a better AGF (Fig. 1).
With reference to the methods described in older
studies [11, 17], the test environment was arranged asfollows (Fig. 1). The assessment was conducted in aquiet environment. An adjustable table was utilized with
its height adapted to the test subject’s preference, basedon the distance from their seat or chair to the table,
to increase the ease of using the device. In order toAsian J Occup Ther 15: 69−75, 2019

Kaneno T et al.

71

Fig. 1. Adjustability of grasping force assessment using the iWakka.
(a) The iWakka device (b) Real-time graph indicated on the monitor, with the graph indicating the variability of thegrasping force (in grams) over time (in seconds) (c) Schematic of the test arrangement.
Reproduced with permission of the Society of Physical Therapy Science from [Kaneno, et al.]. [Assessing the adjustability of grasping force using the iWakka in elderly individuals. J Phys Ther Sci. 2017; 29: 2215−9].

maintain a uniform seating position and posture for all
study subjects, no backrest was provided. The subjects
were seated with their legs shoulder-width apart andtheir knee joint was kept in a 90 degrees flexed position.
The distance from the table to the body was maintained
at 10-cm, and the monitor was placed at a distance of
50-cm from the edge of the table. Subjects were instructed to maintain the position of the test-hand in the“Functional position”, i.e. in dorsiflexion at 30° withthe metacarpophalangeal joint of the digitus minimus
attached to an acrylic plate. In order to eliminate theimpact of the upper arms and maintain an equal shoulder
height during measurement, the subjects were seatedwith both elbows on the table with both their forearms
positioned at a point in-between pronation and supination, while the iWakka was placed on the acrylic plate,so that the device would not be tilted.
2.2.2 Assessment of gripping force
An analog tester (Takei Scientific Instruments Co.,
Ltd.) was utilized to measure the gripping force forall subjects. With reference to the positioning method
described by Edo et al. [18], in this study, the gripping-force measurements were performed with subjects

seated upright with their upper limbs placed down along
the body. The gripping width was set in such a mannerthat the proximal interphalangeal joint of the index
finger was bent at 90°. Since it has been reported thatmeasuring the one-time gripping-force provides reliabledata [19], we also carried out only one-time measurement of the gripping force for each study-subject.
2.3 Measurement procedure
Firstly, basic information such as age and gender
was collected in an interview. Following this, a laterality
index was estimated using the Edinburgh Handedness
Inventory [20] to determine the dominant hand in eachsubject. As per the criteria described by Sakano [21],those with a laterality index value from 80−100 were
determined to be right hand-dominant, and those withscores from −20 to −100 were considered to have adominant left hand. Thereafter, prior to the assessment,a short practice session was conducted for each subject
to familiarize them with the details of the tasks to be
performed using the iWakka. Different target values
were used from those in the assessment for this practice.
A five-minute break was given after completion of thepractice tasks, and the assessment were carried out in

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A COMPARATIVE STUDY OF AGF BETWEEN YOUNG PEOPLE AND ELDERLY INDIVIDUALS

the same environment as that used for practice. Subjects
performed assessment tasks twice each with the dominant and the non-dominant hand, and the mean value ofthe two attempts was used as the measurement value. In
order to eliminate the effect of order of testing, counterbalancing was used by dividing the subjects into those
who started the assessment with their dominant hands
and with their non-dominant hands, respectively.
2.4 Data analysis
Subjects were categorized into a young group andan elderly group. The Chi-square test was used to analyze the distribution of baseline characteristics including
sex and handedness, between the two groups. Furthermore, the groups were compared using t-tests for independent samples, in order to evaluate deviations in thevalues of both gripping force and AGF.
We performed adjustment to control variations infactors including sex, handedness and gripping force sothat the difference between the two groups would only
be limited with respect to age to the maximum possible
extent. Subject-matching was conducted between bothgroups for the comparative analysis of AGF. While performing the analysis, factors, including both sex and thedominant hand of the subjects, were completely matched(e.g., right-handed young men and right-handed elderlymen). In addition, the permissible ranges of gripping
force were set at ± 5 kg and ± 3 kg for males andfemales, respectively, and the pair whose values of gripping force were as similar as possible were matched. As
per data on variations in gripping force with age, issued
by the Japanese Government Ministry of Education,
Culture, Sports, Science and Technology, the standard
deviations in both males and females aged 70−74 years
were smaller than in those aged 20−24 years. In ourstudy, the standard deviations among males and females
aged from 70−74 years were referred to for setting thestandard deviation values [12]. After matching, a t-test
for analysis of independent samples was repeated.
The software IBM SPSS Statistics 25 was used forstatistical analysis, and the level of significance was set
at 5%.

the dominant and the non-dominant hand was calculated
as 4.4 ± 1.2 g (95% CI: 3.8, 5.0) and 4.4 ± 0.6 g (95%
CI: 4.1, 4.7), respectively, in the young age-group.
The mean age of the group of 20 elderly subjects
was 71.1 ± 4.1 years (95% CI: 69.1, 73.0), and it
included 15 males and 5 females (Table 1). The mean
MMSE score of the group was 28.8 ± 2.0 points (95%
CI: 28.1, 29.4), and all 20 subjects were found to beright-dominant. The mean gripping force was 29.1 ±7.8 kg (95% CI: 25.4, 32.7) and 28.4 ± 8.2 kg (95%
CI: 24.5, 32.2) for the dominant and the non-dominanthand, respectively. The mean AGF was 8.9 ± 4.0 g (95%
CI: 7.0, 10.7) and 7.6 ± 2.8 g (95% CI: 6.3, 8.9) for thedominant and the non-dominant hand, respectively, inthe elderly group.
An analysis of AGF between the two groups
through a t-test indicated that it was significantly lower
in the elderly group than in the young group for both
the dominant and non-dominant hands ( p < 0.01 for
both, Cohen’s d = 1.52, Cohen’s d = 1.58, respectively)(Table 1). No significant difference in gripping force
was observed between the two groups for both dominant
and non-dominant hands ( p = 0.35 and p = 0.17, respectively). The number of female subjects was significantly
larger in the young group, and that of male subjects was
significantly larger in the elderly group ( p = 0.03). No
significant difference in the number of right and leftdominant was observed between the two groups ( p =0.31).
The two groups were matched for sex, the dominanthand, and the gripping force of the subjects, in order tocontrol these factors (Table 2). Following matching, thenumber of subjects in in each of the two groups was 6with a sex-distribution of 2 males and 4 females in eachgroup. A t-test conducted after controlling the disparate
factors (sex, handedness, gripping force), showed that
there was a significant difference in AGF between theyoung and the elderly groups for both the dominant ( p =0.03, Cohen’s p = 1.61) and the non-dominant ( p = 0.02,
Cohen’s p = 2.04) hands, indicating that the AGF of theelderly subjects was significantly lower than that of theyoung subjects.

3. Results

4. Discussion

The mean age of the group of 20 young subjects
was 21.0 ± 0.7 years (95% confidence interval [CI]:20.7, 21.3), and it included 4 males and 16 females.
Nineteen subjects were right-dominant, while 1 wasleft-dominant (Table 1). The mean gripping force forthe dominant and the non-dominant hand was found to
be 26.9 ± 6.4 kg (95% CI: 24.0, 29.9) and 24.9 ± 7.1 kg(95% CI: 21.6, 28.2), respectively. The mean AGF for

Since there have been no AGF-assessment methods described in existing literature, it was unclear
whether elderly individuals had a higher or lower AGF
as compared to that of young people. However, thisstudy showed that elderly people have lower AGF than
young people, even after performing adjustment for sex,
handedness and gripping force of the test-subjects. It has
been reported that since innervation ratio increases with

Kaneno T et al.

Asian J Occup Ther 15: 69−75, 201973

Table 1. A comparison of adjustability of grasping force between the young and the elderly study-groups.

Age (year)
Gender (no. of people)

Male
FemaleYoung groupn = 20Elderly groupn = 2021.0 ± 0.7

71.1 ± 4.1

4
16

15
5

MMSE (score)p

Cohen’s d

0.03

28.8 ± 2.0

Dominant hand (no. of people)

Right
Left

19
1

20
0

0.31

Gripping force (kg)

Dominant hand
Non-dominant hand

26.9 ± 6.4
24.9 ± 7.1

29.1 ± 7.8
28.4 ± 8.2

0.35
0.17

0.31
0.46

AGF (g)Dominant hand
Non-dominant hand

4.4 ± 1.2
4.4 ± 0.6

8.9 ± 4.0
7.6 ± 2.8

< 0.01< 0.01

1.52
1.58

AGF: adjustability of grasping force; MMSE: Mini-Mental State Examination.
MMSE was measured for elderly subjects only. Chi-square tests were performed to assess the differences between the twogroups with respect to the sex and the dominant hand of the subjects. To comparatively evaluate gripping force and AGF,
t-tests for independent samples were performed. AGF indicates the absolute value of error of the actual grasping force fromthe target grasping force. Therefore, when AGF is high, the measurement value is small.

Table 2. A comparison of adjustability of grasping force between the young and the elderly groups after performing adjustment for factors including sex, handedness and gripping force of the subjects.

Age (years)
Gender (no. of people)

Male
FemaleYoung groupn=6

Elderly groupn=6

21.2 ± 1.0

70.5 ± 3.9

2
4

2
4

MMSE (score)p

Cohen’s d

1.00

29.0 ± 2.2

Dominant hand (no. of people)

Right
Left

6
0

6
0

1.00

Gripping force (kg)

Dominant hand
Non-dominant hand

24.8 ± 7.4
22.9 ± 9.5

24.6 ± 7.7
21.9 ± 7.5

0.97
0.84

0.03
0.12

AGF (g)Dominant hand
Non-dominant hand

4.9 ± 2.0
4.5 ± 0.8

12.2 ± 6.1
9.4 ± 3.3

0.03
0.02

1.61
2.04

AGF: adjustability of grasping force; MMSE: Mini-Mental State Examinationage, elderly people tend to find it difficult to perform
precise movements that require a subtle adjustmentof force [22, 23], and the impairment was considered
to be related to a decrease in AGF in this population.
Additionally, a report has also suggested that the inelderly individuals, the capability of adjusting force
while holding an object reduces, because the sensitivityof sensory receptors including those responsible fortactile sensibility and mechanoreception, declines withage [24]. The Japanese Association of Occupational
Therapists [25] has reported that about 30% of elderly
people, who have no specific diseases and are livingin the community, find it difficult to perform certain

everyday tasks, indicating a difficulty in conducting
their ADL. The Association develops occupational
therapeutic interventions with a focus on ADL, and theeffects of such interventions have been published [26].
This study demonstrated that local elderly residents
who can apply the same level of gripping force as thatexerted by young people demonstrate a lower AGF than
young people. Since AGF is the capability of adjusting
the force exerted while holding any object (depending
on its shape, weight and material), it can be consideredthat individuals with reduced AGF may face difficulties
in performing actions in their everyday lives, such as
dropping a grasped object or accidentally crushing an

74

A COMPARATIVE STUDY OF AGF BETWEEN YOUNG PEOPLE AND ELDERLY INDIVIDUALS

object in the hand. Therefore, this study suggested that
it is necessary to assess the AGF of elderly people separately from gripping force and have an understandingof to what degree their AGF has been reduced from anearly stage, in order to alleviate difficulties which local
elderly residents face in their everyday lives.
The elderly population is expanding at a global
level, and it is particularly expected to rapidly increasein Japan [27]. Consequently, Japan is also expected tostart facing difficulties related to the care of this agegroup relatively earlier than other countries, and themanner in which, the country would address such issues
is currently of interest to the international community.
The World Federation of Occupational Therapists [28]has expanded its scope for occupational therapy to beextended not only to those with health problems but also
to any individuals, who are occupationally involved,
indicating that those who do not have health issues canalso benefit from the therapy. Preventive interventions
have been provided through occupational therapy, basedon knowledge related to the reduced capabilities of
elderly people as compared to those of young people[29−31]. This study elucidated that elderly individuals
have significantly reduced AGF as compared to young
people, suggesting that it is necessary to provide interventions for this reduced capability from a preventive
perspective.
This study, after making adjustments for factors
including sex, handedness and gripping force of thesubjects, was able to determine that the AGF of elderly
people was lower than that of young people. However,the number of pairs assumed in advance was not createdas a result of matching. Therefore, we calculated theactual power from the effect size of AGF value on thetwo groups following matching, using software G*Power
at a setting of α = 0.05 and sample size of 6. The results
indicated that the power of our comparison for both
dominant hand and non-dominant hand was sufficient(power = 0.71, power = 0.89, respectively), as the effectsize after matching was higher than before matching. In
addition, the impact of reduced AGF on ADL has notbeen elucidated till date, indicating the necessity of further research on this aspect. Moreover, while this study
indicated that AGF may reduce with aging, it did notclarify what kind of factors may have been responsible
for the reduction. In particular, AGF may be affected byhand size and sensory function. Therefore, in the future,in order to provide effective interventions for reduced
AGF, it is necessary to elucidate these factors that influence AGF. Also, further investigations of AGF, not onlyof elderly individuals able to live in the community,
but also of weaker elderly people and those facing difficulties in their everyday lives are required, in order toaccumulate knowledge that will be useful in developing
effective intervention programs for this vulnerable agegroup.
Acknowledgements: The authors would like to thankthe subjects in this study. This work was supported by
JSPS KAKENHI Grant Number JP 18K17762.

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Prospects [cited 2017 February 15]. Available from:https://esa.un.org/unpd/wpp/publications/files/key_
findings_wpp_2015.pdf.
[28] World Federation of Occupational Therapists [on line].
Geneva: Statement on occupational therapy [cited 2017
June 4]. Available from: http://www.wfot. org/Portals/0/
PDF/STATEMENT%20ON%20OCCUPATIONAL%20
THERAPY%20300811.pdf.
[29] Steultjens EM, Dekker J, Bouter LM, Jellema S, Bakker
EB, van den Ende CH. Occupational therapy for community dwelling elderly people: a systematic review. Age
Ageing 2004; 33(5): 453−60.
[30] Arbesman M, Mosley LJ. Systematic review of occupation- and activity-based health management and maintenance interventions for community-dwelling older adults.
Am J Occup Ther. 2012; 66(3): 277−83.
[31] Clark F, Azen SP, Zemke R, Jackson J, Carlson M,
Mandel D, et al. Occupational therapy for independentliving older adults. A randomized controlled trial. JAMA.
1997; 278(16): 22−9.

■ORIGINAL ARTICLE

Hand and Finger Functions and Characteristics
of Line Drawing Movement in Preschool Children
with Autism Spectrum Disorder: Preliminary Study
Kaori Yamaguchi, Ph.D., OTR1, Misako Sano, Ph.D, OTR2,
Reiko Fukatsu, Ph.D., MD3
1

School of Health Sciences at Narita, International University of Health and Welfare
National Rehabilitation Center for Children with Disabilities
3
Research Institute of National Rehabilitation Center for Persons with Disabilities
2

Abstract: It is well known that children with autism spectrum disorder show handwriting difficulty. Although it isconsidered that not only cognitive but also motor impairments affect the difficulty, remarkably little is known about
the motor characteristics of handwriting in autistic children. Therefore, the purpose of this study is to investigate: 1)
peculiarities of hand and finger functions; and 2) characteristics of handwriting movement in preschool children with
ASD during the chrysalis stage of handwriting. Participants were children with ASD and age- and partially IQ-matched
controls. We conducted assessment of muscle strength, motor coordination, separate finger movement, dexterity, grasp
posture and line drawing movement. We compared data between ASD and control groups. Significant differences wereobserved in repetitive hand tapping, pronation and supination, sequential finger tapping, finger lifting and pegboard.
Considering components of handwriting, there seems to be no prominent difference between the two groups in grasp
posture, although ASD showed poorer motor coordination on the drawing line task compared to that of controls. The
present results also showed atypical characteristics of hand and finger motor functions and line drawing movement in
ASD. These findings provide further insight into the motor aspects of handwriting and suggest investigating correlation between hand and finger functions, especially separate finger movement and manual dexterity and motor aspect ofhandwriting may be important to clarify effective bottom up training for acquisition of handwriting skills.
Keywords: handwriting, developmental disorders, tool use, motor coordination(Asian J Occup Ther 15: 77−83, 2019)

Introduction
The Diagnostic and Statistical Manual of Mental
Disorders 5th edition (DSM-5) characterizes autism
spectrum disorder (ASD) by deficits in social communication and social interaction as well as restricted,
repetitive patterns of behavior, interests or activities [1].
In addition to the main peculiarities, it is well known
that persons with ASD demonstrate various motor
impairments, such as impaired gross motor function,
Received: 14 September 2018, Accepted: 14 August 2019
Corresponding to: Kaori Yamaguchi, School of Health Sciences at
Narita, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba 286-8686, Japane-mail: yamaguchi.kaori.1005@gmail.com©2019 Japanese Association of Occupational Therapists

motor coordination and manual dexterity [2−6]. These
impairments are also referenced in DSM-5 [1]. Thosedifficulties have a large impact on activities of dailyliving as well as social activities in persons with ASD.
There is literature on handwriting difficulty inchildren with ASD. Several studies have demonstrated
handwriting impairments in ASD using a standard
assessment battery of handwriting [7−13]. A previous
study suggested that more than 65% of persons with
ASD have handwriting difficulties [8]. Handwriting is ahighly important skill for schoolchildren to achieve academic progress, acquire language and build self-esteem.
Fuentes et al. suggested that general motor skills
could predict handwriting impairments in children withASD [10]. However, they used the score for gross motor
functions to represent motor skills, therefore, it remains
unclear how hand and finger movements affect their

78

HAND AND FINGER FUNCTIONS IN AUTISTIC CHILDREN

handwriting skill.
Writing is a complex behavior involving motor
control, visual perception, language, memory and otherfunctions. Considering its motor aspects, it is a complex
tool use activity and adequate hand and finger motor
development is essential for skillful writing. Hand andfinger function is required for appropriate pen grip andfine adjustments while drawing and writing [14]. There
are a few studies demonstrating relevance between
hand and finger function and handwriting in normal,
healthy children. Schneck showed correlation between
pencil grip pattern and writing skill [15] and Berninger
and Rutberg found that finger functions (e.g., finger
tapping, finger lifting and finger cognition) correlatedwith writing skills in early elementary school children[16]. Finger lifting is a test for separate finger movement
and it is necessary for approximate posture of pen grip
and fine control of a pen point [14, 17, 18]. In clinicalsettings, children with ASD who had lower performanceon separate finger movement test showed difficulty inmanipulating a writing utensil [19].
As described above, even though hand and finger
function is known to be important for handwriting, little
is known about these functions in ASD. Dufield et al.
reported ASD showed lower performance on functional
tests such as grip power, tapping and pegboard, but
subjects in their study showed a wide age range from 5
to 33 years old [20]. Thus, there is no information about
these functions in preschool children who are acquiringhandwriting skill. Clarifying the development of handand finger functions and its relation to handwriting in
ASD is expected to contribute to the establishment ofefficient interventions to address these difficulties.
Therefore, the purpose of this study is to investigate: 1) peculiarities of hand and finger functions; and2) characteristics of handwriting movement in preschool
children with ASD during the chrysalis stage of handwriting. As a preliminary study, we conducted several
tests and tasks for this research; tests of muscle strength,
motor coordination, separate finger movement and dexterity and assessment of grasp posture and line drawing
task. Line drawing task was selected to focus on motor
aspects of writing, while minimizing the influence ofTable 1.

ASD
controls

cognitive aspects as much as possible.

Methods
ParticipantsThis study examined 17 children with and without
ASD. Subjects were eight children diagnosed with
ASD aged 4−6 (yrs.) and nine age- and nonverbal IQmatched children demonstrating typical developmental
milestones as controls. A summary of subjects is shownin Table 1. Children in control group were recruited withleaflet in community around the research institute where
this study was conducted. Regarding ASD group, there
was child and adolescent psychiatrist among cooperative
researchers and children with ASD were recruited fromher patients. Children with ASD were diagnosed with
autism spectrum disorder following DSM-5 criteria
or diagnosed Pervasive Developmental Disorder andAsperger’s Syndrome following DSM-4 revised criteria.
In addition, all subjects were evaluated by the Japaneseversion of the Social Responsiveness Scale (SRS) [21].
SRS is a standardized battery for assessment autistic
traits for individuals aged 4 to 18 years. It consists of
65-items questionnaire categorized into five subscales;social awareness, social cognition, social communication, social motivation and autistic mannerism. T-score
calculated by raw score and standard deviation is applied
to assess autistic trend. The score above 76 is considered
as “ASD-possible”, from 60 to 75 as “ASD-probably”
and bellow 59 as “ASD-unlikely”. Diagnoses wereconfirmed in all ASD children by scores above the cutoff value and all control children were confirmed as nothaving ASD by scores below the cutoff value on SRS(Table 1). All subjects had a full-scale IQ (FIQ) greaterthan 75 and Perceptual Reasoning Indices (PRI) greaterthan 80 on the Wechsler Intelligence Scale for Children,
4th edition (WISC-IV) [22]. There are significant differences in FIQ and primary index scores except for PRI
between two groups. PRI was considered the primary
intelligence measure for our study since we employeda nonverbal, motor-based task. None of the subjects
was receiving any medication. None of the controls had
any history of neurological or psychiatric disorders. All

Summary of subjects.
numberage (yrs.)

SRS T score (range)

full IQ

VCI

PRI

WMI

PSI

8 (M:F = 6:2)
9 (M:F = 4:5)

5.6
5.6

70.8 (61−105)
41.9 (40−51)

82.4
104.8

82.1
104.0

92.4
103.5

76.3
96.6

91.3
108.0

Subject backgrounds are shown in the table. All data from “age” to “PSI” are presented as the average of the group. Range of
SRS T score is presented in brackets. Items of “Full IQ” to “PSI” are the results of intelligence quota assessments on WISCIV. “VCI”, “PRI”, “WMI” and “PSI” indicating Verbal Comprehension Index, Perceptual Reasoning Index, Working Memory
Index and Processing Speed Index, respectively.

Asian J Occup Ther 15: 77−83, 2019subjects had normal or corrected-to-normal vision andno one had any detectable sensory abnormality of thehands or fingers. Each subject could understand the task
instructions and was able to continuously concentrate
their attention on the task for at least 30 minutes while
maintaining an appropriate posture. All participants
were right handed according to the results of Edinburgh
Handedness Inventory [23] as well as an interview with
their parents about activities of daily living.
Prior to the study, written informed consent was
obtained from the parents of each child in a manner
approved by the ethical committee of the National
Rehabilitation Center for Persons with Disabilities inaccordance with the Declaration of Helsinki.
Materials and Procedure: Assessments for hand andfinger functions
Assessments for hand and finger motor functions,muscle strength (grip and lateral pinch), motor coordination (hand tapping, pronation and supination, finger
tapping and sequential finger tapping), separate finger
movement and fine motor skills (Perdue pegboard),
were conducted. All assessments were basically conducted for both hands. We applied some parts of Zurich
Neuromotor Assessment: ZNA which is standardized
assessment of duration and degree of motor functions[24] for assessment of motor coordination. “Handtapping” requires movement of tapping knee with one
hand repeatedly and “finger tapping” requires movementof tapping with thumb and index finger. Participant isasked to repeat the movement 20 times and the durationis measured. “pronation and supination” is task of pro­nation and supination with forearm repeatedly. Ten setsof movements (pronation and supination are one set)is required and the duration is measured. In the task of“sequential finger tapping”, participant is required totapping with their fingers; thumb and the other fingers.
The tapping is done in order of thumb-index finger,
thumb-middle finger, thumb-ring finger and thumb-little
finger. Three sets of order are required and the durationis measured [24]. For separate finger movement, weapplied a modified version of the test developed by
Wolff et al. [17]. Subjects were asked to put their hands
palms-down on the table and lift the finger touched by
the experimenter in random sequence. They were asked
to immediately lift the touched finger only. We evaluated voluntary control of separate finger movements bycounting how many other fingers lifted when the child
tried to lift the touched finger only.
Materials and Procedure: Components of handwriting
We measured pen grasping posture and line drawing movement as components of handwriting.

Yamaguchi K et al.

79

Fig. 1. Line drawing task.
Two conditions of line drawing task. Participants
drew a line from dot to dot.

Pen grasping posture was evaluated using a fivepart score (score of 1 indicating the lowest and 5 thehighest) on Pencil-Grip Assessment by Schneck andHenderson [25].
Subjects were asked to draw a 2 cm straight line
using a pen-type writing pressure gauge (DP-1000
USB version; Japan System Development Co., Ltd) tomeasure motor elements. We recorded pen pressure as
power control and trajectory of line as motor coordination. Subjects were asked to draw a line from dot to
dot within the limited space. They moved the pen point
forward at their own speed without touching either ofthe parallel lines (Fig. 1). We referred to standard assessment battery; Developmental Test of Visual Perception(DTVP), subtests 1, visuomotor coordination to fix thetask setting [26]. The line drawing task consisted of two
conditions ranked by difficulty in order to investigate
whether their movement is affected by a difference inthe visual information provided during the task. Twoparallel lines were presented in order to designate thelimits of the drawing space and subjects were asked to
draw a line between the parallel lines. The parallel lines
were 2cm apart in the easy condition and 2mm apart in
the difficult condition. Two dots were presented as thestarting and ending points of drawing line. Before thetrials, subjects practiced a few times to confirm theirunderstanding of the instructions. The task was limited
to 12 trials in order to avoid tiring the subjects. Six trials
were in the easy condition, while the other six were in
the difficult condition. Each child held the pen with their
dominant hand in their own grasp posture.
Statistical analysis
We conducted statistical analyses of all test results
to compare ASD to controls. All data were analyzed
using R (version 3.1.0.). Because there were few subjects, we applied Wilcoxon rank sum test as a nonparametric test.

80

HAND AND FINGER FUNCTIONS IN AUTISTIC CHILDREN

Fig. 2. Results of assessments for hand and finger functions.
A−E: Assessment results for Strength, Tapping, Finger Lifting, Pegboard are shown in Figures A to E. The score of each participant was plotted in the figure. Bar and square besides each plots indicates range of 2 standard deviation and median, respectively.

Results
Although all subjects in both groups completed
the tests and task, data on finger lifting, pegboard, pen
force and deviation from one or two subjects in the
ASD group were considered unreliable because they
appeared to respond facetiously. Therefore, those data
were excluded from analysis. Ultimately data from six
participants for finger lifting, pen force and deviationand data from seven participants for pegboard in ASD
were statistically analyzed. Results of assessments forhand and finger functions and components of handwriting were shown in Figs. 2, 3.
Assessments for hand and finger functions
We compared data of hand and finger functions
between ASD and control groups (Fig. 2). Measured
value of muscle strength, time durations of motor coordination test, score of separate finger movement andfine motor skills were applied. Significant differenceswere observed in repetitive hand tapping on the left side
( p = 0.02), pronation and supination on the right andleft sides ( p = 0.001, p < 0.001 respectively), sequential

finger tapping on the right and left sides ( p = 0.001, p =0.04 respectively), finger lifting on the right and left
sides ( p = 0.01, p < 0.001 respectively), and pegboard on
the right and left sides (single hand use) ( p = 0.01, p <0.01 respectively).
Components of handwriting
Considering grasp posture, that of all participants inboth groups were scored at the level 4 or 5. There werefour grasp types observed; Four-finger grasp and Cross
thumb grasp as in level 4 and Lateral tripod grasp andDynamic tripod grasp as in level 5 (Fig. 3). There were
no prominent differences between the two groups.
For the line drawing task, we evaluated deviationof the line trajectory to evaluate motor coordination
based on differences between the length of the actual
drawn line and a straight 2 cm line connecting the two
dots. There was significant difference in deviation in the
difficult condition ( p = 0.01) (Fig. 3). Thus, deviation
demonstrated the degree of motor coordination. ASD
group showed poorer motor coordination than controls.
Furthermore, two participants in ASD whose resultsof deviation were superior to the others got better resultsAsian J Occup Ther 15: 77−83, 2019

Yamaguchi K et al.

81

Fig. 3. Results in components of handwriting.
A−C: Results of evaluation for Grasp Posture are shown in figure A. Grasp posture identified in the figure is based on Pencil-Grip
Assessment by Schneck and Henderson [24], which shows 10 postures at 5 levels. Average scores for each participant for Pen
force and Deviation on drawing line were calculated and are shown on figures B and C. Bar and square besides each plots indicates range of 2 standard deviation and median, respectively.

in finger lifting and pegboard among ASD group.

Discussion
We investigated: 1) hand and finger motor functions; and 2) components of handwriting in ASD. Persons with ASD show motor impairments in some areas.
In this study, we demonstrated atypical motor characteristics in ASD that have not been reported previously.
Hand and finger functions
ASD showed significantly lower performance on
both sides for pronation and supination, sequential finger
tapping, finger lifting and pegboard (single hand use).
Our results were consistent with those of previous
studies demonstrating impairments in manual dexterity[4, 20, 27]. Duffield et al. reported that ASD showedsignificantly lower performance on finger tapping andpegboard test, but not on grip strength [20]. For grip
strength and pegboard, our results were consistent with
their research. Simple finger tapping did not show asignificant difference between groups in our study, although there was a difference in their study. The smaller
number of subjects in our study may have affected theresult. Previous structural or functional neuroimaging
studies also support our findings in terms of atypicalneural patterns in ASD [20, 28, 29]. The lower performance on sequential finger tapping and finger lifting
test in ASD indicates a developmental delay in separate

finger movement. Previously, Virginia and Berninger
reported a correlation between handwriting and bothsequential finger tapping and finger lifting in normalchildren [16]. Investigating correlation between separate
finger movement and handwriting skill in ASD is required.
Components of Handwriting
Certain characteristics of line drawing were observed in ASD. Slightly less pen force was observed in
ASD, although the difference did not reach significance.
Deviation was significantly larger for ASD than controls in the difficult condition. Heuvel et al. previously
reported that in normal adults, pen force increased forlarge targets and decreased for small targets [30], that is,pen force decreased under more difficult conditions. Our
results for both controls and ASD were consistent withthose findings. Since there was no difference in handor finger strength between groups, the lower pen force
in ASD may indicate that appropriate power control isdifficult for ASD. Larger deviation in ASD suggests
impaired sensorimotor coordination, especially visuomotor coordination. Glazebrook et al. and Rinehart et al.
reported that ASD exhibited more spatial variability
during reaching tasks [31−33]. Papadopoulos et al.
showed more widely variable errors in ASD during areciprocal reaching task [34]. It may be beneficial that
influence of impaired motor coordination on handwriting in ASD.

82

HAND AND FINGER FUNCTIONS IN AUTISTIC CHILDREN

There seems to be no difference in grasp posture between groups. Considering previous literature [15, 16],
handwriting difficulty in ASD may be caused by motor
impairment rather than grasp posture.
Although we could not analyze correlation between
hand and finger functions and handwriting components
in this study, in ASD group, two children who scoredbetter in deviation performed better in finger lifting andpegboard. The result may suggest that separate finger
movement and manual dexterity are factors of skill ofdrawing line regarded as motor aspects of handwriting.

Limitations and Recommendations
for Further Research
There are methodological limitations of our study.
In the study, eight autistic children and nine control children participated. Limited number of participants might
have influenced the findings. Gender and IQ differences
except for PRI might be another factor. In addition,
participants were asked to perform a limited number oftrials for each condition in order to avoid their loss ofinterest in doing the same task repeatedly. Recruiting
more autistic and control participants whose IQ are
totally equal and analyzing the correlation between handand finger functions and characteristics of drawing line
should be considered in future studies.

Summary and Conclusions
The present results showed atypical characteristicsof hand and finger motor functions and line drawing in
ASD. These findings provide further insight into themotor aspects of handwriting in ASD. Investigating correlation between hand and finger functions, especiallyseparate finger movement and manual dexterity andmotor aspect of handwriting may be suggested to clarify
effective bottom up training for acquisition of handwriting skills.

Conflict of Interest
The authors affirm that there were no conflicts ofinterest related to this study.
Acknowledgements: This work was supported by Healthand Labor Sciences Research Grants in Japan.

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■ORIGINAL ARTICLE

Effects of Seat Cushion Material on Center of Pressureand Movement Trajectory during a Reaching Task
Takeshi Kodama, OTR, Ph.D1, Yuji Nakamura, OTR, Ph.D2,
Sonomi Nakajima OTR, Ph.D2, Kenichi Kamoshita, OTR3,
Yasuhito Sengoku OTR, Ph.D2
1

Saiseikai Nishi Otaru Hospital, Midori-no-Sato
Department of Occupational Therapy, Sapporo Medical University
3
Shizuoka Children’s Hospital2

Abstract: This study investigated the effects of seat cushion material during a reaching task. Ten healthy adults andthree individuals with cerebral palsy participated. All subjects performed the reaching task on two urethane cushions
and one silicone cushion. Anterior/posterior and medial/lateral displacement of the center of pressure and straight rate
were assessed. In addition, the movement trajectory of the hand was recorded. No differences among seat cushions
were observed in healthy adults. However, all of individuals with cerebral palsy were able to perform the task more
efficiency while seated on the silicone cushion than the others. These findings suggest that seat cushion design may improve movement in individuals with cerebral palsy who have postural control disabilities.
Keywords: cerebral palsy, reaching task, center of pressure(Asian J Occup Ther 15: 85−92, 2019)

I. Introduction
Individuals with cerebral palsy (CP) usuallyexperience disabilities in postural control, such as direction-specific patterns of adjustments and center of mass
stability [1]. Therefore, many such individuals require
support to maintain balance while sitting and are limitedin the performance of upper-limb tasks that move thecenter of gravity. Individuals with postural issues require
extrinsic support to perform activities of daily livingwith unobstructed voluntary movement. Seat cushion
adjustment in wheelchairs is one approach for providing
postural support. Previous studies show that seat surface
inclination can affect sitting posture and upper-extremity
function in children with CP. A more vertical trunk position is associated with more efficient performance [2‒4],
and the use of an anterior inclined seat is related to
Received: 3 March 2019, Accepted: 11 September 2019
Corresponding to: Takeshi Kodama, Saiseikai Nishi Otaru Hospital,
Midori-no-Sato, 3-24-1 Nagahashi, Otarushi, Hokkaido 047-0036,
Japan
e-mail: kodatak.skyducks@gmail.com©2019 Japanese Association of Occupational Therapists

initial head position [5]. However, such an anterior inclination could cause forward slippage or burden the lower
limbs if used during activities of daily living. The useof seat cushions may help avoid the risks of seat surface
inclination. Many seat cushions have been developed
to disperse pressure for individuals with CP. However,soft seat cushions and materials that avoid high pressure
have some problems concerning instability during move­ments [6]. As individuals with severe motor disability
spend much of their life sitting, it is necessary to investigate seat cushions appropriate for dynamic tasks. Therefore, we developed a seat cushion that aims to facilitate
movement for individuals with CP and instability. The
cushion specifically uses silicone material, which not
only has flexibility but also viscoelasticity, providing
mobility to the material of the seat cushion itself.
We previously measured the effect of this siliconee
seat cushion in terms of the displacement of centerof pressure (COP) during a dynamic task. The COP,
which is calculated by the dispersion of pressure andan area added to the seat surface, is an index of body
disturbance that is closely associated with body sway
[7‒9]. We observed no difference in COP displacement
between seat cushions of different materials in healthy

86

EFFECT OF SEAT CUSHION MATERIAL DURING REACH TASK

Table 1. Charateristics of cerebral palsy.

cp1
cp2
cp3

GenderAge

HeigthWeigthBMI

Arm Length

Type

GMFCS

Fine motor skill

Trunk tone

F
M
F

49
47
41

149.0
151.7
162.0

61.0
46.5
55.0

27.5
20.2
21.0

49.6
50.2
55.0

SQ
SQ
SD + Ath

III
IV
III

severeseveresevere

Low
Low
Low

Note. M = male. F = female. SQ = spastic quadriplegia. SD = spastic diplegia. Ath = Athetosis
GMFCS = Gross Motor Function Classification System. (Palisono et al.,1997).
Fine motor skill: severe = The performance is slow and achieved with limited success regarding quality and quantity.
modulate = Handles most objects but somewhat reduced quality and speed of achivement.
mild = At most, limitations in the ease of perfmorming manual tasks requiring speed and accuracy.

adults; however, the silicone seat cushion was associatedwith decreased COP displacement in individuals with
CP [10]. However, the effects of the silicone seat cushion on the timing of movement onset during a reachingtask in individuals with CP were not thoroughly investigated. The onset of trunk motion related to movement
stability occurs significantly earlier than the onset of
peripheral motion related to manipulation during a
dynamic task that requires trunk movement [11]. Thus,
when evaluating stability, it is necessary to evaluate not
only COP displacement but also the timing of movement
onset in the peripheral limb and trunk to establish theefficiency of the new silicone seat cushion. Therefore,
this study examined COP displacement and the timingof movement onset during a reaching task using threedifferent cushions including a new design made with silicone materials and two others made with conventional
urethane materials.

II. Methods
1) Subjects
The study group consisted of 10 healthy adults andthree individuals with CP. The healthy adults (all males,mean age 22.9 ± 2.5 years, height 172.5 ± 5.0 cm,
weight 64.5 ± 6.4 kg, body mass index [BMI] 21.7 ±1.7 kg/m2, and arm length 72.0 ± 2.4 cm) had no physiological impairments. Individuals with CP (1 male and2 females, mean age 45.7 ± 4.2 years, height 154.2 ± 6.9cm, weight 54.2 ± 7.3 kg, BMI 22.9 ± 4.0, arm length
51.6 ± 3.0 cm) were able to maintain an independent sitting position and follow oral instructions (Table 1). Two
subjects with CP had level III disability, and one had
level IV disability according to the Gross Motor Function Classification System (GMFCS) [12]. They had
low muscle tone in the trunk, indicating the absence of
postural stability. Two subjects had instability but a low
magnitude of body sway and no involuntary movementin activities of daily living. The other subject had bothinstability and involuntary movement, and sometimes
fell during walking. In addition, all of them had func-

tions of reach for the objects during sitting, however
limitations manipulating objects of varying quality andquantity. All subjects signed informed consent forms
approved by the Ethics Committee of Sapporo Medical
University. In addition, this study was performed incompliance with the Declaration of Helsinki and placed
careful attention on protecting the privacy and humanrights of the subjects. And the authors have no conflictsof interest directly relevant to the content of this article.
2) Instrumentation
During the reaching task, the pressure distribution
at the body–seat interface was recorded at 10 Hz using
a FSA mat (Vista Medical, Canada), which consists of
225 force sensors organized on a flexible mat in a 15
× 15 grid. The FSA mat was calibrated up to its maximum pressure of 520 mmHg. A web camera (BWC130MS03A, Buffalo, Japan) was connected to the FSA.
Movements were recorded kinematically with a
Locus 3D MA-3000 video monitoring system (Anima
Corp, Japan) using a six-camera configuration at asampling frequency of 100 Hz. Reflective markers
were placed on the side of the body corresponding to
the dominant hand on the following landmarks: (1)processus spinosus at C7, (2) processus spinosus at T10,
(3) processus spinosus at L5, (4) right acromion, (5) left
acromion, (6) olecranon of the dominant hand, and (7)styloid process of the ulna of the dominant hand (Fig. 1).
3) Reaching task
The distance between the popliteal fossae and frontedge of the seat was adjusted to 5 cm. Subjects wereseated on a stool with their hips and knees both bent at
90°, feet hanging free, and without back, leg rest, or arm
support. Arm length was measured using a measuring
tape from the acromion process to the tip of the third
finger while the subject sat in a seated position with theupper limb extended in the horizontal plane and pointing
in a forward direction. A small 1 × 1-cm yellow switch
was used as a target and set at a distance of 120% of thearm length, level with shoulder height. The task used inKodama T et al.

Asian J Occup Ther 15: 85−92, 2019

87

(5)
（5（

(4)
（4（

120% arm length
Target(1cm×× 1cm)
(1)
（1（

(4)
（4（

(2)
（2（
(3)
（3（

(6)
（6（

(7)
（7（

FSA
Seat cushion

Fi
g
ur
e
.
1
Te
stconditionFig. 1. Test condition.
Dots denote the postion of the ANIMA reflective markers used for kinematic recordings.
Dots denote thepostion of the ANIMA reflective(3)markers
used for kinematic(4) right acromion(1) processus spinosus at C7(2) processus spinosus at T10
processus spinosus at L5
recordings. (6) olecranon of the dominant hand (7) styloid process of the ulna of the dominant hand.
(5) left acromion(1) processus spinosus at C7(2) processus spinosus at T10(3) processus spinosus at L5(4) right acromion(5) left acromion(6) olecranon of the dominant hand(7) styloid
processof theulna of the dominant
this study involved reachingfor thetargetrepeatedly.
material. hand.
For subjects with CP, the number of successful

The subject started with his or her hand resting on theipsilateral thigh for the initial position. During reaching,
the unused hand was placed on the contralateral thigh toensure stability.
Subjects performed the reaching task for 60 seconds using the following three seat cushions in random
order: a low-rebounding urethane cushion (cushion A,
density 55 ± 5 kg/m3, impact resilience > 15%), a highrebounding urethane cushion (cushion B, density 40 ±2 kg/m3, impact resilience > 30%), and the new silicone
seat cushion (cushion C). The silicone cushion consistedof 12 × 12 columns (height 5 cm, diameter 3 cm) withindividual columns separated by 5 mm. The hardness ofthe silicone, determined by a durometer (TECLOCK,Japan), was A15.
The pace of the reaching task for healthy adults
was modulated with a metronome (46 beats/min). No
instructions on movement speed were given to individuals with CP. They were instead instructed to perform thereaching movement as many times as possible without
losing their postural balance. The subjects practiced thetask three times before measurement.
4) Analysis
Movement time (MT) was defined as the duration
between the beginning of one reaching movement andthe next in healthy adults. Mean MT was calculated over
20 trials for each seat cushions as the achievement oftask. We set the target of analysis 20 times after the startin order to clarify the effect of the movement by the seatreaches was assumed the achievement of task for eachseat cushions.
The pressure exceeding 20 mmHg measured by the
FSA was analyzed as COP displacement. The straightrate (SR) was calculated as the total hand path frombeginning the reaching movement to touching the target
divided by the difference between the target and starting
position. SR represents the straightness of the hand trajectory [13] and has an ideal value of 1; the smaller theSR, the straighter the hand trajectory and more efficientthe movement. In addition to SR, displacement in theanterior/posterior (AP) and medial/lateral (ML) directions was also calculated. The mean values ± 2SD of theSR, AP, and ML in healthy adults were considered thestandard values in this study.
Statistical analyses were performed using SPSS version 21 (SPSS Inc., USA). Repeated-measures ANOVA
was used to examine the effects of seat cushions on SR,
AP, and ML. The threshold for statistical significancewas p < 0.05.
The marker on the styloid process of the ulna ofthe dominant hand was defined as the hand marker. The
movement trajectory of the hand marker in the horizontal and sagittal planes was calculated. In addition, themaximum velocity of each joint marker was calculated
during the reaching task, and movement onset was defined as the continuous change in hand velocity exceeding 5% peak velocity. The timing of movement onset
was calculated in terms of the difference in movement
onset of each joint marker from that of the hand marker.

88

EFFECT OF SEAT CUSHION MATERIAL DURING REACH TASK

b

a

10

(cm)

c (cm)

10

10

8

8

8

6

6

6

4

4

4

2

2

2

0
seat cushion A seat cushion B

seat cushion C

0seat cushion A

seat cushion B

seat cushion C

0seat cushion A

seat cushion B

seat cushion C

Fig. 2. 㻲㼕㼓㼡㼞㼑㻚㻞
Mean SR,AP, and ML displacements of COP in healthy adults.
㻹㼑㼍㼚㻌㻿㻾㻘㻌㻭㻼㻘㻌㼍㼚㼐㻌㻹㻸㻌㼐㼕㼟㼜㼘㼍㼏㼑㼙㼑㼚㼠㼟㻌㼛㼒㻌㻯㻻㻼㻌㼕㼚㻌㼔㼑㼍㼘㼠㼔㼥㻌㼍㼐㼡㼘㼠㼟Mean(a) (a)Mean
SR SR, (b) Mean AP displacements, (c) Mean ML displacements
significant
deferences were odserved between the cushions.
(b) NoMean
AP displacements
(c) ※
Mean
displacements
SR:MLstraight
rate, AP: anterior/posterior, ML: medial/lateral, COP: center of pressure
No significant deferences were odserved between the cushions.
※ seat cushion; A: low urethane, B: high urethane, C: silicone※ SR:straight rate; AP:anterior/posterior, ; ML:medial/lateral, COP:center of pressure※ seat cushion; A : low urethane, B: high urethane, C: silicone

seat cushion A

seat cushion Bseat cushion C

Horizontal

Sagittal

10cm
10cm

Upper graph showed the horizontal plane. Lower graph showed the sagittal plane.
Fig. 3. The trajectoryof the wrist joint motion inheathy adults.
Left graph is seat cushion A, center graph is seat cushion B, Right graph is seat cushion C.
Upper graphshowedthelefthorizontal
plane.
Lower graphsagittalplane.
In eachtrace, theside is the startof movement,
and theshowed
right sidetheis thecompletionof the reach.
of the A,
reachmotiongraphfrom completionof one reaching
movement
to thestart position
Left graphTheis trajectory
seat cushion
Centeris seat cushion
B, Right
graph backis seatcushion
C. was excluded.
Each curve represents a trace from a single trial, and each graph contains all trial.
In each trace,
the
left
side
is
the
start
of
movement,
and
the
right
side
is
the
completionofthe reach.
※ seat cushion; A : low urethane, B: high urethane, C: silicone
The trajectory of the reach motion from completion of one reaching movement back to the start position was excluded.
Each curve represents a trace from a single trial, and each graph contains all trial.
※ seat cushion; A: low urethane, B: high urethane, C: silicone

III. Results
1) Healthy adults(1) MTAll healthy adults successfully performed the repeated reaching task. The means MT for seat cushions
A, B, and C were 2.61 ± 0.02, 2.62 ± 0.05, and 2.62
± 0.02 s, respectively. There were no significant
differences between seat cushions (F2,18 = 0.114, p =0.894).
(2) Measurement of body pressure
Figure 2 presents the means of COP for healthy

adults. No significant differences in SR, AP, or ML
were observed among cushions. Therefore, the standard values in this study were SR, 1.60; AP, 12.45;
and ML, 1.49.
(3) Trajectory of the hand marker
Subjects were consistently able to reach straightly tothe target from the initial position (Fig. 3). No difference was observed among seat cushions.
(4) Movement onset of each joint
Figure 4 shows the timing of the movement onset ineach joint. The graph depicts the start time lag (s) ofKodama T et al.

Asian J Occup Ther 15: 85−92, 2019

1

(sec)

12 (the number of times)
10

0.5

8

0

1

n

ol
ec
ra
no

rig

L5

10
Th

C7

-1

le
ft
of
…

6

-0.5

ht
of
…

seat cushion A

CP1

ol
ec
ra
no
n

f…
le
ft
o

rig
ht
of
…

L5

Th
10

C7

-0.5

1

2

seat cushion A

0

-1

4
0

(sec)

0.5

seat cushion B

89

CP2seat cushion B

CP3seat cushion C

Figure 5. Number of successful reaches in subjects with cerebral palsy
Fig. 5. Number of successful reaches in subjects with cerebral palsy.
※ seat cushion; A: low urethane, B: high urethane, C: silicone※ seat cushion; A : low urethane, B: high urethane, C: silicone

cushion C than the other seat cushions.

(sec)

0.5

(4) Movement onset of each joint
Figure 8 shows the timing of movement onset in-0.5
each joint. Using seat cushions, A and B, almost all-1
trunk markers started moving after the hand marker.
By contrast, in the seat cushion C, trunk markers, inFigure 4. Mean the timing of the movement onset in each joint in healthy adults
Fig. 4. Mean the timing of the movement onset in each joint inparticular the acromion, started moving earlier thanThe timing of the movement onset depicts the start time lag (s) of other
healthy adults.
markers with respect to the hand marker when the movement onset of the hand marker.
n

ol
ec
ra
no

le
ft
of
…

ht
of
…

rig

L5

Th
10

0

C7

seat cushion C

The timing of the movement onset depicts the start time lag

hand marker was set to 0.
(s) of other markers with respect to the hand marker when the※ seat cushion; A : low urethane, B: high urethane, C: silicone

movement onset of the hand marker was set to 0.
※ seat cushion; A: low urethane, B: high urethane, C: silicone

other markers with respect to the hand marker whenthe movement onset of the hand marker was set to
0. In all cushions, all markers on the trunk started
movement earlier than the hand marker.
2) Individuals with CP(1) Number of reaches
Subjects with CP were able to reach the target 10 ormore times using seat cushion C. By contrast, they
were unable to reach the target 10 times using thetwo urethane seat cushions (Fig. 5). In particular,
the fewest reaches were observed using the highrebounding cushion (cushion B).
(2) Pressure (Fig. 6)
The SR of seat cushion C was almost 1 or smaller
than the standard value. The mean AP was smaller
than the standard value in every seat cushion. ML
was greater than the standard values in all subjects
regardless of the seat cushion used. CP1 and CP3
subjects demonstrated the smallest disturbance in
ML on seat cushion C.
(3) Trajectory of the hand marker
Figure 7 illustrates the trajectories of movement.
Traces were more linear and consistent with seat

IV. Discussion
1) Effects of seat cushions in healthy adults
Healthy adults were able to perform the task at
the prescribed pace and number of times. The speed
control of arm motion varies when the movement speed
slows down [14]; therefore. the task was designed witha constant rhythm. As a result, there was no difference
in movement velocity among the seat cushions. In addition, the SR, AP, and ML values of the COP were notsignificantly different among seat cushions. The healthy
subjects’ proficient posture adjustability can be considered a factor in their high performance regardless of theseat cushion material used as a base of support.
Movement analysis supported this hypothesis,
indicating the right acromion began moving earliest
with all cushions and that the trunk moved prior to peripheral parts. This timing is due to anticipatory posturaladjustment (APA) [15, 16]. APA is a postural adjustment
function that stabilizes posture during disturbancecaused by voluntary movement and is largely related todevelopmental processes [2, 17]. Various investigations
into APA have been conducted since it was first reported
in 1967 by Belen’kiĭ [18]; however, in healthy adults
with mature motor function, APA is thought to function
by increasing the efficiency of a movement. In otherwords, by stabilizing the trunk, the center of the body,during a movement and reducing shaking, APA helps
exercise the pectoral girdle, a moving segment, more efficiently and improves the accuracy of a movement [14].

90

EFFECT OF SEAT CUSHION MATERIAL DURING REACH TASK

20
19
18
17
16
15
14
13
12

〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰
〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰
a 7b

15 (cm)

c

6
5

10

4
3

5

2
1
0
cp1

cp2

cp3

seat cushion A

seat cushion B

seat cushion C(Subjects)

0
cp1

cp2

seat cushion A

seat cushion B

cp3
seat cushion C

8
7
6
5
4
3
2
1
0

(cm)

cp1
seat cushion A

cp2

cp3

seat cushion B

seat cushion C

Figure 6. Mean SR, AP and ML displacements of COP in subjects with cerebral palsy
Fig. 6. Mean SR, AP and ML displacements of COP in subjects with cerebral palsy.
The horizontal line indicates the mean value of healthy adults plus 2SD
Thehorizontal line indicates the mean value of healthy adults plus 2SD(a) Mean SR(a)(b)Mean(b) Mean AP displacement, (c) Mean ML displacement
MeanSR,
AP displacement
Mean ML displacement
No(c)significant
diference was observed between seat cushions.
Nostraightsignificant
diference
was observed between
seatcushions.
SR:
rate,
AP: anterior/posterior,ML:medial/lateral,
COP: center of pressure
SR:straight rate, AP:anterior/posterior, ML:medial/lateral, COP:center of pressureseatcushion;A:
lowurethane,B:highurethane,
C: silicone※※ seat cushion; A : low urethane, B: high urethane, C: silicone

Seat cushion A

Seat cushion BSeat cushion C

Horizontal

Sagittal

10cm

10cm

Fig. 7.

Upper graph showed the horizontal plane. Lower graph showed the sagittal plane.
graph isseat motion
cushion A,
graphwithis seatcushion B,
right graph is seat cushion C.
TrajectoryLeftof wrist
joint
incentersubjects
cerebralpalsy.
In each trace, the left side is the start of movement, and the right side is the completion of the reach.
Upper graphshowedthehorizontal
plane.
Lower
graph
showedsagittalplane.
The trajectory of the reach motion from completion of one reachingthe
movement
back
to the start position was excluded.
Left graphEach
is seatcushion
A,aCentergraph
is trial,
seat andcushionB, right
graphis seat cushion C.
curve
represents
trace froma singleeach graphcontains
all trial.
※ seatA :islowhigh urethane,and
C: silicone
In each trace,
thecushion;left side
theurethane,start ofB:movement,
the right side is the completion of the reach.

The trajectory of the reach motion from completion of one reaching movement back to the start position was excluded.
Each curve represents a trace from a single trial, and each graph contains all trial.
※ seat cushion; A: low urethane, B: high urethane, C: silicone

As the reaching task was designed to require a reachlonger than arm length, forward movement of the trunk
was required, and movement of the center preceded thatof the periphery for more efficient movements. Previous
studies also reported that the center begins moving

earlier than the arm and suggest a connection between
the movements of the center and arm [11]. Therefore, it
can be presumed that healthy adults use this strategy for
efficient movement wherein they stabilize their center tomove closer to an object.

Kodama T et al.

Asian J Occup Ther 15: 85−92, 2019

1.5

seat cushion A

1.5

(sec)

1

0.5

0.5

0.5

0

0

0

-0.5

-0.5

-0.5

1.5

C7

Th10

L5

right ofleft of olecranon
acromion acromion

1.5

(sec)

C7

Th10

L5

-1

right ofleft of olecranon
acromion acromion

1

0.5

0.5

0.5

0

0

0

-0.5

-0.5

-0.5

Th10

L5

1.5

right ofleft of olecranon
acromion acromion

Th10

L5

-1
1.5

(sec)

C7

right ofleft of olecranon
acromion acromion

(sec)

1.5

1

1

0.5

0.5

0.5

0

0

0

-0.5

-0.5

-0.5

C7

Th10

L5

right ofleft of olecranon
acromion acromion

C7

Th10

L5

right ofleft of olecranon
acromion acromion

Th10

-1

CP1

L5

right ofleft of olecranon
acromion acromion

C7

Th10

L5

right ofleft of olecranon
acromion acromion

Th10

L5

right ofleft of olecranon
acromion acromion

-1

1

-1

C7

1.5 (sec)

(sec)

1

C7

(sec)

-1

1

-1

seat cushion C

1.5

1

-1

seat cushion B

(sec)

1

91

(sec)

C7

-1

CP2

CP3

Figure 8. Mean the timing of the movement onset in subjects with cerebral palsy
Fig. 8. Mean the timing of the movement onset in subjects with cerebral palsy.
The timing of the movement onset depicts the start time lag (s) of other markers with
The timing
ofthe
thehandmovement
onset
theonsetstartoftime
lag marker(s) of was
other
with
respect tomarker whenthedepicts
movement
the handsetmarkers
to 0.
respect
hand marker
when theonsetof the hand marker was set to 0.
※ toseatthecushion;A : low urethane,
B:movement
high urethane,
C: silicone※ seat cushion; A: low urethane, B: high urethane, C: silicone

2) Effects of seat cushions in individuals with CP
Individuals with CP completed fewer reaches thanhealthy adults, because individuals with CP who havea disability in postural adjustment experience difficulty
maintaining postural stability and moving the upper
limbs independently. This was apparent in the results
for all seat cushions. However, the number of reaches
performed by individuals with CP differed among seatcushions, with the silicone cushion, resulting in the mostsuccessful reaches.
Corroborating these observed differences in task
performance, we confirmed that on the urethane seatcushions, subjects tended to increase the SR of the COP
to at least the same extent as that for the silicone seatcushion, which affected their periphery, with the upper
limb initiating the movement followed by the movementof the trunk. The task used in this study required moving
the center of gravity of the trunk during reaching; thismay have been difficult to accomplish without increasing the tension of the trunk muscles and then moving
forward. A urethane seat cushion tends to sink withforward movement because of its material properties.
Therefore, the trunk leans forward. At this time, hypotonic CP patients must maintain their posture more
consciously, making it difficult for them to perform asmooth reaching movement. Therefore, their performance of the reaching task can be considered to involve
first increasing trunk muscle tension, then raising theupper limbs, and finally leaning forward.

According to a previous report, in a reaching task
requiring greater posture adjustment such as circumnut­
ation of the trunk, CP patients prioritized the stabilityof the center rather than the motion efficiency of theperiphery; thus, the movement of the peripheral controlling part tended to be unstable [13]. The resultsof the present study also demonstrate that the motion
trajectory of the wrist joint was extended on a moreunstable seat cushion, requiring posture stabilization. By
contrast, all subjects had a stable motion trajectory, andtheir motion start time was similar to the motion patternof healthy adults on the silicone seat surface. Therefore,
we hypothesize that the improvement of trunk support
enabled the forward movement of the trunk, leading to
improvements in task performance and stability of the
motion trajectory compared to those on the urethane seatsurface.
The cause of the improvement in trunk support withthe silicone seat cushion might be the sensory feedback
exerted from each silicone tube, supplying the posturecontrol mechanism of the trunk with more information.
CP patients cannot gain adequate sensory feedback
because of somatosensory system dysfunction and may
have difficulty controlling their posture [7, 19], which
can result in increased shaking during balancing in thestanding position [7]. As this study confirms the effectsof the silicone seat cushion specifically in subjects
whose trunks were hypotonic, it demonstrates the possibility that the postural control of such subjects can be92

EFFECT OF SEAT CUSHION MATERIAL DURING REACH TASK

promoted by environmental factors such as seat surface
material to help them exercise more efficiently.

V. Conclusion
The findings of this study indicate that the use of asilicone seat cushion increases the number of reaches,
efficiency of COP displacement, and stability of the
trajectory of peripheral movement in individuals with
CP who have hypotonic trunk muscles. Therefore, seatcushion design may improve movement in individuals
with cerebral palsy who have postural control disabilities. However, further larger studies considering multiple
clinical conditions are needed. In addition to the current
reaching task, the use of a silicone cushion should be
investigated in many reaching and manipulation tasks
resembling activities of daily living.
Acknowledgements: The authors would like to express
their sincere thanks to the study participants with cerebral palsy. The study was partially supported by the
Fukushimura Hokkaido Social Welfare Corporation,
Japan.

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■CASE REPORT

Effect of Combining the Canadian Occupational
Performance Measure with Cognitive Behavioral Therapy
to Enable Occupation in a Client with Depression:
A Case Study in Home-Visiting Support
Mai Sakimoto1, Takayuki Kawaguchi2, Aki Watanabe2
12Link Yokohama Home-visit Nursing Station
Department of Rehabilitation, Kitasato University School of Allied Health Sciences

Abstract: Introduction: Few reports describe interventions combining the Canadian Occupational Performance Measure (COPM) with cognitive behavioral therapy (CBT) although both are important in enabling occupation for a clientwith depression. We outline the therapy process conducted by an occupational therapist combining the COPM with
CBT to enable occupation for a client with depression.
Methods: A single-system research design was implemented. The intervention was based on behavioral activation, andthe cognitive restructuring was divided into three phases: baseline (Phase I), intervention 1 (Phase II), and intervention
2 (Phase III). Baseline consisted of behavioral activation only. In intervention 1, the COPM was used in addition to thebaseline action. In intervention 2, cognitive restructuring was conducted in addition to intervention 1.
Results: There was no significant difference in the client’s frequency per week of going out in Phase II compared with
Phase I ( p = 0.062), but the rate increased significantly in Phase III compared with Phase II by binomial test ( p = 0.002).
As assessed by the COPM, the performance and satisfaction scores for going out were 4 and 3 at the 5th week, but they
improved to 7 and 6 at the 17th week.
Conclusion: Combining the COPM with CBT significantly increased the frequency of going out that a client with depression hoped to attain. The present intervention might facilitate enabling occupation for clients with depression. Ourfindings suggested that in clients with depressive symptoms, enabling occupation is possible by combining the COPM
with CBT.
Keywords: enabling occupation, COPM, cognitive behavioral therapy, depression, single system design(Asian J Occup Ther 15: 93−96, 2019)

Introduction
It is important to focus on an individual’s occupation and to select appropriate interventions for enabling
occupation in a client with depression. The Canadian
Occupational Performance Measure (COPM) is an useful
method for focusing on the occupation of a client [1].
Schindler [2] showed that an occupation-based practiceincreased client scores on satisfaction and performance
Received: 25 December 2018, Accepted: 11 September 2019
Corresponding to: Mai Sakimoto, Link Yolohama Home-visit Nursing Station, 1-4-2-118, Nishikubocho, Hodogaya-ku, Yokohama-shi,
Kanagawa-ken 240-0022, Japane-mail: sakimot116@gmail.com©2019 Japanese Association of Occupational Therapistsof occupational performance problems identified on the
COPM in psychiatric disorders.
Cognitive behavioral therapy (CBT) is one effective
intervention for depression [3, 4]. When appropriately
self-assessing themselves, clients with depression tend
to have difficulty in recognizing positive results.
Although the self-assessment of positive changes
in daily activity by using the COPM might promote theeffect of CBT, few studies in depression show the effectof combining the COPM with CBT.
The purpose of this study was to outline the therapy
process conducted by combining the COPM with CBTfor enabling occupation of a client with depression.
Signed informed consent for this study was obtained
from the client.

EFFECT OF COMBINING COPM WITH CBTBaseline

Intervention 1

Intervention 2

Phase I: 1st to 4th week

Phase II: 5th to 11th week

Phase III: 12th to 20th week

Behavioral
activation

Behavioral
activation

Behavioral
activation

+

➕

➕

94

+

COPM
(5th week)

COPM(17th week)+➕

Cognitive
restructuring

Fig. 1. The experimental
procedure.
Figure 1.
Baseline therapy consisted of behavioral activation only. In intervention 1, the Canadian Occupational Performance Measure(COPM) was used in addition to the baseline action. In intervention 2, cognitive restructuring was carried out in addition to intervention 1.

Subject
The client was a woman in her 40s with depression. She lives with her husband and daughter and is ahousewife. Her symptoms of depression such as anxiety
and sleeplessness first appeared 10 years ago, and she
was diagnosed as having anxiety disorder. After that,
her symptoms worsened from one year ago, and she
was diagnosed as having depression. Her symptoms
were mainly anxiety that often worsened when she did
nothing during the day. Although she had hoped to go
out shopping and eat in restaurants, she was unable toact with her own intention and was in a double bind dueto the influence of her symptoms.
We adopted “behavioral activation” using a tableof her self-recorded daily activities to enhance behavior
that reduced her anxiety by visualizing the relationshipbetween her behavior and mood. Behavioral activation
is a technique of CBT that promotes engagement withactivities and focuses on increasing pleasure and productive experiences [5, 6].
“Cognitive restructuring” was also adopted to allow
her to behave in a manner that would reduce her anxiety
after stressful events. Cognitive restructuring is a CBTtechnique that focuses on automatic thoughts, cognitive
distortion, and decreasing feelings such as depression
and anxiety, and corrects non-adaptive behaviors [7].

MethodTherapy process
The interventions based on the COPM, behavioral
activation, and cognitive restructuring were divided
into three phases and were carried out via home-visiting

support once a week (Fig. 1). The only services used byour client were outpatient treatment and home-visiting
support.
Phase I (baseline: 1st to 4th week)
As an intervention based on behavioral activation,
performance of daily activities and changes in her
anxiety were self-recorded by the client. In addition,
activities that would decrease her anxiety were checked,
and an executable daily schedule was planned collaboratively.
Phase II (intervention 1: 5th to 11th week)
Assessment with the COPM for the purpose of focusing on her occupations was added to the interventions
in Phase I. In addition, the use of COPM was proposed
to promote the client’s self-awareness of satisfaction
and occupational performance of going out. Therefore,
the presentation of the COPM score to compare with thecurrent situation were conducted in the interview.
Phase III (intervention 2: 12th to 20th week)
Cognitive restructuring was added to the interventions in Phase II, and her tendency to grasp ideas,
automatic thoughts, and cognitive biases generated bystressful events were confirmed. Moreover, the adjustive
thoughts and behaviors that reduced her anxiety were
examined collaboratively.
Procedure
A single-system research design comprising threetarget outcomes was conducted to clarify the effect ofintervention for the client (Fig. 1).

Sakimoto M et al.

Asian J Occup Ther 15: 93−96, 201995

Fig. 2. Frequency per week of going out.
Going out indicates that the client hoped for it. The broken grey line shows the celeration line in Phase I. The solid grey line
shows the celeration line in Phase II. Going out was not done in Phase I. Visual observation was found to increase in Phase II
compared with Phase I, and it increased significantly in Phase III compared with Phase II by the binomial test ( p = 0.002). PhaseI = 1st to 4th week; Phase II = 5th to 11th week; Phase III = 12th to 20th week.

1) Frequency of going out
The target behavior was the frequency per week ofgoing out that she hoped to achieve. “Going out” wasdefined as eating at restaurants and going shopping.
2) COPM performance and satisfaction scores
We conducted COPM assessment to determine theoccupation “Going out” that she hoped to achieve andanalyzed changes in COPM performance and satisfaction scores in Phases II and III.
3) Degree of anxiety
The changes in her degree of anxiety (range, 0 to100) for each hour of every day that she self-scoredwere monitored.
Data analysis
Visual analysis, the split-middle technique, and thebinomial test were adopted to compare the frequency per
week of going out, which was counted in each phase.
A p value < 0.05 was considered to indicate statisticalsignificance.

Results
The average frequency per week of going out ineach phase is shown in Fig. 2 and Table 1. There was no
significant difference in the client’s frequency per weekof going out in Phase II compared with Phase I ( p =0.062), but the rate increased significantly in Phase III
compared with Phase II by binomial test ( p = 0.002).
As assessed by the COPM, the performance andsatisfaction scores for going out were 4 and 3 at the 5thweek, but they improved to 7 and 6 at the 17th week
(Table 1). The client recognized that she went out for
mandatory and rehabilitative activities to help reduce
her anxiety in Phase I. The number of destinations she
visited in Phase II had increased, but she still had no
confidence in going shopping. In Phase III, she began
to experience the feeling of leisure when she went out.
However, her average degree of anxiety did not change
during each phase (Table 1).

Discussion
Identifying factors inhibiting occupational performance and selecting appropriate interventions areimportant roles of occupational therapists in the practiceof enabling occupation [8]. The present results show thatthe behavior of our client with depression was difficult
to change with either COPM or CBT alone. A combination of prompt self-monitoring and other techniques
is effective in initiating behavioral changes [9]. The
combination of COPM and several CBT techniques wasan appropriate method for addressing the factors that
inhibited her occupational performance. Therefore, her
COPM scores improved, and she began to understandthe meaning of leisure and to achieve enabling occupation via the present interventions without exacerbating
her anxiety.
Depressive symptoms have a negative effect on
the quality of life. However, the process of changing
one’s attitudes, goals, and skills to live a satisfying life
by overcoming the limitations caused by mental disease
is important [10]. Visualization of the behaviors andanxiety based on CBT and focusing on meaningful oc-

96

EFFECT OF COMBINING COPM WITH CBTTable 1. Changes in target outcomes in each phase.
Phase I

Phase II

Phase III0±0

1.3 ± 0.8

2.7 ± 1.0

Number of destinations visited
Reason for visiting destination

1• Mandatory visit

2• Mandatory visit• Eating out at restaurants

4• Mandatory visit• Eating out at restaurants• Visiting town
• Shopping

COPM
Performance score (range: 1−10)
Satisfaction score (range: 1−10)

―
―

4
3

7
6

Degree of anxiety (range: 1−100)

41.8 ± 20.1

40.9 ± 17.5

41.6 ± 17.9

Frequency per week of going out (times)

Notes. Phase I = 1st to 4th week; Phase II = 5th to 11th week; Phase III = 12th to 20th week; COPM = The Canadian Occupational
Performance Measure. Values are mean ± SD, n, or score.

cupation based on performance and satisfaction scoresof the COPM prompted the client to positive thought for
enabling occupation. Therefore, our findings suggested
that if enabling occupation of clients with depression isdifficult to achieve due to their symptoms, an intervention combining the COPM with CBT might be effective
in home-visiting support. Further research and increaseof sample size are required to validate the effectivenessof combining the COPM and CBT.

Conclusions
An intervention combining the COPM with CBT
was sufficiently appropriate to facilitate the enabling
occupation of a community-dwelling client with depression.
Acknowledgements: We thank the client for her participation in this study.

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