■PROFESSIONAL TRENDS IN ASIA
A 3-year Follow-up Study on the Alternating Useof Static Splints after Metacarpophalangeal Joint
Arthroplasty in a Patient with Rheumatoid Arthritis
Hiroyuki Hayashi, BS, OTR1, Jun Uchiya, OTR2
1 Division of Occupational Therapy, Faculty of Care and Rehabilitation, Seijoh University
2 Rehabilitation Division, Gifu University Hospital

Abstract: Burr et al. (2002) reported the results of a 19-month follow-up study on a static splinting regimen as an alternative to dynamic extension splinting after metacarpophalangeal (MCP) joint arthroplasty. However, the long-term results ofstatic splinting therapy have not been reported. Therefore, we conducted a 3-year follow-up study on the use of alternating
static splinting in extension and flexion after MCP joint arthroplasty. Active flexion and extension of the MCP joints and grip
strength were evaluated before surgery and at 12 weeks and 3 years after surgery. The range of motion (ROM) of the MCP
joints and grip strength improved at 12 weeks and 3 years postoperatively. The efficacy of dynamic extension splinting after
MCP joint arthroplasty indicated no change in the ROM and grip strength. The findings in this case indicate the positive
long-term results of a static splinting regimen.
Key words: rheumatoid arthritis, splint, range of motion(Asian J Occup Ther 9: 1–5, 2011)

Introduction
Common hand deformity in rheumatoid arthritis(RA) results from the destruction and dislocation of themetacarpophalangeal (MCP) joints and ulnar deviation of
the finger (Chung, Kotsis & Kim, 2004).
Hand deformities caused by RA are often treatedwith surgery and rehabilitation to improve a patient’s
hand function-associated activities of daily living (ADLs)(Mannerfelt & Andersson, 1975; O’Brien, Jones, Mullis,
Mulherin & Dziedzic, 2006).
MCP joint arthroplasty with implants has been adopted for treatment of RA patients since the 1960s (Swanson,1972), because RA can damage the MCP joints resulting
in flexion and ulnar deviation deformities. Surgical intervention via MCP joint arthroplasty using Swanson implants has been performed for improving hand function.
The use of a dynamic extension splint has been recReceived: 5 March 2010, Accepted: 23 February 2011
Corresponding to: Hiroyuki Hayashi; Division of Occupational
Therapy, Faculty of Care and Rehabilitation, Seijoh University, 2-172
Fukinodai, Tokai, Aichi 476-8588, Japan
Phone: 81-52-601-6451 Fax: 81-52-601-6451
e-mail: hayashi-h@seijoh-u.ac.jp©2011 Japanese Association of Occupational Therapists

ommended after MCP joint arthroplasty (Swanson, 1972).
A number of studies have reported that this method results in an increased extension MCP joint range of motion(ROM), but a decreased flexion (ROM), especially in theulnar digits (Rothwell, Cragg & O’Neill, 1997; Moller,
Sollerman, Geijer, Kopyylov & Tagil, 2005). Furthermore, Blair, Shurr & Buckwalter (1984), Bieber, Weiland& Volenec-Dowling (1986), and Delaney, Trail & Nuttall (2005) indicated that there were no changes in pre- or
postoperative grip strength.
We have been carrying out dynamic splinting as
therapy for patients undergoing MCP joint arthroplasty,
and although MCP joint extension can be improved, ourexperience shows that MCP flexion and grip strength decrease after surgery. This finding is consistent with thoseof previous reports (Blair et al. 1984). Restricted MCP
joint flexion and decreased grip strength may lead to increased difficulties in performing ADLs such as grippinga knife to cut food or squeezing a towel.
On the other hand, Burr, Pratt & Smith (2002) suggested the usefulness of alternating daily the applicationof static extension and flexion splints. Their study reported improved extension and flexion ROM. Furthermore, ascompared to the results of the method recommended by
Swanson (1972), the flexion ROM was much improved.

2

Alternating Use of Static Splints after MCP Joint Arthroplasty

Table 1. Postoperative MCP joint ROM with dynamic extension splinting
Extension (degrees)
Our result
Mannerfelt et al.
Goldfarb et al.

Flexion (degrees)

Index

Long

Ring

Small

Index

Long

Ring

Small

26
8
23

20
12
27

16
10
24

26
4
16

60
51
60

56
55
60

46
50
60

52
39
49

Their study also highlighted the comfort, simple design,ease of production, and low cost as added advantagesof the alternating splinting method. The purpose of thisstudy was to investigate the 3-year follow-up results ofalternating static splinting after MCP joint arthroplasty.
We adopted the alternating static splinting method
after MCP joint arthroplasty rather than the dynamic
splint because we believe that it is easier to both manipulate the splints after being discharged and flex the MCP
joints while wearing the splints.

Case
The patient was a woman in her sixties whose condition had been diagnosed as RA 14 years previously. The
patient had functional motion of the shoulder, elbow andwrist. However, because of the ulnar deviation and subluxation of the fingers at the MCP joints, the patient experienced weak palmar grip. Therefore, she was surgicallytreated. First, Swanson implants were inserted in 4 MCP
joints of her right hand to correct the ulnar drift, and thepalmar subluxation as well as to relieve pain. After the
MCP joint arthroplasty, dynamic splinting was performed.
At the 12th postoperative week, the results were nearly thesame as those reported in other studies (Mannerfelt & Andersson, 1975; Goldfarb & Stern, 2003) (Table 1).
Nine months after the initial MCP joint arthroplasty,
bridging calluses developed due to bone spurs near the
MCP joints of the ulnar digits. Approximately 1 year after
the initial MCP joint arthtroplasty, the MCP joint ROM
of the ulnar digits was diminished. Therefore, the bone
spurs were surgically removed and the implants in all the
MCP joints were replaced. After the second MCP joint
arthroplasty, we employed an alternating static splinting
method.
The patient was prescribed methotrexate (MTX) andprednisolone in the case of the dynamic extension splinting. However, tacrolimus hydrate and prednisolone wereprescribed in the case of the alternating static splinting.

Progress and Rehabilitation Program
Evaluation
Although the postoperative rehabilitation program
was completed 12 weeks after the second operation, a fol-Fig. 1. Alternate splints of same type with splints the patient wore.
The wrist is extended at 30 degrees, the MP joints are flexed
at 70 degrees, and IP joints are extended at 0 degrees (a). The
wrist is extended at 30 degrees, and the MP and IP joints areextended at 0 degrees (b).

low-up rehabilitation program continued for 3 years. Objective measurements of active ROM of the MCP joints inflexion and extension were obtained with a small goniometer over the dorsum of the digital joints. The arc of active
motion was determined by subtracting the active extension lag value from the active flexion value. Grip strength
was measured using the JAMAR hand dynamometer.
Active flexion and extension of the MCP joints andgrip strength were evaluated preoperatively (before thefirst and second operations) and at 12 weeks and 3 years
after the second operation.

Alternating static splinting
Exercise and splinting were conducted according to
the rehabilitation plan reported by Burr et al. (2002). Rehabilitation began on the third postoperative day. Static

Hayashi H et al.

Asian J Occup Ther 9: 1–5, 2011

3

Table 2. Rehabilitation after MCP joint arthroplasty
Time Frame

Therapeutic Intervention

3–4 wk postop

Active ROM initiated for MCP and IP joints every hour
2 splints used alternatively for 24 hours at a time
Operated hand not used for ADLs at first 4 weeks

4–8 wk postop

Active ROM was continued
2 splints worn alternatively for protection and resting only
Patient began to perform light activities at 4 postoperative weeks

8–12 wk postop

Active ROM was continued until 12 postoperative weeks
2 splints were worn alternatively only at night until 12 postoperative weeks
The patient began using the operated hand for normal ADLs

extension and flexion splints were used for 12 weeks (Fig.
1).
With the static extension splints the MCP and interphalangeal (IP) joints were extended at 0 degrees. With
the static flexion splints the MCP joints were flexed at
70 degrees, and the IP joints were extended at 0 degrees.
With both splints, the wrist was extended at 30 degrees(Fig.1). The basic aim of using the static extension splint
was to maintain the MCP joints at maximum extension,
whereas with the static flexion splint we aimed to achieve
maximum flexion by extending the collateral ligamentand articular capsule, and by excursing the extensor digitorum tendon distally.
The 2 splints were worn on alternate days for 24hours at a time.

Postoperative rehabilitation program
The therapeutic intervention provided to the patientis shown in Table 2.
During the day, 2 types of exercises were performed.
The MCP and IP joints together were actively extended
and flexed, after which the MCP joints were actively
flexed and extended; the IP joints were completely extended throughout. This sequence was performed 10
times every hour for 12 weeks after surgery.
The patient was advised to remove the splints every
hour during the exercise during the first 4 postoperative
weeks; moreover, she was instructed not to use the affected hand during these 4 weeks. After 4 postoperative
weeks, the patient was allowed to use the affected handfor light ADLs such as fastening buttons and using afork. At the 8th postoperative week, normal ADLs suchas squeezing a towel and opening a tight jar were permitted. Thereafter, the patient was instructed to alternate
between the 2 splints only at night until the 12th postoperative week. Therapy was completed by the end of the
12th postoperative week.
The patient was discharged three weeks after surgery,and the patient subsequently received regular outpatient
treatment twice weekly for 3 months.

Results
Figure 2 shows the ROM and the grip strength of the
2 different splinting methods.
The ROM of the MCP joints before the first operation was 16 (–40/56) degrees in the index finger, 24(–20/44) degrees in the middle finger, 12 (0/12) degrees in
the ring finger, and 14 (–46/60) degrees in the little finger.
The ROM of the MCP joints before the second operation
was 24 (–40/64) degrees in the index finger, 40 (–26/66)
degrees in the middle finger, 0 (–26/26) degrees in thering finger, and 0 (–28/28) degrees in the little finger. The
ROM at the 12th postoperative week with the use of alternating splinting was 24 (–40/64) degrees in the index finger, 46 (–20/66) degrees in the middle finger, 48 (–16/64)
degrees in the ring finger, and 34 (–36/70) degrees in thelittle finger. The ROM three years after surgery was 32(–40/72) degrees in the index finger, 48 (–22/70) degrees
in the middle finger, 58 (0/58) degrees in the ring finger,and 32 (–40/72) degrees in the little finger (Fig. 3). The
passive MCP joint extension at the 12th postoperative
week for both operations was 0 degrees.
In addition, grip strengths before the first and second
operations were 3.0 and 2.0 kg respectively. It increased to
6.0 kg after 12 weeks of therapy using alternating splinting,and 3 years after the second operation it increased to 8.0 kg.
Subjective patient comments indicated a preference
for the alternating static splinting therapy. The patientjudged dynamic extension splinting to be heavy on thehand and not easy to wear. The patient also found it difficult to flex the fingers. On the other hand, the patientjudged the alternating static splinting to be lighter on thehand and easier to wear. The patient also reported increased facility in finger flexion.

Discussion
In general, dynamic splinting is implemented to maintain and increase the ROM of the MCP joints after MCP
joint arthroplasty. Blair et al. (1984) reported that dynamic
splinting increased active extension. However, it has been

4

Alternating Use of Static Splints after MCP Joint Arthroplasty

Fig.2. ROM of the MCP joints and grip strength before the first andsecond operationand at 12 weeks and 3 years after the second
operation.

Fig. 3. Flexion (a) and extension (b) of the MCP joints three
years after surgery.

reported that both active flexion of the MCP joints and grip
strength using dynamic splinting decreased on average
from 72 N to 62 N 54 months after surgery. O’Brien (1996)
stated that there was no significant change in motion. However, our patient’s motion and grip strength improved after
3 years as compared with the motion grip strength before
the first and second operation, and those at 12 weeks after
the second operation. el-Gammal & Blair (1993) reported
that the best motion is during the first 2 years, but the ROM
tends to decrease thereafter. However, our patient continued to show improved palmar grip after 3 years.
MCP joints are commonly known to be the most important joints for hand function; they contribute to 77%
of the total arc of finger flexion (Moran & Berger, 2003)
and are important for MCP joint flexion. However, flexing
the MCP joint against the resistant forces of a dynamic
splint can be very difficult for some patients (Burr et al.,2002). On the other hand, a static splint placed at MCP
joint maintains the MCP joints at 70 degrees in a flexion
position. Therefore, it is easy to increase the flexion angleof the MCP joint.
Active flexion ROM of the MCP joints and adequate
grip strength is an important pre-requisite for various
ADLs such as cutting vegetables with a kitchen knife,turning on the water tap, unscrewing the lid of a jar, or
squeezing a towel. Alternating static splinting resulted
in higher grip strength as compared to the grip strengthAsian J Occup Ther 9: 1–5, 2011

achieved with dynamic splinting after the first operation,and the grip strength further improved over 3 years.
Hume, Gellman, McKellop & Brumfield (1990) reported that the average functional ROM of the MCP joints
should be 61 degrees to perform ADLs. Therefore, a flexion ROM of more than 60 degrees has to be achieved in
the case of the MCP joints. In this patient, with the use ofalternating static splinting, the flexion of the MCP joints
was maintained at over 70 degrees for 3 postoperative
years, except in the case of the ring finger. Thus, a functional ROM of the MCP joints was maintained in this patient. Three years after surgery, the increase in the ROMof the MCP joints as well as the increase in grip strength
was due to fact that the patient used the affected hand frequently for ADLs 12 weeks after surgery, thus achieving
MCP joint flexion.
The static splint is easy to put on and comfortable towear; it is also aesthetically pleasing. Furthermore, thissplint is not disturbed during ADLs as compared to the
dynamic splint. In addition, when getting dressed or walking the outrigger of the dynamic splint sometimes damages clothes, but this does not occur with static splints.
However, the improvement in the extension ROM of
the MCP joints was not as significant as that reported byBurr et al. (2002). This may be due to insufficient exercising of the affected hand.
The use of alternating static splints can be useful forthe treatment of patients after MCP joint arthroplasty. The
ROM of the MCP joints and grip strength achieved in thecase of our patient suggests that alternating static splinting could be an effective postoperative therapy.

Conclusion
We investigated the 3-year progress of a patient withthe use of alternating static splints after MCP joint arthroplasty for RA. Three years after surgery, MCP joint
flexion and grip strength continued to improve. Therefore,
alternating static splinting may be an effective postoperative therapy and could be used as a suitable alternative fordynamic MCP extension splinting.

References
Bieber, EJ., Weiland, AJ., & Volenec-Dowling, S. (1986).
Silicone-rubber implant arthroplasty of the metacarpophalangeal joints for rheumatoid arthritis. The Journal ofbone and joint surgery. American volume. 68, 206–209.
[Medline]
Blair, WF., Shurr, DG., & Buckwalter, JA. (1984). Metacar-

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5pophalangeal joint implant arthroplasty with a Silastic
spacer. The Journal of bone and joint surgery. American
volume. 66, 365–370. [Medline]
Burr, N., Pratt, AL., & Smith, PJ. (2002). An alternative
splinting and rehabilitation protocol for metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis.
Journal of hand therapy. 15, 41–47. [Medline] [CrossRef]
Chung, KC., Kotsis, SV., & Kim, HM. (2004). A prospective
outcome study of Swanson metacarpophalangeal joint arthroplasty for the rheumatoid hand. The Journal of handsurgery. 29, 646–653. [Medline] [CrossRef]
Delaney, R., Trail, IA., & Nuttall, D. (2005). A comparative
study of outcome between the neuflex and Swanson metacarpophalangeal joint replacements. Journal of hand surgery (Edinburgh, Scotland). 30, 3-7.
el-Gammal, TA., & Blair, WF. (1993). Motion after metacarpophalangeal joint reconstruction in rheumatoid disease.
The Journal of hand surgery. 18, 504–511. [Medline][CrossRef]
Goldfarb, CA., & Stern, PJ., (2003). Metacarpophalangeal
joint arthroplasty in rheumatoid arthritis: A long-term assessment. The Journal of bone and joint surgery (American volume). 8-A5, 1869-1878.
Hume, MC., Gellman, H., McKellop, H., & Brumfield, RH.
Jr. (1990). Functional range of motion of the joints of thehand. The Journal of hand surgery. 15, 240–243. [Medline] [CrossRef]
Mannerfelt, L., & Andersson, K. (1975). Silastic arthroplastyof the metacarpophalangeal joints in rheumatoid arthritis.
Journal of Bone and Joint Surgery. 57, 484–489. [Medline]
Moller, K., Sollerman, C., Geijer, M., Kopyylov, P., & Tagil,
M. (2005). Avanta versus Swanson silicone implants in the
MCP joint: A prospective, randomized comparison of 30
patients followed for 2 years. Journal of Hand Surgery. 30,
8–13. (British and European). [Medline]
Moran, SL., & Berger, RA. (2003). Biomechanics and handtrauma: What you need. Hand clinics. 19, 17–31. [Medline] [CrossRef]
O’Brien, ET. (1996). Surgical principles and planning for therheumatoid hand and wrist. Clinics in Plastic Surgery. 23,
407–420. [Medline]
O’Brien, AV., Jones, P., Mullis, R., Mulherin, D., & Dziedzic,
K. (2006). Conservative hand therapy treatments in rheumatoid arthritis: A randomized controlled trial. Rheumatology. 45, 577–583. [Medline] [CrossRef]
Rothwell, AG., Cragg, KJ., & O’Neill, LB. (1997). Hand function following silastic arthroplasty of the metacarpophalangeal joints in the rheumatoid hand. Journal of Hand
Surger (Edinburgh, Scotland)y. 22, 90–93. [Medline]
Swanson, AB. (1972). Flexible implant arthroplasty for arthritics finger joints: Rationale, technique, and results oftreatment. Journal of Bone and Joint Surgery. 54, 435–
455. [Medline]

■ORIGINAL ARTICLE
Application of Constraint-induced Movement Therapy
for People with Severe Chronic Plegic Hand
Hirofumi Tanabe, OTR, MS1, Toru Nagao, OTR, PhD2,
Rumi Tanemura, PhD, OTR2
1 Self-Defense Force Central Hospital Rehabilitation Center2 University of Kobe Graduate School

Abstract: Objective: To determine the efficacy of intense constraint-induced movement therapy (CIMT) for patients who
cannot achieve finger extension due to a severe plegic hand after stroke. Design: Pre-post, pre-1 month follow-up, singleblinded, multi-baseline case. Participants: Fifteen participants who were all >12 months post-stroke. Interventions: Two
weeks of CIMT including restraint of the nonparetic upper extremity and 6 hours of training each day. Outcome: There
was a statistically significant effect of CIMT on upper extremity motor impairment assessed by the Fugl-Meyer Motor
Assessment (FMA), the Motor Activity Log for low functioning patients (Grade 5 MAL) and Active Range of Motion(AROM). Post hoc analysis showed significant differences between pre- and post-treatment motor impairment scores, andthe improvements in these scores were maintained at 1 month after completion of treatment. Improvements were mostly inthe use of the involved upper extremity for bimanual activities. Conclusions: Intense CIMT conferred significant changes
in objective measures in subjects with chronic severe plegic hand after stroke. Additional studies of the long-term benefitsof this treatment on post-stroke motor impairments and related functional disabilities are warranted.
Key words: occupational therapy, hemiplegia, exercise training, rehabilitation, stroke(Asian J Occup Ther 9: 7–14, 2011)

Introduction
Constraint-induced movement therapy (CIMT) is
used to improve motor function after stroke and to increase use of the affected hand in daily life (Taub et al.,2006; Taub, Uswatte & Pidikiti, 1999; Taub, Uswatte &Elbert, 2002; Morris & Taub, 2001). CIMT has been used
for mild to moderate motor impairment (Taub et al., 2006;
Taub et al., 1999; Taub et al., 1993; Winstein et al., 2003),
and from moderate to “moderate to severe” (Bonifer, Anderson & Arciniegas, 2005b). The CI Therapy Research
Team of the University of Alabama established the Constraint-Induced Therapy Criteria (UAB grade) (Bowman
et al., 2006; Shaw et al., 2005) based on reported indication criteria for CIMT. This scale categorizes motor ability into five levels based on active range of motion, with
Received: 2 November 2010, Accepted: 9 November 2011
Corresponding to: Hirofumi Tanabe, Self-Defense Force Central Hospital Rehabilitation Center, 1-2-24 Ikejiri, Setagaya, Tokyo 154-8532,
Japane-mail: info@citherapy.sakura.ne.jp©2011 Japanese Association of Occupational Therapists

grade 1 indicating the highest motor ability and grade
5 the lowest, with no extension of the wrist, fingers or
thumb. Most studies of CIMT have used the ability to extend the metacarpophalangeal (MP) and interphalangeal(IP) joints of each finger and thumb by at least 10° andto extend the wrist by at least 20° (UAB grade 1 or 2 )as the indication for CIMT (Taub et al., 1993; Liepert etal., 1998; Liepert, Bauder, Miltner, Taub & Weiller, 2000;
Kopp et al., 1999). Slightly broader criteria of extensionof at least 10° at the wrist and IP joints of any two fingers,
and to abduct the thumb at least 10° (UAB grade 3) havealso been used (Bonifer et al., 2005a).
Based on these studies, patients with stroke must beable to extend at least 10° at the wrist and each finger
and thumb to be eligible for CIMT (Bonifer et al., 2005a).
Thus, many hemiplegic patients who wish to undergo
CIMT have been excluded from this therapy. However,
CIMT for severely affected hands without extension of
fingers and thumbs: UAB grade 4 (Page & Levine, 2007),UAB grade 5 (Bowman et al., 2006; Page et al., 2007)
has also been reported. Among these studies, a case report
including detailed exercises showed that CIMT with up-

8

CONSTRAINT-INDUCED MOVEMENT THERAPY

48.6 ± 29.1 months. Thirteen had left hemiplegia. The
participants submitted informed written consent to participate in this study after they received a full explanation of
CIMT. The members of the rehabilitation team confirmedthat each prospective participant met the following inclusion criteria: (1) at least a year after stroke, (2) UAB grade
4 or 5 (Table 2), (3) no severe speech disability (score ofat least 4/6 on the Token Test), and (4) no severe dementia(score of at least 24/30 on the Mini Mental State Examination). The exclusion criteria were a history of injection
for botulinum toxin for treatment of epilepsia, mental disorder (ICD-10), and spasticity.

per extremity braces and splints is effective for recovery
of motor function and increasing use of the affected hands
in daily life. Page et al. also reported CIMT combinedwith mental practice. These reports showed the generalefficacy of CIMT, but included few subjects and did notprove that CIMT is effective for severely affected handsof UAB grade 4 or 5.
However, the outcomes suggested that CIMT forsuch hands can improve the ability of the patient to use
household items through utilization of self-help devices
and splints.
Further verification of CIMT for severely affected
hands is important to enlarge the indication for CIMT, toimprove motor function of more patients after stroke, andto increase use of a plegic hand in daily life. The objectiveof the present study was to examine the efficacy of CIMTwith self-help devices/splints for severely affected handswith little or no extension of the wrist, fingers and thumb(UAB grade 4 or 5).

ProtocolAll participants underwent two weeks of intensive
training for the affected side extremity, fingers and thumbon weekdays for six hours each day. In many reports, constraint of the non-affected hand is recommended for 90%
of waking hours (Bonifer et al., 2005a; Bowman et al.,2006; Shaw et al., 2005), but since use of a severely affected hand in daily living is difficult, the constraint timeneeds to be reduced. Therefore, in the present study, thenon-affected hand was immobilized in a padded mitt (NAVIS Inc.) for 80% of waking hours. The time of use of
the non-affected hand was recorded in a daily diary andchecked by the occupational therapist (OTR) every week.
The mitt was used in the action assignment to prevent the
non-affected hand from seizing an object.

Methods
Participants
The participants were 15 patients with chronic hemiplegia after stroke who were admitted to the Rehabilitation Center of our hospital between November, 2009 andOctober, 2010. Participants (Table 1) had a mean age of
48.4 ± 9.6 years old and a mean interval after stroke ofApparatus
Participants who cannot extend the fingers and thumbcannot grasp and release items. Thus, we developed various splints that enable action assignments. The finger extension assisting splint (Fig. 1) utilizes the restoring force
of a wire made of a shape-memory alloy to assist extension of the fingers with maintenance of the opposing extremity positions of the thumb and other fingers. The wire
width may be changed in response to different levels of
the active finger flexor force. The finger extension splint(Fig. 2) has Velcro tapes on the palm side of the main

Table 1. Participant characteristics
Item
Age (years)
Time poststroke (months)
Sex (men/women)
Paralysis side (right/left)
Dominant hand affected
UAB grade 4 / 5Motor Activity Log AOU
QOM

Value
48.5 ± 9.6
48.6 ± 29.1
15/ 0
2/13
7
7/8
0.4 ± 0.7
0.5 ± 0.7

Values are shown as the mean ± SD or n.

Table 2. UAB grade 4 or 5active range of motion criteria
Impairment

ShoulderElbow

Wrist, Fingers, Thumb

Grade 4
  
Low MAL < 2.5  

10° wrist extension at any arc of ROM,
10° extension or abduction of thethumb, extension of at least 2 additional fingers at any joint >0° and <10°

Grade 5At least one of the following:
Low MAL < 2.5 flexion ≥30°
abduction ≥30°
scaption ≥30°

Initiation*of
both flexionand extension

Must be able to either initiate* extensionof the wrist or initiate extension of
one digit

Each movement must be repeated 3 times in 1 minute. Initiation is defined for the purposes of these criteria as
minimal movement (i.e., below the level that can be measured reliably by a goniometer).

Asian J Occup Ther 9: 7–14, 2011

Fig. 1. A splint for assistance of finger extension. A: Motion of theparticipant in grasping an object. B: When the grasping force
weakens, the force of the shape-memory alloy extends the fingers and the object can be released.

body, and a spoon and a pen holder may be affixed to the
Velcro tapes. We also devised self-help devices on objects
used in daily living to allow operation of these items withthe affected hand. These devices include door knob turners, tap turners, drawer straps, terry cloth bath mitt, adaptive cups, and clothes with magnetic buttons.

Design and interventions
The study was designed as a single-blinded multibaseline case series. Before starting training, each participant and the OTR selected three specific goals that theparticipant wanted to achieve in daily life after intense
CIMT. For UAB Grade 4 participants, these goals were
holding a rice bowl, opening and closing a refrigerator,
typing on a keyboard of a personal computer, holding atelephone receiver, opening an umbrella, shooting witha rifle, putting on one’s socks with both hands, putting
on trousers with both hands, holding a cardboard box,
holding on to a strap in an electric train, turning a tap on
and off, using a knife and a fork, carrying a baby in one’sarms, slipping into clothes and holding a cup. For UAB
Grade 5 participants, the goals were holding a shoppingbag, washing one’s body, holding a form when filling it in,raising a flag for a karate referee, holding a wallet, holding a book, holding an umbrella, washing one’s hands,
swinging a golf club, holding a plastic bottle, drying oneself with a bath towel, holding a bag, opening and closing
a door, unrolling a chart with both hands, and walking
with a bag on one’s arm.
Action assignments in the intensive training were
performed with splints. The functional training included
transferring a ball, pegging a board, building blocks, andTanabe H et al.

9Fig. 2. Finger extension splint. (1) Main body, (2) Pen holder, (3)Spoon holder, (4) Golf ball holder, (5) Tennis ball holder, (6)Scoop holder, (7) Video-game controller holder.

shouldering an object; activity of daily living (ADL) andinstrumental activity of daily living (IADL) training included dressing, washing one’s body and turning a door
knob; and applied behavior training included gardening,writing, drawing (painting), playing a video game, wiping a table and sweeping a floor. Participants underwent
six hours of training daily under the supervision of OTRs
with at least six years of involvement in CIMT and many
years of experience. The same OTRs worked with the participants throughout the study.
The training content was set individually to matchthe affected level and character of the participant and thegoals. In action assignments, “shaping” based on operant reward learning (Morris, Taub & Mark, 2006; Taub &Wolf, 1997) was used, with a gradual increase in difficulty
and access. Linguistic feedback including “acclaim” wasgiven only when the training was successful. In addition,
exercise for general use of the affected hand in daily life
(transfer package) (Morris et al., 2006) was performed
twice daily for 20 minutes in the morning and evening.
Since the affected fingers could not be used practically,
the non-affected hand was required for self care suchas eating, going to the bathroom, bathing, dressing, andstanding up, and the mitt was removed for these purposes.
Additionally, since some of the participants required awalking stick or wheelchair for movement, the mitt was
not used during movement due to safety considerations.

Assessments
Independent observers (OTRs not in charge of theCIMT) evaluated the participants on the day before thestart of CIMT (pretreatment), one day after completion of
CIMT (posttreatment), and one month after completionof CIMT (1-mo follow-up). Differences were determined

10

CONSTRAINT-INDUCED MOVEMENT THERAPY

blindly by mixing of participants who received training
other than intense CIMT. Fugl-Meyer assessment (FMA)(Fugl-Meyer et al., 1975) is a method for evaluation ofrecovery of motor function after stroke. This method
is widely used (Bonifer et al., 2005a) and its test-retest
reliability and validity have been verified (Gladstone,
Danells & Black, 2002; Duncan, Propst & Nelson, 1983).
In FMA, the degree and balance of range of motion, pain,
sensation and damage to upper and lower extremities aremeasured. The upper and lower extremity subscales arescored on a 3-point scale from 0 to 2 (0 = cannot perform;
2 = can perform sufficiently). In the present study, only
the upper extremity subscales (perfect score = 66) wereused.
The modified Ashworth scale (MAS) (Bohannon &Smith, 1987) was used as a method with high reliability for quantitative evaluation of the degree of spasticity.
The validity of the MAS has been confirmed specificallyfor the elbow (Gregson et al., 1999). With each patientin the supine position at rest, testing was conducted on
the abductor of the shoulder on the plegic side, flexor of
the elbow, flexor of the wrist, and flexor of the fingers bymobilizing the joint and recording the score based on thequality and degree of resistance. Each joint was scoredon a 6-point scale from 0 (contraction around the joint
and flexion/extension is impossible) to 5 (no increase inmuscle tone). A perfect score in this test was 20.
The Active Range of Motion Test (AROM) is suitable for evaluation of active motor performance (Lin &Sabbahi, 1999). Evaluation was conducted based on thecontents in the “Measurement of Joint Motion: A Guide to
Goniometry” (Norkin & White, 2009). The active rangeof motion from a neutral position was measured for flexion and abduction of the shoulder joint on the plegic side,
flexion and extension of the elbow joint, dorsal flexion of
the wrist and extension of the MP and IP joints of eachfinger and thumb. For extension of the elbow, measurement was started from the 90° flexion extremity position.
The Motor Activity Log (MAL) includes evaluationof 30 common items in ADL and IADL, through scoring of the amount of use (AOU) and quality of movement (QOM) of the upper extremity on the plegic side
based on a questionnaire (Uswatte, Taub, Morris, Vignolo& McCulloch, 2005; Van der Lee, Beckerman, Knol, de
Vet & Bouter, 2004). The MAL has high test-retest reliability and validity. The MAL was modified based on apreceding study (Bowman et al., 2006) to allow evaluation of patients with low finger function of UAB Grade
4 or 5 (MAL grade 5) during CIT. In this modification,
the 20 items of the standard MAL-30 that require good
hand function were altered so that each action assignment
required reduced motion skills.

Statistical analysis
Statistical analysis was performed to examine thehypothesis that significant effects of intense CIMT are
indicated by FMA, MAS, and AROM evaluation of participants of UAB Grade 4 or 5. Differences among pretreatment, posttreatment, and 1-mo follow-up scores for
the FMA, MAS, AROM, and Grade 5 MAL were tested.
Since all test data were normally distributed, repeatedmeasures analysis of variance (ANOVA) was used, followed by multiple comparison using a Tukey post-hoc
test. Calculations were performed in EXSAS ver. 7.5 forWindows and STATCEL ver. 2 for Windows Microsoft
Excel add-in software.

Results
All participants underwent intense CIMT according
to the predetermined protocol. The mean time of use of
the mitt based on self-recorded diaries was 83% of waking
hours. All pretreatment, posttreatment, and 1-mo followup scores are shown in Table 3. The FMA score for upper extremity motion showed significant improvement forparticipants in both Grades 4 and 5. Post hoc analysis indicated significant differences between pre- and posttreatment scores for both grades, and the mean FMA scores
increased by 12.2 and 15.5 (P < 0.01, P < 0.05) for Grades
4 and 5, respectively. The effect was maintained for both
grades at 1-mo follow-up (post vs. 1-mo follow-up: Grade4, P = 0.64; Grade 5, P = 0.94). The MAS scores showeda significant attenuation effect on spasticity for Grades 4
and 5, with post hoc analysis revealing significant differences between pre- and posttreatment scores (Grade 4, P
< 0.01; Grade 5, P < 0.05). The effect was also maintained
at 1-mo follow-up (post vs. 1-mo follow-up: Grade 4, P =0.45; Grade 5, P = 0.92).
There were significant differences between preand posttreatment and between pretreatment and 1-mo
follow-up AROM scores for Grade 4 cases for shoulder
flexion, elbow extension, wrist extension, and finger extension, but only small differences between posttreatment
and 1-mo follow-up scores for these motions. For Grade4, there were also only small differences among pretreatment, posttreatment, and 1-mo follow-up AROM scoresfor shoulder abductor and elbow flexion. For Grade 5cases, there were significant differneces between pre- andposttreatment and between pretreatment and 1-mo follow-up AROM scores for shoulder flexion and abductor,
elbow flexion and extension, but only a small difference
between posttreatment and 1-mo follow-up scores forthese motions. There were only small differences among
pretreatment, posttreatment, and 1-mo follow-up AROM
scores for wrist extension and finger extension in Grade
5 cases. P values for the significant differences in AROM

Tanabe H et al.

Asian J Occup Ther 9: 7–14, 201111

Table 3. Summary of scores for outcome measures
Pretreatment

Posttreatment

1-mo Follow-up

FMA UE score

Measures
Grade 4
Grade 533.1 (6.9)
11.5 (10.0)

45.3 (2.5)**
27.0 (16.7)*

43.6 (2.8)**
27.6 (17.5)*

MAS score

Grade 4
Grade 58.1 (2.0)
7.8 (2.9)

12.1 (1.8)**
11.2 (2.5)*

11.3 (2.3)*
11.3 (2.7)*

Shoulder flexion

Grade 4
Grade 5112.9 (15.2)
38.8 (27.2)

139.3 (18.6)*
103.1 (37.5)**140.0 (18.3)*
103.1 (37.1)**

Shoulder abductor

Grade 4
Grade 596.4 (24.8)
58.1 (12.2)

120.7 (24.6)
80.6 (11.2)**

120.7 (24.7)
80.6 (12.4)**

Elbow flexion

Grade 4
Grade 5116.4 (19.9)
21.9 (15.3)

125.7 (20.1)
48.8 (10.3)**

125.7 (18.4)
46.9 (11.6)**

Elbow extension

Grade 4
Grade 534.3 (11.3)
8.8 (12.5)

56.4 (15.7)*
40.0 (15.8)**

57.1 (15.5)*
41.3 (11.9)**

Wrist extension

Grade 4
Grade 515.7 (3.5)
8.1 (3.7)

31.4 (6.9)**
12.5 (4.6)

31.4 (6.9)**
13.8 (5.2)

Finger extension

Grade 4
Grade 524.3 (3.5)
1.3 (2.3)

54.3 (10.6)**
1.9 (3.7)

52.1 (12.2)**
1.9 (3.7)

Grade 5 MAL AOU Grade 4
Grade 50.6 (0.8)
0.3 (0.5)

2.0 (1.3)**
1.0 (1.2)**

2.1 (1.4)**
1.1 (1.3)**

Grade 5 MAL QOM Grade 4
Grade 50.7 (0.8)
0.3 (0.6)

2.0 (1.3)**
1.1 (1.3)**

2.1 (1.4)**
1.2 (1.4)**

AROM

Values are shown as the mean ± SD ; *P<.05. **P<.01.
Table 4. Effect size (Cohen d) for each post hoc comparison
Pre vs. post

Pre vs. 1-mo

Post vs. 1-mo

FMA UE

MeasureGrade 4 Score
Grade 5 Score

3.34
1.06

3.02
1.17

0.28
0.04

Grade 5 MAL AOU

Grade 4 Score
Grade 5 Score

1.3
0.84

1.36
0.89

0.07
0.07

Grade 5 MAL QOM

Grade 4 Score
Grade 5 Score

1.26
0.84

1.34
0.89

0.12
0.07

scores are given in Table 3.
In the Grade 5 MAL evaluation, the changes in mean
AOU from pre- to posttreatment were 1.4 and 0.7 for
Grades 4 and 5, respectively. Post hoc analysis revealed
significant differences between pre- and posttreatment
and between pretreatment and 1-mo follow-up for Grades
4 and 5 (both P < 0.01). There were only small differences between posttreatment and 1-mo follow-up scoresfor Grades 4 and 5, indicating that AOU was maintained
at 1-mo follow-up (post vs. 1-mo follow-up: Grade 4, P
= 0.48; Grade 5, P = 0.46). The MAL evaluation showeda significant effect of CIMT on QOM, with changes inmean values of QOM from pre- to posttreatment of 1.3
and 0.8 for Grades 4 and 5, respectively. Post hoc analysis showed significant differences between pre- and posttreatment and between pretreatment and 1-mo follow-up
for Grades 4 and 5 (both P < 0.01). There were only small
differences between posttreatment and 1-mo follow-up

scores for Grades 4 and 5 (post vs. 1-mo follow-up: Grade4, P = 0.24; Grade 5, P = 0.45).
A Cohen d test (Cohen, 1988) was used for post hoc
analysis of pre vs. post, pre vs. 1-mo follow-up, and post
vs. 1-mo follow-up scores, and each effect size was calculated (Table 4). At least two specific goals established by
the participant before starting intense CIT were attained.
The specific goals included actions not requiring active
finger extension.

Discussion
In this study, we verified the efficacy of intense
CIMT for severely affected hands that did not meet theusual indication for CIMT. All participants had an intervalof at least one year after stroke, and rehabilitation specialists had judged that motor dysfunction would be maintained. However, our results showed that intense CIMT

12CONSTRAINT-INDUCED MOVEMENT THERAPY

for severely affected hands of UAB Grades 4 and 5 is aneffective regimen that can improve affected-side upper
extremity functions in the chronic phase and increase theactive use of paralyzed hands, with maintenance of theseeffects for at least a month after CIMT.

Functional outcome measures
The mean FMA score for the upper extremity in
Grade 4 participants improved by 12.2 from pre- to posttreatment, and the effect size was 3.34. This result compares favorably with the effect sizes of 1.03 in Page et al.
(Page, Levine & Hill, 2007), with UAB Grade 2 as theindicator, and of 0.62 in Bonifer et al. (Bonifer, Anderson& Arciniegas, 2005a), with UAB Grade 3 as the indicator.
The mean FMA score in Grade 5 participants improvedby 15.5 from pre- to post-treatment, and the effect size
was 1.06, similar to that in Page (Page, Levine, Leonard,
Szaflarski & Kissela, 2008).
The MAS results showed that intervention with intense CIMT significantly attenuated spasticity for Grades
4 and 5, and that the effect was maintained for at least one
month. The mean pretreatment score for all participants
was approximately 2/point, equivalent to spasticity, andshowed an increase in muscle tone for almost all rangesof motion. Intensive training with repeat grasping/releasing with an affected hand with strong spasticity and notallowing extension may strengthen spasticity. However,using a splint to assist extension of the fingers in intensive
training may attenuate spasticity of the fingers and wrist.
The AROM results showed that intervention withintense CIMT significantly improved shoulder flexion,
elbow extension, wrist extension and finger extension for
Grade 4 cases, but did not improve shoulder abductionand elbow flexion. The combination of joint motions thatshowed improvement has a different pattern from that of
the flexor cooperative motion of the upper extremity/handof the affected side. Thus, it seems that the intervention
subdivided motions in Grade 4 cases. In Grade 5 cases,
improvement occurred only in the proximal parts of theupper extremity at the shoulder and elbow joints, while
wrist extension and finger extension in the distal parts
were not improved. This is important for determining indication criteria for therapy for finger and wrist extension,
since the result suggest that UAB Grade 4 is the lower
limit of the indication for intense CIMT to increase practical use of affected hands in daily life.
The results of Grade 5 MAL indicated that intense
CIMT significantly improved the AOU and QOM of theaffected hand in daily life for cases of Grades 4 and 5.
In a study of CIMT in patients of UAB Grades 2–4 withtraumatic brain injury in the chronic phase (Shaw et al.,2005), the effect size between pre- and post-treatment
AOU was 1.4 for Grade 4 cases, which is almost the sameas the value of 1.3 in our Grade 4 participants. In Grade 5
MAL evaluation of CIMT, the effect size between pre- andpost-treatment is considered to be significant and may be
simpler and larger compared with that of standard MAL.
The subjects who participated in CIMT had specific goals
that might have motivated them to use their plegic hands.
Placing devices on items for achieving specific goals to
make them easier to use may also be beneficial for improving use of an affected hand in the real world.

Constraint of non-affected hands
Our recommended time for which non-affected
hands were constrained with mitts was over 80% of waking hours. In general CIMT, constraint for 90% of waking hours is used for cases of Grades 1–3, but in intense
CIMT in patients of Grades 4 and 5, eating and standing
up are not possible with the affected hand, and 80% is thepractical upper limit. Several reports (Taub et al., 1999;
Taub & Wolf, 1997) have shown that constraint of nonaffected hands is not important among the elements of
CIMT. Therefore, we believe that the reduced constraint
time in this study did not influence the effects of CIT.
Splints
Since participants with a severely affected hand withlittle or no extension of the fingers and thumb cannot
grasp items, it was difficult for them to conduct the action assignments for intensive training for six hours eachday. This may be one of the reasons why severely affected
hands have previously been excluded from CIMT. However, in the present study, by using a splint to assist finger extension, the participants were able to fasten, pinch,
grasp, rotate, and release items, and to draw, write, andstrike in the same way as participants meeting the common indication criteria for CIMT. Therefore, they wereconsidered to have undergone effective treatment for theaffected extremity. Since these splints may be made easily
and inexpensively, they can be widely used in a variety ofrehabilitation settings.

Study Limitations
It is difficult for CIMT participants with little or no
extension of the fingers and thumb to undergo intensive
training involving repeated manipulation of items withthe affected hand. Therefore, to make the intensive training effective for such participants, combined use of traditional rehabilitation techniques with a therapist’s hands
and therapy utilizing splints and self-help devices was
performed. This is a disadvantage since it increases thecost of CIMT. Furthermore, since splints and self-help
devices have their own therapeutic effects on affected
hands, their use might bias the results of the tested effects

Asian J Occup Ther 9: 7–14, 2011of CIT. In addition, the sample size in this study was relatively small and further investigation is needed to verify
the findings in the general population.

Conclusion
The results of the study suggest that intense CIMT
for severely affected hands with little or no extension of
the fingers and thumbs improves the functions of the affected-side upper extremity, despite the hand not meeting
the indication criteria for conventional CIMT. However,for a hand with no finger extension, the finger function
was unchanged and functional recovery of the hand to thepoint that it could be used practically was not found, despite increased assistive use of the hand in daily life. We
conclude that there is a need to develop CIMT further forseverely affected hands and to enlarge the indication for
CIMT.
Acknowledgments: We would like to thank Michi Mitsuda, Hisako Sakaguchi, Hiroki Ogasawara and Fumio
Ochi for their help and advice with this work.

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■ORIGINAL ARTICLE
Community-based Interventional Programmes for
Family Caregivers of Persons with Traumatic
Brain Injury
Yusuke Suzuki, OTR, MS1, 2, Rumi Tanemura, OTR, PhD3
1 Faculty of Health Sciences, Kobe University Graduate School of Health Sciences
2 Department of Rehabilitation, Kinki University School of Medicine

3 Faculty of Health Sciences, Kobe University Graduate School of Health Sciences

Abstract: The purpose of this study is to verify the effects of interventional programmes to reduce the psychological distressof family caregivers of persons with traumatic brain injury. An interventional programme was conducted over five sessions
which were held for four hours and took place once a week, involving a total of 16 persons. The interventional programme
mainly consisted of providing basic knowledge of traumatic brain injury, ways of treating cognitive dysfunction and training of communication skills applying assertiveness training. Evaluation criteria were GHQ-30, SDS, STAI, and RAS as
assessment measures and were analysed before and after the intervention and at three month and six month follow-ups after
the interventional programme. A considerable reduction of the mean score was statistically recognised compared with SDS
at pre-intervention and after the six month follow-up, and STAI at pre-intervention and post-intervention in the analysis ofvariance of pre- and post-intervention and follow-ups.
Key words: traumatic brain injury, family interventions, communication skills training, assertiveness training for family(Asian J Occup Ther 9: 15–22, 2011)

Introduction
Cognitive dysfunction caused by traumatic brain injury affects the ability to respond to and process information, memory, attention, and stimulus of patients (Lezak,
2004). Among patients with traumatic brain injury, someexhibit neurobehavioral changes such as aggressivenessand self-centeredness and have difficulty performing
daily living and social activities. Furthermore, aggressive
language and behaviour are said to worsen, whereas otherdisability indexes improve over time (Brooks, Campsie,
Symington, Beattie & McKinlay, 1987). Family members
are confused by such changes in patients with traumaticbrain injury and feel the burden of their care. Hall et al.
(1994) indicate that the behavioural factors which cause
family caregivers of persons with traumatic brain injury toexperience the burden are those such as severe emotional outbursts, self-centeredness, slowness, forgetfulness
Received: 4 July 2011, Accepted: 26 November 2011
Corresponding to: Yusuke Suzuki, Department of Rehabilitation,
Kinki University School of Medicine, 377-2 Ohnohigashi, Osakasayama-city, Osaka 589-8511, Japane-mail: yusukesuzuki2011@yahoo.co.jp©2011 Japanese Association of Occupational Therapists

and aggressiveness. In addition, Kreutzer, Gervasio, andCamplair (1994a) report behaviour problems and emotional and personality disturbances as behavioural factors(Kreutzer, Marwitz & Kepler, 1992), while Brooks and
McKinlay (1983) report personality change as a factor.
Moreover, evidence has been accumulated fromrecent decades of research that most family caregivers
have psychological distress such as depression and anxiety caused by the neurobehavioral change of patientswith traumatic brain injury (Perlesz, Kinsella & Crowe,1999). Despite this evidence, both domestic and international, few intervention studies have been conducted toreduce the psychological distress of family caregivers of
persons with traumatic brain injury (Boschen, Gargaro,Gan, Gerber & Brandys, 2007). Previous international
studies have been trying to reduce the psychological distress of family caregivers through interventions such as
information instruction on cognitive dysfunction (Sanguinetti & Catanzaro, 1987), behaviour management programmes (Carnevale, Anselmi, Busichio & Millis, 2002),
stress management programmes (Singer et al., 1994) andproblem-solving training (Rivera, Elliott, Berry & Grant,
2008). However, methodology problems have been reported, such as most of the preceding studies using as-16Community-based Interventional Programmes for Family Caregivers of Persons with TBI

sessment measures which are not effectively standardized, and information is lacking regarding the contents of
the interventions (Sinnakaruppan, Downey & Morrison,2005). On the other hand, the authors’ prior study (Suzuki& Motomura, 2009) showed brain contusion patients’emotional and behavioural changes, such as Shouting
out loudly with anger and Violent behaviour, were undermining the family caregivers’ mental health. Also, theauthors’ clinical experience indicated that family caregivers are struggling with communication with patients whoare experiencing emotional and behavioural changes dueto the offensive behavior cannot be helped or the need
to be quietly patient without saying anything because awarning might adversely promote anger. Kreutzer, Gervasio, and Camplair (1994b) in research using The Family Assessment Device (FAD) point out communication
problems between primary caregivers and patients by referring to primary caregivers who could not frankly andclearly express their thoughts and feelings, and in someinstances expressed anger and aggressiveness toward
patients. Therefore, we conducted communication skills
training applying assertiveness training as a communication method to express oneself without anxiety and tried
to reduce the psychological distress of family caregivers.
The concept of assertiveness originated in the USA andis a communication skill used to express oneself withoutanxiety based on maintaining one’s own opinions while
respecting the opinions of others (Alberti & Emmons,
2008). The assertiveness training method was originallyestablished for persons with psychosocial problems (Riley & McCranie, 1990). Recent studies of occupations
with high stress have been carried out (Johnson, 1993;
Kilkus, 1993), and assertiveness training is used as partof interpersonal effectiveness training in Japan (Suzuki,
Kanoya, Katsuki & Sato, 2007).

Aims
The purpose of this study is to verify the effect of
an interventional programme which uses communication
skills training as a core, applying assertiveness training inorder to reduce psychological distress of family caregivers of persons with traumatic brain injury.

MethodSubjects
The participants were recruited from family members (240 related members) of persons with traumaticbrain injury within the Kinki area of Japan. Preconditions
for joining were: (1) a patient treated for traumatic brain
injury; (2) a feeling of difficulty communicating with thepatient; and (3) the ability to participate in the entire interventional programme schedule. Moreover, the numberof candidates was limited to 20 persons in total (10 persons at each meeting site) because the interventional programme consisted of communication skills training withrole-playing. After a three-month period from the start ofrecruitment, we received 16 applicants and all of the 16
applicants fulfilled the preconditions. We randomly divided the 16 applicants in half, allocating them to Kobe andOsaka sites, and conducted the interventional programme.
This study was approved by the ethics committee of Kobe
University Graduate School of Health Science (Date of
approval, December 8th, 2009).

Assessment measures
The following assessment measures were used forevaluation of the degree of psychological distress and assertiveness of family caregivers.
1. The General Health Questionnaire-30 (GHQ-30)(Goldberg, 1978)
This is an assessment measure consisting of 30 items
in a self-administered questionnaire. It is a screening device for clarifying the mental health status of the respondent. Higher scores indicate lower mental health. The
GHQ-30 Japanese version was used (Nakagawa & Obo,1985).
2. Self-rating Depression Scale (SDS) (Zung, 1965)
This is an assessment measure consisting of 20 items
in a self-administered questionnaire to examine depression in the respondent. Higher total scores indicate greater
depression. SDS Japanese version was used (Fukuda &Kobayashi, 1983).
3. Stated-Trait Anxiety Inventory (STAI) (Spielberger,
Gorsuch & Lushene, 1970)
This is an assessment measure consisting of 40 items
in a self-administered questionnaire. 20 items pertain toStated Anxiety, which examines how the patient feels at
the moment moment’ and 20 items pertain to Trait Anxiety, which inquires about the general feeling of the subject. Higher total scores indicate greater anxiety. STAIJapanese version was used (Mizuguchi, Shimonaka &Nakasato, 1991).
4. Rathus Assertiveness Schedule (RAS) (Rathus, 1973)
RAS is an assessment measure consisting of 30 items
assessing assertiveness. In this study, we followed the
RAS scoring method. Each item is scored from –3 to +3
excluding 0. +3 means very characteristic of me, or extremely descriptive and –3 means very uncharacteristic ofme, or extremely non-descriptive. The scale ranges from–90 (least assertive) to +90 (most assertive). The higher
the score the more assertive the respondentis. RAS is
multipurpose and has been widely utilized including assertiveness training in adolescent character development
enhancement programs for high school students (Kessler,
Ibrahim & Kahn, 1986), the effect of assertiveness train-

Asian J Occup Ther 9: 15–22, 2011

ing for sociophobic patients (Cottraux, Mollard & Defayolle, 1982) and a study of anxiety and assertiveness in therelatives of alcoholics (Schuckit, 1982). It is possible touse RAS in the field of Health and Welfare. The reliability
and validity of RAS has been verified by several researchers (Linehan & Walker, 1983; McCartan & Hargie, 1990).
RAS Japanese version was used (Shimizu et al. 2003).

Procedure
The participants were explained the purpose andmethod of the study, and consent to participate in thisstudy was granted. The descriptive information regarding
the participants and the patients with traumatic brain injury was collected and confirmed, and we received answers
to the assessment measures of GHQ-30, SDS, STAI, andRAS which was set as the pre-intervention variable. We
conducted the interventional programme a total of fivetimes, once weekly, for four hours each time. After thefifth session, we once again received answers to the assessment measures and set this as the post-intervention
variable. At three months and six months after finishingthe interventional programme, we mailed assessment
measures to the participants as follow-up variables. After
finishing the interventional programme at the Kobe site,
we conducted an interventional programme of exactly thesame content and frequency for the participants of the
Osaka site. All of the participants participated in the entire interventional programme schedule and replied to allof the assessment measures.
Interventional programme
The interventional programme was mainly structured
as Basic knowledge of traumatic brain injury, Methods forcoping with cognitive dysfunction and Communication
skills training. The operation of the interventional programme was directed by occupational therapists including the author who were schooled in assertiveness training and well-experienced in the rehabilitation of traumaticbrain injury patients. Two occupational therapists assistedwith the operation of the interventional programme during each session.
1. Basic knowledge of traumatic brain injury
We provided basic information regarding disturbance of attention, memory disturbance, dysexecutive behaviour, and emotional and behavioural changes.
2. Methods for coping with cognitive dysfunction
We provided various coping strategies to family
caregivers for the above cognitive dysfunctions, including errorless learning for memory disturbance. Errorlesslearning allows patients to store information effectively,
and immediately correct mistakes when the patient islearning. Memory aids adaptation. We explained how toboth adapt memory aids to the needs of the patient, andSuzuki Y et al.

17

improve them according to the patients’ conditions. With
regard to emotional and behavioural changes, referring to“Assessment and management of behaviour problems associated with traumatic brain injury” by Ponsford, Sloan,
and Snow (1995), a method of responding to problematicbahavior ofpatients utilizing 6 factors was exlained: Environmental arrangement, positive enhancement, time out,
passive attitude, supportive attitude and records. Environmental arrangement acts to eliminate environmental factors which tend to induce problematic behaviour. Positiveenhancement provides a bonus, encourages, praises, andnotices when good behaviour is performed. Time-out has
the participant ignore the problematic behaviour when it
does not stop, leave the room, and isolate the patient. In
Passive attitude criticising, blaming, and pushing or prodding must be absolutely avoided. In Supportive attitude
always maintain support for the family member. (f) Regarding Records a record of problematic behaviour must
be maintained in each case.
3. Communication skills training
Assertiveness training followed the standard guidelines and principles suggested by the authors on assertiveness (Alberti & Emmons, 2008). We explained the basis
and information of assertiveness training by distributing
written information on the subject. Role-playing of assertive behaviour was practiced through coaching and demonstration aids by the directors and other participants. The
following roleplay method was suggested to family caregivers to convey their own wants to patients with behaviour
problems stress free, while respecting the other person.
(1) Identify the problem behaviour through explaining
the situation which gives rise to the problem behaviour of the patients.
(2) Present the request and suggestion which the participant carried out regarding the problem behaviour.
(3) Assign participants to the roles of patient and caregiver. The participants provide information on thepatient’s expected response and way of speaking inorder for the role playing member to act easily.
(4) Encourage other participants to observe the roleplay
and provide positive and negative feedback on thefocused the objectives of the request and suggestion,
the ability to voice feelings, and intention to understand the patient.
(5) Revise the request or suggestion based on the participants and leaders discussion of the contents of thefeed-back.
(6) Repeat the roleplay taking into account the revised
request and suggestion methods.

Statistical analyses
SPSS (Statistical Package for Social Sciences v16 forWindows) was used for the statistical analyses. In order to18Community-based Interventional Programmes for Family Caregivers of Persons with TBI

Table 1. Descriptive information of families and patients
Participants
Sex

Age

The family relationshipwith the patients

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

53y
57y
61y
59y
50y
49y
68y
65y
44y
60y
75y
47y
60y
75y
39y
66y

MotherMotherMotherMotherWife
MotherFatherMotherMotherMotherMotherWife
FatherMotherWife
MotherPatients
Length ofcaregiving

No. of others
in homeSex

AgeBarthel
Index

5y
15y
15y
13y
8y
8y
6y
11y
8y
5y
17y
6y
11y
10y
3y
19y

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

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

24y
29y
32y
30y
50y
26y
34y
38y
20y
35y
46y
43y
29y
41y
39y
34y

90
80
60
95
80
95
100
85
65
100
100
90
100
100
60
95

Note. M=Male; F=Female.

study the relationship between assertiveness and psychological distress, we conducted regression analysis basedon setting the pre-intervention GHQ-30, SDS, and STAI
each as dependent variables and RAS as an independent
variable. We also conducted repeated measure analyses ofvariance in order to analyse the variance of variables frompre-intervention, post-intervention, and follow-ups (after
three months and after six months) for verification of theeffect of the interventional programme. If a significant
difference in variance analyses was determined, post-hoc
analyses were performed. Tukey’s honestly significant
difference test was used for multiple comparisons.

Results
Descriptive information of family participants andpatients
Table 1 shows descriptive information of family participants and patients. Family participants consisted oftwo males and 14 females, between 39 and 75 years of age(M=58, SD=10.5), and 13 were parents and three were
spouses. The duration of care giving was between 3 and19 years (M=10, SD=4.7). The number of other persons
living with each family participant and patient was between 0 and 4 persons (M=1.8, SD=1.1), while the numbers of patients living with persons other than the family
participant was 13 males and three females. Their ages
were between 20 and 50 years old (M=34.4, SD=8.2). The
Barthel Index (Mahoney & Barthel, 1965) was used forthe functional evaluation of daily living activities of thepatients. This 10-item assessment tool evaluates physicaldependence in daily living activities. The scoring range of

the Barthel Index is between 0 and 100 points and a higher score indicates a greater independence in daily living
activities. The Barthel Index of the patients was between
60 and 100 points (M=87.2, SD=14.4).

The relationship between assertiveness and psychological distres
A regression equation called SDS=46.5200.240xRAS
was formulated. This regression equation was more significant at p=0.043 than the analysis of variance table,
and the coefficient of regression was also significant at
p=0.043. However, the coefficient of determination R2
was small at 0.262 and too low for prediction accuracy.
Although a multiple regression analysis was conductedusing a forced entry method by entering factors, such as
the length of caregiving and the Barthel Index, whichwere considered to be related ethically, there was no significance at p=0.255 in the analysis variance table, and amultiple regression equation, which could be significant,could not be formulated.
Verification of the effectiveness of the interventional
programme
1) GHQ-30
The mean score for pre-intervention was 12.63(SD=8.38), for post-intervention was 7.88 (SD=7.27),
after the three-month follow-up was 10.81 (SD=8.72)
and after the six-month follow-up was 8.56 (SD=7.77).
Although the mean score for post-intervention decreased
compared to pre-intervention, it increased again after thethree-month follow-up and then again decreased after thesix-month follow-up. There was no significant differenceSuzuki Y et al.

Asian J Occup Ther 9: 15–22, 2011

19

Table 2. Means, SD, and comparison of means―GHQ-30, SDS, STAI, and RAS―pre- and post-intervention and follow-up

GHQ-30SDS

STAI (Stated anxiety)

STAI (Trait anxiety)

RAS

rep ANOVA

M

SD

Pre
Post
Follow-up (3 M)
Follow-up (6 M)

12.63
7.88
10.81
8.56

8.38
7.27
8.72
7.77

Pre
Post
Follow-up (3 M)
Follow-up (6 M)

48.88
44.63
45.19
44.00

8.12
7.26
8.72
9.95

Pre
Post
Follow-up (3 M)
Follow-up (6 M)

52.88
45.69
49.56
49.19

12.18
13.91
14.62
14.73

3.538

0.042

Pre
Post
Follow-up (3 M)
Follow-up (6 M)

55.81
52.94
52.31
53.06

11.65
12.11
16.53
15.40

0.544

0.655

Pre
Post
Follow-up (3 M)
Follow-up (6 M)–10.88
–7.13
–0.56
–8.38

22.86
27.26
35.14
25.65

2.450

0.076

F

p value*

2.217

0.099

2.966

Tukey HSDp value**

Pre―Follow-up (6 M)

0.045

Pre―Post

0.033

0.042

M=Mean; SD=Standard deviation. * repeated measure ANOVA, ** multiple comparison (Tukey HSD).

in the comparison of mean scores (F=2.217, p=0.099) atthe time of measurement (Table 2).
2) SDS
The mean score for pre-intervention was 48.88(SD=8.12), for post-intervention was 44.63 (SD=7.26),
after the three-month follow-up was 45.19 (SD=8.72)
and after the six-month follow-up was 44.00 (SD=9.95).
Although the mean score at post-intervention decreased
compared to pre-intervention, it again increased after thethree-month follow-up and then again decreased after thesix-month follow-up. At the time of measurement, there
was a significant difference (F=2.966, p=0.042) whencomparing the mean scores, and the result of post-hoc
analysis shows that there was a statistically significant decrease (p=0.045) when comparing the mean scores of preintervention and after the six-month follow-up (Table 2).
3) STAI (Stated anxiety)
The mean score for pre-intervention was 52.88(SD=12.18), for post-intervention was 45.69 (SD=13.19),
after the three-month follow-up was 49.56 (SD=14.62)
and after the six-month follow-up was 49.19 (SD=14.73).
Although the mean score at post-intervention decreased
compared to pre-intervention, it increased again after
both follow-ups. There was a significant difference whencomparing the mean scores (F=3.538, p=0.042) at thetime of measurement, and the result of post-hoc analysis
shows that there was a statistically significant decrease(p=0.033) comparing pre-intervention and post-intervention mean scores (Table 2).

4) STAI (Trait anxiety)
The mean score for pre-intervention was 55.81(SD=11.65), for post-intervention was 52.94 (SD=12.22),
after the three-month follow-up was 52.31(SD=16.53),
and after the six-month follow-up was 53.06 (SD=15.40).
Although the mean scores through the time of evaluation
after the three-month follow-up gradually decreased, itagain increased after the six-month follow-up. There wasno significant difference (F=0.544, p=0.655) comparing
the mean scores at the time of measurement (Table 2).
5) RAS
The mean score for pre-intervention was –10.88(SD=22.86), for post-intervention was –7.13 (SD=27.26),
after the three-month follow up was –0.56 (SD=35.14),
and after the six-month follow-up was –8.38 (SD=25.65).
Although the mean scores through the time of evaluation
after the three-month follow-up gradually decreased, itagain increased after the six-months follow-up. There wasno significant difference (F=2.450, p=0.076) comparing
the mean scores at the time of measurement (Table 2).

Exemplification of the result of the interventional
programme
In addition to verification of the effect by statisticalanalysis, we present here an example of the roleplay andprotocol.
(1) Presentation of problematic behaviour: a female
participant (Person A) experienced stress caused by the
behaviour of the patient (the son) who insistently asks her

20Community-based Interventional Programmes for Family Caregivers of Persons with TBI

Table 3. Selected list of participants demands and suggestions used in role-playing· Do not stay up late at night. Go to the bed earlier (between 11 pm and 12 pm).
· Fix your clothing by looking in a mirror after using the toilet.
· I want you to willingly go to see a doctor with no resistance.
· I want you to make sure to put things in their designated places because you forget where you put things.
· I want you to keep promised appointments.
· I want you to keep up a daily routine with regular hours. (I want you to make up a list of your daily schedule.)· I want you not to get angry when I point out a mistake.
· Do not try to come along with me when I go out.
· I would like to refuse when you ask me to take you out. I want to say I cannot do it today.
· I want you not to shout in reaction to small noises around you.
· I want you to speak slowly and calmly.
· I want you to cut down the time you spend playing TV games by even just one hour.
· I want you to stop getting angry when you cannot get into a group circle.

to Listento what has happened today while she was busy
cooking dinner.
(2) Presentation of request and suggestion: Person A
requested that the son Not tell her what has happened during the day while she is cooking dinner.
(3) Role-play: we started the role-play by setting ascene such as cooking dinner.
The cast mate (acting as the son) performed the behaviour of insisting that Person A listen to him based on
information such as the patient’s manner of speaking andthe patient’s anticipated reaction when hearing Person
A’s request and suggestion, and acted out the part of notlistening to Person A. The roleplay became stalled in a
deadlocked situation.
(4) Feedback; other participants gave feed-back suchas advising Person A to talk to the cast mate (acting as theson) in a calmer manner?, and encouraging Person A to
be more honest and forthcoming about her son’s bahavior.
The leader gave feedback to Person A regarding when Person A should make requests of her son that would meet his
cognitive function level, such as ‘‘Can her son remember
her request? ’’ (As her son has memory impairment, there
is a possibility that he might forget Person A’s request.)(5) Modification of request and suggestions; as a result of the discussion of the content of the feedback, Person A modified her request like this. “Until now, I have
not had a chance to tell you that I was having a hard time
when you begged me to listen to you while I was cooking
dinner. Well, I will be able to listen to you after dinner, so
please let me listen to you then when I can be relaxed.”(6) Re-role playing- although the cast mate (acting as
the son) acted out accepting Person A’s request, he added
some improvised dialogue, such as “I am not confident that
I can remember this until tomorrow, ” which took into consideration the son’s memory impairment. Therefore, Person A added the suggestion “Shall we put a written promisenote in the kitchen just in case you forget? ” The cast mate(acting as the son) accepted her suggestion and the role-play ended without them being aggressive to each other.
Person A gave the following feedback after finishing the roleplay: “Although until now I became emotionaland often tended to talk aggressively, by performing theroleplay, I could understand what the other person thought
after the way I had talked to him. I feel like I can actuallypresent my requests and suggestions to my son, starting
tomorrow, after this.” The other participants also gave
their feedbackback based on observing this roleplay. They
indicated that they felt all this time, they had only been
thinking about and speaking for themselves. And they
got a tip on how to present demands and suggestions to apatient. Table 3 shows a selected list of the participants’demands and suggestions used in the roleplays.

Discussion
The purpose of this study was to verify the effectiveness of the interventional programme to reduce psychological distress of family caregivers for persons withtraumatic brain injury. We focused on the problem of communication between family caregivers of persons withtraumatic brain injury and patients with traumatic brain
injury. In this study, the interventional programme consisted primarily of communication skills training throughassertiveness training. As a result, after a six month follow-up, the mean scores of all psychological distress assessment measures were reduced compared to the pre-intervention mean scores. Through statistical analysis, both
SDS, which compared the mean scores between pre-intervention and six months follow-up, and STAI (stated anxiety), which compared the mean scores between pre-intervention and post-intervention, recognised a statisticallysignificant decrease in the mean scores. This indicatesthat the interventional programme relieved the psychological distress (especially depression and anxiety) of
family caregivers of persons with traumatic brain injury.
It is characteristic of the results that although the degree

Suzuki Y et al.

Asian J Occup Ther 9: 15–22, 2011of psychological stress decreased at post-intervention, it
tended to increase again at follow-up. Therefore, the results suggest the necessity of continuous support evenafter finishing the intervention program. We conductedhearings for reference concerning impressions of the interventional programme, and the majority of the participants thought that the interventional programme would
be beneficial for many other family caregivers of persons
with traumatic brain injury. We also asked for continuous
support focussing on each individual participant after finishing the interventional programme. Follow-up counselling for individual participants, including checking how
the material learned from the interventional programme isbeing used in everyday communication with the patient,
will enhance the effect of the interventional programme.
As was indicated in the exemplification of the effect of theinterventional programme, family caregivers who had experienced the interventional programme could objectively
monitor their own past communication with the patient byrecreating everyday communication exchanges between
caregivers and patients through role-playing. This monitoring brought the realization that until now the requests
and suggestions to the patient were one-sided and emotional. Furthermore, the monitoring not only improved
making requests and suggestions through re-role-playing,
it is also surmised that the biggest reason for reducing thepsychological distress of family caregivers is that selfefficacy could be built up when necessary, and that one
could make adjustments in behaviour and thinking. In thisstudy, RAS was adopted to assess levels of assertiveness.
As regression equations could be formulated for pre-intervention RAS and SDS, it is presumed there is a possibility of reducing depression symptoms through assertive
communication. The evidence suggests the need for training communication skills, especially assertiveness training in order to reduce the psychological distress of family
caregivers of persons with traumatic brain injury.
However, although the mean score of RAS increased
until the three- month follow-up, there was no statisticalsignificance at the time of measurement. This suggeststhat a different manner of intervention might be needed
for behaviour modification of assertiveness. However,through RAS we see a degree of self-assertion or a trend
in communication behaviour, and we believe it was meaningful to adapt the assessment measures in this study.

Study limitation
In the methodology of this study, we have adequately
stated the information of the contents of the intervention
by using widely acknowledged assessment measures.
However, this study is limited due to the small sample sizeof only 16 persons. The reason the sample size was small
was due to the fact that the interventional programme was21

to be with participants of intended family caregivers inorder to extract the frank opinions of the participants. That
is to say, patients with traumatic brain injury often need
to be watched by others on a daily basis. Therefore, there
are many cases where the family caregivers cannot leave
home. In order for family caregivers to participate in aninterventional programme like the one in this study, family members other than the participant need to take overwatching the patient. As a result, it was difficult for family
caregivers to participate in the interventional programme.
This suggests the necessity of developing human resources, aid agencies and social support services who can monitor the patients. An additional limitation was that due toethical considerations, there was a lack of a control group.
However, the inclusion of a control group would have led
to a tendency for the group to only answer psychologicalassessment measures a total of four times, including theperiod of six months after the interventional programme,
not only before and after the interventional programme.
Several researchers have pointed out a lack of scientificvalidity for not setting a control group in this and previous
studies (Boschen, Gargaro, Gan, Gerber & Brandys, 2007;
Sinnakaruppan, Downey & Morrison, 2005). This is acommon issue of intervention studies, not only studies offamily caregivers of persons with traumatic brain injury.

Conclusion
This study suggests that an interventional programme focussing on communication skills training applying assertiveness training is effective in reducing thepsychological distress of family caregivers of persons
with traumatic brain injury. However, the results of thisstudy suggest that further research taking into account thelimitations mentioned previously is necessary.
Acknowledgements: We would like to thank all thosecarers who participated in this study. Also, we would liketo thank the Society for Families with Patients with Traumatic Brain Injury which gave us their cooperation when
we were recruiting participants.

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