■ORIGINAL ARTICLE

Effectiveness of the Movable Seat Surface Evaluatedfrom the Difference in the Start Time of Muscle Activity
and Anticipatory Postural Adjustment
Yuji Nakamura1, Shingo Umeda2, Yuta Nakaya3,
Sonomi Nakajima1, Yasuhito Sengoku1
1

Department of Occupational Therapy, School of Health Sciences, Sapporo Medical University
Graduate School of Health Sciences, Sapporo Medical University
3Child support room Miyanosawa
2

Abstract: Objective: To examine the effects of a movable seat surface with forward tilting and forward locomotion
mechanisms from muscle activation time and anticipatory postural adjustment of the trunk and lower limbs in the forward reach task.
Methods: There were 15 healthy adults, and the muscles to be examined were the deltoid muscles, which are the mainmuscles for reach movement, as well as the left and right external oblique muscles, the left and right erector spinae
muscles, and the left and right rectus femoris muscles. The subjects performed a forward reach task using a fixed anda movable seat surface, that was created, and the examiner analyzed the reach time and the start time of each muscle
activity.
Results: The reach time did not differ between the two conditions, but the start time of the erector spinae muscle waslater than that of the other muscles in the movable condition. Anticipatory postural adjustment associated with reachtask was not confirmed.
Conclusion: It was suggested that the movable seat surface enhances the stability of the trunk movement at the beginning of the reach movement and contributes to the reach movement with less sway of the center of gravity.
Keywords: seat surface, reach task, electromyography(Asian J Occup Ther 17: 1−8, 2021)

Introduction
The sitting posture is the central posture in life, andhealthy adults spend a lot of time sitting in their daily
lives. McCrady et al. [1] investigated the time spentsitting on workdays and holidays by healthy adults andreported that they spend 400 minutes or more per day
sitting on holidays. Burton et al. [2] investigated thesitting time at home for middle-aged people in their
40s and 60s and reported that they tend to spend theirleisure time in the sitting position as they get older. It is
speculated that this tendency is more pronounced in the
Received: 25 September 2020, Accepted: 7 October 2020
Corresponding to: Yuji Nakamura, Sapporo Medical University, South
1 West 17, Chuo-ku, Sapporo 060-8556, Japane-mail: yujin@sapmed.ac.jp©2021 Japanese Association of Occupational Therapists

elderly. Wattanapan et al. [3] reported that among stroke
patients, those who were able to acquire a sitting posture
at discharge had high mobility and ability of activities
of daily living. From these studies, we believe thatintervention in the sitting posture of disabled persons
and elderly people who are the target of rehabilitation isespecially important from the viewpoint of life support.
The authors are developing a seating surface thatcan support trunk function even during movement as anintervention in the sitting posture of the subject. Previous studies on reach movements in the sitting posture[4, 5] found that in reach movements exceeding theupper limb length, it was necessary to reach while tilting
forward and flexing the trunk and hip joints, and there
is a possibility that the seat structure that assumes only
static posture maintenance is not sufficient. We aredeveloping a seat surface to assist the original trunk andpelvic movements that occur during the forward reach.

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EFFECTIVENESS OF THE MOVABLE SEAT SURFACE

The feature of this seat surface is that it tilts forward,
and can be moved forward to assist the reach movement
without changing the positional relationship between
the pelvis and the trunk. This seat surface is designed
to move forward with weight load to the front andreturn backward while tilting backward owing to theweight load to the rear. This seat surface may assist in
the movement of the upper limb. This is because it tilts
forward to assist the tilting movements of the pelvis andlower parts of the trunk. It also moves forward to help
the trunk tilt forward and rotate.
In a co-author’s study using this movable seatsurface for healthy adults [6], it was possible to performforward reach with less anterior tilts and rotation of
the trunk than the normal seat surface. In addition, it
was clarified that the muscle activity of the external
oblique muscle in the first half of the reach and that of
the erectus spinal column muscle in the latter half of thereach were less than those of the normal seating surface.
Due to such characteristics of muscle activity, this seatsurface may be effective for subjects with weakened
trunk function. However, since this study focused on the
total amount of muscle activity after the start of reachmovement, it was not sufficient to evaluate the posturalcontrol required for the sitting-reach movement.
Sufficient postural control ability is indispensablefor the performance of voluntary movements [7, 8], andthe strategy including anticipatory postural adjustments(APA) that act functionally prior to movement is important. It is said that this APA has a role of minimizing
the sway of the center of gravity caused by movements[9], and in the temporal phase, it is often divided from
200 msec before the start of movement to 50 msec after
the start of movement [10]. Shimura et al. [11] investigated the relationship between exercise speed and APA
appearance time in healthy adults. As a result, when theweight is attached to the upper limb in the standing position and the upper limb is lifted, the movement speedof the upper limb decreases, and the start time of biceps
femoris activity is delayed relative to the deltoid muscle,
which is the main muscle of movement. In addition,
Sadeghi et al. [12] verified the APA of the trunk andlower limbs in patients with and without chronic LBP.
The task was to raise the upper limbs in the standing
position. As a result, APA of the transversus abdominismuscle and oblique abdominal muscle was confirmed inthose without back pain, and the gastrocnemius muscle
was confirmed in patients with back pain. It is possiblethat the difference in the exercise strategy when raising
the arms between the two groups may have an effect.
Thus, it has been reported that APA that precedes
the activity of the main muscle movement is confirmedin voluntary movements such as reach movements of

the upper limbs, and its appearance is influenced by the
movement speed and individual movement strategies.
However, these have been studied in a standing positionin which body sway due to movement is likely to occur.
The movable seat surface we made this time has a backrest, and the specifications are such that the movement
starts from the state where the back of the subject is
attached to the backrest. Therefore, it is expected thatthe posture using this movable seat surface will notcollapse, but studies to examine the timing of muscle
activity start in the reach task in such a sitting posture
have not been sufficiently conducted. The purpose ofthis study is to clarify the effectiveness of the movable
seat surface from the viewpoint of the timing of the startof muscle activity, including APA.

Method
1. Subjects
The subjects were 15 healthy adults in their 10 s to
30s. The average age, height, weight, BMI, upper limb
length, and leg length of the subjects were: 22.5 ± 2.7
years old, 171.9 ± 5.2 cm, 60.4 ± 9.0 kg, 20.4 ± 2.5, 73.5
± 3.2 cm, and 44.9 ± 3.1 cm, respectively. All the subjects were right-handed, so the right side was the reachside. We included participants with a standardized BMI(18.5–25) and no orthopedic, ophthalmologic, otolaryngological, or neurological history. Excluded were those
with: BMI exceeding the standard value, back pain,
musculoskeletal disease that impaired reach movement,
and those who were unable to follow the explanation.
2. Experimental preparation and equipment
2-1. Surface EMG
EMG was measured using TELEMYO DTS EM-801(Noraxon), a transmitter (EMG probe) was attached tothe derived muscle, and the sampling frequency was
set to 1000 Hz and the filter characteristic was set to
15 to 500 Hz. The electrodes were made of silver, andthe distance between the electrodes was 2 cm. The
measurement region of muscle activity was disinfectedwith alcohol, skin resistance was reduced with a skinpretreatment agent, and the electrode was attached tothe body with a seal. The lead-out muscles are the:anterior deltoid fibers on the reach side, which act as themain muscles of the reach movement, external obliquemuscles that are the trunk flexors, lumbar spine erectorsthat are the trunk extensors, and thigh straight muscles
that are the hip flexors. The left and right muscles were
measured except for the deltoid muscle. The electrodeattachment region of the deltoid muscle was placed on
the line connecting the acromion and thumb, one lateralfinger distal from the anterior acromion, referring to a

Nakamura Y et al.

Asian J Occup Ther 17: 1−8, 2021

3

Touch light
130% of upper limb length

WEB camera

Seat Surface
EMG measuring device (wireless type)

Supplementary platform

Figure 1 Experimental environment
Fig. 1. Experimental environment.
The WEBcameraplacedthe achievement
the reachmovement
The WEBcamerawas
was placed
so sothatthat
the achievementof the reachof
movement
could
be confirmed.could be confirmed.
The seatsurfaceproduced
produced does
not moveshown asin thefigure under
fixed
conditions,but under
conditions
it tilts
forwardand movesconditions it tilts
The seatsurfacedoes
not asmove
shown
in thefigureunder
fixedmovableconditions,
but
under
movableforward.
forward and moves forward.

previous study [13]. Similarly, the erector of the lumbar
spinal column is located 2–3 cm outside the spinous
process along the fiber run in the abdominal muscle. The
external oblique muscle is located below the outer sideof the 8th rib, along the run of the muscle fiber, and therectus femoris was placed 10% proximal from the centerof the line connecting the anterior iliac spine and theupper part of the patella.
2-2. Movement task
The movement task was a forward-reach task.
Figure 1 shows the experimental environment and thearrangement of the measuring instruments. The starting
posture and the method of performing the reach movement were based on previous research [14]. Specifically,
the starting limb position was seated with the backresting on the back, the foot was grounded on the floor
with ankle dorsiflexion of 0°, and the hand on the reachside was held on the thigh. Reaching was performed by
the subject's dominant hand, and the upper limbs on the
opposite side of the reach were kept in a comfortable
position on the body side so as not to affect the sitting
posture. The subject reached a switch connected to asensor light at the level of the acromion at 130% of thelength of the upper limb and reached a free speed toreturn to the starting posture. After sufficient practice,
the reach movement was performed 5 times in this trial,
but to clarify the breaks for each trial, after returning to
the starting posture, resting for 3 seconds was followedby the next trial. Afterwards, the seat surface condition

was changed, and the task was repeated.
2-3. Seat surface and experimental conditions
In this study, we used a seat made by the co-author(Fig. 2). The size of the seat surface is 40 cm in width ×
41 cm in depth, and the seat back angle is 95°, which isthe same as that of a general wheelchair. It has a spring
structure under the chair, and when the user moves his/her weight backward while sitting down, the spring
contracts, the seat surface tilts up to 4° and stops. When
the weight is moved from the buttocks to the feet, theelastic force of the spring works, the seat surface leansforward up to 8.7°, its midpoint moves forward by 6.5
cm and moves upward by 3.5 cm. Previous studies [15]reported that tilting the chair forward by 10° or more
has little benefit to subjective sitting comfort and spinal
muscle activity, especially in the elderly. As we expectedthat the seating surface we created in this study will be
used by elderly people in the future, we set the forwardtilt angle to 10° or less. The spring under the chair has
a hydraulic damper mechanism; therefore, the moving
speed of the seat surface is almost constant both forward
and backward.
The experimental conditions were fixed and movable. The seat surface angle at the beginning of theexperiment was 4° backward tilt, which is the angle
used in general wheelchairs in both conditions. The seatheight was adjusted to 4 cm below the length of thelower leg [16]. Under the fixed backward tilt condition,
it does not move as it is, and under the movable condi-

4

EFFECTIVENESS OF THE MOVABLE SEAT SURFACE

a.

b．

c.

Seat back angle: 95 degrees
Seat tilt angle: 4 degrees

Seat back angle: 95 degrees
Seat forward tilt angle: 8.7 degrees

Figure 2 Seat surface and movable range
Fig. 2. Seat surface and movable range.
(a) is a photo of the movable seat surface used. (b) and (c) are diagrams that schematically show the movable seat surface, and (b)Fig.
is astarting
photo oftheofmovableseat
surface conditions.
used. Fig. b(c)andis cthe
arestate
diagrams
that schematicallyshow the movable
is athestate
fixed andmovableof maximum
forward tilting.
seat surface, and b is the starting state of fixed and movable conditions.
Fig. c is the state of maximum forward tilting.

tion, the seat tilts forward and moves forward within theabove range.
3. Data analysis
Three trials between the 1st and 5th trials were adopted as trials for data analysis. We measured the timingof the muscle activity start and reach time when thesubject underwent a reach task under fixed and movableconditions. In this study, we analyzed data from the startof the operation to touching the target. The start point of
the reach movement was the timing when the activity of
the anterior deltoid muscle fiber was observed. Moreover, the timing of touching the target object was judged
from the blinking of the sensor light on the WEB camerathat was shooting the sagittal plane. From these times,
the reach time for each subject was analyzed.
Data analysis of muscle activity was performed
using Myo Muscle Master (Noraxon). The analysis was
performed after rectifying all the waveforms to be analyzed, referring to a previous study [17]. The definitionof the onset of muscle activity refers to the method of
Dean et al. [16]; use the average amplitude when restingfor 10 seconds as the baseline, and when muscle activity
was over 3SD of baseline and continued 25 ms or more.

Using the obtained activity start time of each muscle,other muscle activity start times were calculated when
the activity start time of the right deltoid anterior fiber,
which is the main motion muscle, was set to 0 s.
4. Statistics
Comparing the reach time and the start time ofmuscle activity in the reach task obtained under fixed
and movable conditions. As for the statistical processing
method, we performed a paired t-test for the difference
in reach time between conditions and the differencein activity start time for each muscle, and if normality
is not recognized, the Wilcoxon signed-rank test was
performed. A one-way ANOVA was performed todetermine the difference in muscle activity start time
between conditions, and a post-hoc test was performedby the Sidak method when a significant main effectwas observed. Friedman’s test was used for non-normal
distribution, and a post-hoc test was performed using
the Wilcoxon signed-rank test when a significant main
effect was observed. However, the significance level
was modified by Bonferroni correction. The significancelevel was set at 0.05. IBM SPSS Statistics 25 was used
for analysis.

Nakamura Y et al.

Asian J Occup Ther 17: 1−8, 2021

2.5

5. Ethics
This study was carried out with the approval of the
Sapporo Medical University Ethics Committee (approval
number 24-2-33).

2

Result2. Start time of muscle activity
Figure 4 shows the other muscle activity start times(s) when the deltoid muscle activity start time is 0 s, inorder from the earliest activity start time. Under fixed
conditions, in order from the earliest, start time was 0.14
± 0.24 for the right external oblique muscle, 0.36 ± 0.64
for the left external oblique muscle, 0.58 ± 0.39 for theright spinal erector, 0.58 ± 0.43 for the left erector, 0.30
± 0.41 for the right rectus femoris, and 0.26 ± 0.21 forthe left rectus femoris. As a result of statistical processing, no significant difference was found in the muscle
activity start time within the conditions. No APA wasconfirmed to appear between 200 ms before the start ofexercise and 50 ms after the start.

sec

1.5

1. Reach time
Figure 3 shows the reach time from the start of thedeltoid muscle activity until the sensor light is touched.
It was 1.57 ± 0.42 seconds under fixed conditions and1.64 ± 0.40 seconds under movable conditions. As aresult of statistical processing, no significant difference
was found.

1

0.5

0

Fixed condition

Movable condition

Fig. 3. Reach time under each condition.
Figure 3

Reach time under each condition

Similarly, under the movable condition, in orderfrom the earliest, the start time (sec) of muscle activation was 0.22 ± 0.36 for the right external obliquemuscle, 0.21 ± 0.14 for the left external oblique muscle,
0.79 ± 0.49 for the right spinal erector, 0.89 ± 0.52 forthe left spinal muscle, 0.17 ± 0.22 for the right rectus
femoris, and 0.39 ± 0.20 for the left rectus femoris. As
a result of statistical processing, a significant difference
*

1.6

**

1.4

*

1.2
1

sec

5

0.8
0.6

0.4
0.2
0
-0.2

**

-0.4

EO

RF

RF

EO

（Rt）

(Lt）

(Rt）

(Lt） （Rt） （Lt）

ES

ES

RF

EO

（Rt） (Lt）

*

**

EO

RF

(Rt）

(Lt） （Rt） （Lt）

＊p < 0.05

Fixed condition

ES

ES＊＊p＜0.01

Movable condition

Fig. 4. Start time of muscle activity under each condition.
In each condition, the activity start time of each muscle is shown when the activity start time of the anterior fiber of the rightdeltoid muscle is 0 s. The positive direction means that the activity start time is later than that of the anterior deltoid fiber.
EO, external obliqueES, erector
RF, rectusactivity
femoris. under each condition
Figuremuscle;
4 Starttimespinae;of muscle
In each condition, the activity start time of each muscle is shown when the activity start time of the anterior fiber of the right deltoid muscle is 0 s.
The positive direction means that the activity start time is later than WKDWRIWKHDQWHULRUGHOWRLGILEHUEO, external oblique muscle; ES, erector spinae; RF, rectus femoris.

6

EFFECTIVENESS OF THE MOVABLE SEAT SURFACE

was found within the conditions (F5,48 = 2.439, p < 0.05).
As a result of the analysis of variance, the erection of
the right spinal column was significantly later than thatof the right external oblique muscle and the right rectus
femoris ( p < 0.05, p < 0.01, respectively). In addition,
the erectors of the left spinal column had a significantly
later onset time than the right external oblique, left
external oblique, and right rectus femoris muscles ( p< 0.01, p < 0.05, p < 0.01, respectively). No APA wasconfirmed to appear between 200 ms before the start ofexercise and 50 ms after the start.
Furthermore, when the same muscles were compared between the fixed and movable conditions, a significant difference was observed only in the left erector
spinae muscle, and a delay in the activity start time wasconfirmed under the movable conditions ( p < 0.05).

Discussion
In this study, we examined the effectiveness ofthe movable seat surface from the reach time and thestart time of muscle activity in healthy adults. As aresult, there was no significant difference in reach time
between the fixed seat surface and the movable seat surface. Analysis of the muscle activity start time showedthat there was no significant difference in the activity
start time of each muscle on the fixed seat surface, andthe activity was started from the right external obliquemuscle. On the movable seat surface, it was confirmedthat the activity of the left and right erector spinae muscles was delayed compared to the abdominal obliquemuscle and the rectus femoris muscle, and the activity
was started from the right rectus femoris muscle. Fromthese results, it was shown that there is no differencein the time required to perform the reach task, but the
movement strategies may differ between the two seatsurfaces.
1. Appearance of APA
In the movement strategy, APA, which is thought tooccur with voluntary movement, could not be confirmed
within the phase of −200 ms to +50 ms in this study.
This may be related to the seat surface specifications
under the fixed and movable conditions used in thisstudy.
APA was first reported in 1967 by Belen’kiĭ et al.
[9]. They state that when the upper limbs are raised as
quickly as possible in the standing position, the muscle
activity of the biceps femoris on the ipsilateral sideand the erector spinae muscle on the contralateral side
was confirmed before the main motion muscles. Thisis considered to play a role in compensating for the
instability of the body caused by voluntary movement.

Since this research, the frequency of APA occurrence
and changes in related muscle activity mainly due toexercise load in a standing position have been studied[11, 12, 18]. Although there are few studies on APA in
the sitting position, Bigongiari et al. [19] investigated
APA in ball-grabbing motion in a sitting position where
the back and sole of the foot were not grounded inhealthy children. As a result, it has been reported that
posture control ability develops with age and increases
the amount of APA activity. Thus, APA, which acts as
posture control, has been studied in a standing or sitting
posture in which the back and sole do not touch theground. In comparison with these studies, in the present
study, the purpose is to adapt the movable seat surface
to the elderly and subjects with movement disorders in
the future. So, it has started that the reach task is started
when the back is attached to the back and the sole of thefoot is grounded on the floor. This may lead to less swayof the center of gravity associated with forward reach,and APA associated with reach may not have been confirmed.
2. Start time of muscle activity
Among the muscle activities involved in posturalcontrol, the comparison of the start time of other muscle
activities with respect to the main motion muscle revealed a difference in the movement strategy between
fixed and movable conditions. That is, under the fixed
condition, the activity was started from the external
oblique muscle on the reach side, and under the movable condition, the activity was started from the rectus
femoris muscle on the reach side. In the movablecondition, the left and right erector spinae muscles
were activated later than the external oblique and rectus
femoris muscles. It is considered that this is because
the movable seat surface supports the movement of thetrunk in the reach task. Kamisaki et al. [5] performed
a forward reach task at a distance that can be reachedonly by the upper limbs, a distance that can be reachedusing the trunk and upper limbs, and a distance of 33%
and 66% between those distances. As a result, hip flexion was hardly seen at the upper limb length, but at all
distances beyond the upper limb length, the hip flexion
angle increased with increasing reach distance and theanterior tilt of the trunk increased. In addition, in a study
by Nakaya et al. [6], a collaborative researcher who
performed muscle activity and motion analysis using thesame seat surface as in this study, the movable seat surface has less activity in the external oblique muscles atthe beginning of movement in the first half of the reachthan the fixed seat surface, and less forward tilting androtation of the trunk. As described above, the movable
seat surface used mainly assisted the anterior tilting ofNakamura Y et al.

Asian J Occup Ther 17: 1−8, 2021

the trunk necessary for the forward reach movement andcould contribute to the reduction of the muscle activity
amount and the movable range at that time. Furthermore,this time, from the timing of muscle activity start, in thereach task, as shown in the fixed condition, the trunkis flexed by the activity of the external oblique muscle,
the erector spine erector, which is an antagonist muscle,
works almost simultaneously with the flexion of thetrunk and hip joints, and the simultaneous contraction of
the trunk is maintained. On the other hand, by using the
movable seat surface, it assists the anterior movementof the trunk to increase the stability at the beginning of
movement of the trunk. Spine upright muscle activity
may have been delayed relative to the oblique and rectus
femoris muscles. The same reason is considered that
only the contralateral erector spinae muscle was significantly delayed in the comparison between the conditions. In addition, six subjects were asked about the easeof movement under each condition in five stages of “veryeasy to move, easy to move, neither, hard to move,and very difficult to move.” All respondents answered,“easy to move” on the movable seat surface, but under
fixed conditions, 1 responded “difficult to move” and 5
responded “neither” From this, the movable seat surface
is a seat surface that subjectively feels easy to move,and there is a possibility that it is a seat surface that iseasy to reach in terms of muscle activity, start time ofmuscle activity, and movement strategy as seen frommotion analysis. Under the movable conditions, while
the stability of the trunk was maintained, it was necessary to load the seat forward while keeping the sole andbuttocks in contact with the ground to operate the seatsurface. Therefore, it is possible that the rectus femorismuscle acted first and prioritized the flexion of the hip
joint. It is necessary to verify how much muscle activity
is required to operate the movable seat surface in the
future.
In addition, the delay in the onset time of erector
spinae muscle activity, which was shown this time, isan important finding when considering adaptation to theelderly and persons with disabilities who have an imbalance in muscle tone. Yokoyama et al. [20] investigated
the sagittal plane angle of the spine with age, and thethoracic spine entrance angle, thoracic kyphosis, andC2–C7 sagittal vertical axis increased and the roundspine posture increased with age from late middle age.
It is known that such spinal deformity leads to deterioration of ADL ability and motor function, and shortens
the functional reach distance [21]. In the case of such a
subject, it may be difficult to make the trunk extension
motion under fixed conditions confirmed this time.
In addition, in subjects with central nervous systemdisorders such as cerebral palsy, it is often clinically7experienced that trunk extension activity easily affects
the whole-body extension pattern due to abnormal
muscle tone. That is, for such a subject, the movable
seat surface that may delay the extension activity of the
spinal column may support movement while avoiding
excessive effort and posture collapse at the start of thereach movement.

Conclusion
In this research, we showed the effectiveness of the
movable seat surface for healthy adults and the future
clinical application from the difference in start time ofmuscle activity. Since support for the trunk function of
the subject is often static, we consider that the effectof dynamic support, including wheelchairs and seating
system devices that match body movements is a necessary research theme. To verify the effect of the movable
seat surface prepared this time, it is necessary to clarify
not only the reach task but also the daily activities suchas eating and writing on the subject. In addition because
the movable seat surface used this time was designed sothat it moves due to body weight movement, it is necessary for the subject to have a certain level of motor function. Therefore, we would like to study the mechanism,
direction, and degree of seat movement in the future.

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

Acknowledgements
We would like to thank Editage (www.editage.com)
for English language editing.

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[20] Yokoyama K, Kawanishi M, Yamada M, Tanaka H, Ito Y,
Kawabata S, et al. Age-related variations in global spinalalignment and sagittal balance in asymptomatic Japanese
adults. Neurol Res. 2017; 39(5): 414–8.
[21] Katzman WB, Sellmeyer DE, Stewart AL, Wanek L,
Hamel KA. Changes in flexed posture, musculoskeletal
impairments, and physical performance after groupexercise in community-dwelling older women. Arch Phys
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■ORIGINAL ARTICLE

Factors Associated with the Frequency of
Doing Domestic Chores After Mild to Moderate Stroke
Kohei Kusuda1, Rumi Tanemura2
1
2

Kyoto Min-Iren Asukai Hospital
Kobe University

Abstract: Background: While many studies research factors that affect Instrumental Activities of Daily Living after
stroke, few studies research factors that affect domestic chores after stroke. This study aims to investigate factors that
affect domestic chores after stroke.
Methods: In this cohort study, 29 stroke patients were followed from the time they entered the rehabilitation ward to
one month after discharge. Participants were included if they had been independently doing domestic chores before
stroke onset and were independently walking inside the hospital after stroke onset. Variables were selected from demographics, physical function, cognitive function, psychological function, and functioning. The Spearman correlation
between the domestic chores score of the Frenchay Activities Index (FAI) after stroke and variables was calculated.
Results: The Timed Up and Go test (r = 0.41, p = 0.03), the Stroke Self-Efficacy Questionnaire (r = 0.54, p < 0.01) andthe Functional Independence Measure motor domain (r = 0.57, p < 0.01) were significantly associated with the domestic chores domain of the FAI. Unlike previous studies, cognitive function and depression also didn’t show a statistical
relationship with domestic chores after stroke.
Conclusion: Our results show that stroke patients should improve their self-efficacy to resume domestic chores after
stroke, in addition to physical and cognitive functions. The results are also consistent with previous studies about the
research relationship between self-efficacy and functioning.
Keywords: Stroke, domestic chores, IADL, self-efficacy, balance ability(Asian J Occup Ther 17: 9−16, 2021)

1. Introduction
Stroke is a main cause of mortality [1] and the leading cause of adult long-term disability in industrializedcountries [2]. Despite the decreasing incidence rate,
better survival rates are expected to lead to increased
prevalence rate and the need for efficient rehabilitationand healthcare policies for patients with stroke [3].
In describing activities of daily living (ADL) as ameasure of long-term outcome of stroke, it is important
to distinguish between basic ADL (BADL) and instrumental ADL (IADL) [4]. BADL are self-maintenanceskills, such as bathing, dressing, and toileting. In thisstudy, IADL refer to more complex activities, including
Received: 10 January 2020, Accepted: 16 September 2020
Corresponding to: Kohei Kusuda, Kyoto Min-Iren Asukai Hospital,
Kyoto, Kyoto Japane-mail: ten5peace@yahoo.co.jp©2021 Japanese Association of Occupational Therapists

domestic chores, social activities, and gainful work [5].
Because IADL are activities that typically must be
performed by the stroke survivor to continue living in
the community [6], it will be difficult to predict whether
patients can resume IADL or domestic chores while
they are hospitalized. Among IADL, “domestic chores”
is the area where occupational therapy support is needed
for independent living [7]. Walsh et al. [8] found that
two-thirds of stroke survivors need help with domestic
chores up to five years after stroke. Besides, domestic
chores are affected by various factors such as mobility,
cognitive function, family support, and lifestyle [9], andstroke patients may be unable to resume the domestic
chores that they performed before.
The International Classification of Functioning,
Disability, and Health (ICF) defined preparing meals
and doing housework as domestic chores [10]. Studies
in Japan have defined preparing meals, cleaning, washing clothes, and shopping as items of domestic chores
because these activities support living [11]. According

10

FACTORS ASSOCIATED WITH THE DOMESTIC CHORES AFTER STROKE

to the Statistics Bureau of Japan 2017 [12], these are thefollowing characteristics regarding the implementation
time for housework among Japanese individuals; women
spend more time doing housework than men in all ages;
women spend less time doing housework after 65 yearsof age, while men spend more time doing housework
after 65 years of age; people living with a partner spend
more time doing housework than people living alone.
There are two types of IADL assessment tool. One
assesses the patient’s ability to perform IADL, e.g., theLawton scale, and the other assesses the frequency atwhich IADL is performed, e.g., the Frenchay Activities
Index (FAI). We chose FAI as the assessment tool for
IADL and domestic chores as it assesses the frequency
at which patients perform IADL, which provides amotr correct reflection of daily living than the tool thatassesses the patient’s ability to perform IADL.
IADL generally require higher physical functions,such as walking abilities [3, 9, 13], balance abilities [13],cognitive functions such as memory [14], executivefunction [9, 15], and psychological function such as
self-efficacy [13, 16]. Conversely, IADL is negatively
affected by paralyzed limb function [17], cognitive dysfunction [15], and depression [15, 18]. As stated, while
several studies analyzed factors that affect IADL after
stroke, only few studies evaluated the factors affecting
domestic chores after stroke. Moreover, these studies
use tools that assess the patient’s ability to perform
IADL, and few studies use the tools that assess the frequency at which patients perform IADL. Therefore, thisstudy aimed to clarify the factors that affect frequencyof doing domestic chores after stroke. In this study, domestic chores include preparing meals, washing dishes,
washing clothes, cleaning, and shopping.

2 Materials and Methods
2.1 Participants
The dataset utilized in this study was acquired between 2015 and 2018 from the rehabilitation ward. All
participants were patients with first-time stroke (cerebral
infraction, cerebral hemorrhage, or subarachnoid hemorrhage). Other inclusion criteria were as follows: First,
the patients were independent in walking in the hospital.
In the current study, this was defined by an FIM score of
6 or 7 in the walking domain, indicating that participants
were included if they used a stick or orthosis. Second,
they had been independent in domestic chores before
stroke onset. In the current study, this was defined by
FAI score of 15 in the domestic chores domain, indicating that they had usually done preparing meals, washingdishes, washing clothes, cleaning, and shopping before
stroke onset. Patients were excluded if they had severe

hyper-brain dysfunction, such as aphasia, apraxia, andunilateral spatial neglect, or other serious conditions
other than stroke that could affect the study outcome.
All participants underwent a 60–180-min supervised
rehabilitation program daily while they were in the rehabilitation ward. The program consisted of physical andoccupational therapies for all participants and speechtherapy if needed. In addition to individual rehabilitation, they underwent walking practice that was tailored
to individual abilities with a nurse or caregiver. After
hospital discharge, they used a home help service orrehabilitation as needed.
2.2 Procedure
The researcher approached individuals who met theinclusion criteria during hospitalization and we included
them as the participants. A written informed consent was
obtained from the participants. Demographic data andclinical characteristics were collected from the medical
records of our hospital. Other outcome measures except
for post-stroke FAI, including the subscale of domestic
chores, were assessed during the hospitalization. The
assessment time of these outcome measures were thefinal assessment before they were discharged fromthe hospital. Pre-stroke FAI and subscale of domestic
chores were assessed by retrospectively recalling theperformance of domestic chores and other IADL before
stroke onset. Post-stroke FAI and subscale of domestic
chores were assessed by face-to-face interviews at theirresidence post discharge (1 month) from the hospital.
Ethical approval was provided by the researchers’ host
university and written consent was obtained from allparticipants.
2.3 Outcome measures
2.3.1 Functioning
2.3.1.1 Basic activities of daily living
BADL was assessed using the Functional Independence Measure (FIM) [19]. FIM is an 18-item, 7-level
scale that was developed to assess the functional independence of patients with neurological impairments.
FIM consists of the motor domain (FIM-M) and cognitive domain (FIM-C). FIM-M includes 13 items related
to ADL, and the total score is 91 points. Moreover,
FIM-C includes 5 items associated with communicationand socialization.
2.3.1.2 Instrumental activities of daily living
IADL was measured using FAI [20]. It comprises
15 items (preparing meals, washing dishes and clothes,cleaning, local shopping, heavy housework, social
outings, walking outdoors, active hobby, driving a car/traveling on bus, outing/car rides, gardening, household

Asian J Occup Ther 17: 9−16, 2021

and/or car maintenance, reading books, gainful work),
and each item was scored from 0 to 3. In the FAI, thefrequency of each activity is assessed; the higher thefrequency of the item, the higher is the score. The FAI
consists of a single summary score, ranging from 0(inactive) to 45 (highly active). Previous studies showedthat the FAI is a valid, reliable, and sensitive measureof social activity and IADL in patients with stroke [21,22]. The FAI was developed to provide information on
the level of activities observed before and after stroke[21]. Pre- and post-stroke FAI were assessed to show
the levels of premorbid and post-stroke activities. Prestroke FAI and both pre- and post- stroke performanceof domestic chores in the FAI were used as variables.
2.3.1.3 Domestic chores
In this study, we defined preparing meals, washingdishes, washing clothes, cleaning, and local shopping as
domestic chores in the items of the FAI. Preparing meals
and washing clothes are scored three points if performed
most days in a week, and the other items are scoredthree points if performed at least weekly.
2.3.2 Demographic data and clinical characteristics ofstrokeInformation on sex, age, and number of family
members was obtained as demographic data. For clinicalcharacteristics of stroke, data on the etiology, stroke
type, and affected hemisphere were collected.
2.3.3 Physical function
Balance ability was assessed using the Berg Balance Scale (BBS) and Timed Up and Go (TUG) test.
The BBS is a 14-item measure of balance and risk forfalls in older adults through direct observation on a scaleof 0 (inability to complete the task) to 4 (independenttask completion) [23]. The TUG test was developed toevaluate functional mobility of frail elderly individuals
and measure mobility speed [24]. The participants sat
down in a chair and then were timed with a stopwatch
to determine how quickly they could stand up and walk
3 m, turn a corner, walk back, and sit down again. The
severity of paralysis was assessed using the Stroke
Impairment Assessment Set – motor function (SIAS-M).
The SIAS includes 22 items based on nine types ofdysfunction. Each item could be scored as 3 or 5 points.
SIAS-M includes 5 items that assess abilities of affectedarms and legs, with a total score 25 points.
2.3.4 Cognitive function
Attention was assessed using the Trail Making Test
parts A and B (TMT-A and TMT-B, respectively) and
WAIS-III subtest of the symbol digit substitution test

Kusuda K et al.

11(SDMT). In TMT-A, the respondent is instructed to connect randomly arranged circles containing numbers from
1 to 25 following the number sequence and perform it as
quickly as possible. The task in TMT-B is similar to thatin TMT-A, but the respondent has to alternate numbers
and letters. In the SDMT, a coding key showed nine
abstract symbols, each paired with a number. Below
the key, a series of symbols were presented, and theparticipants were asked to write down the corresponding
numbers as quickly as possible. The number of correct
substitutions in a 120-s interval was used as the score.
Executive function was assessed using the Tower ofHanoi (TOH) and Behavioral Assessment of the Dysexecutive Syndrome Dysexecutive Questionnaire (BADSDEX). The TOH consists of a wooden structure with arectangular base with three evenly spaced pegs and several wooden discs. BADS-DEX includes a 20-item questionnaire on executive-type behavioral problems. Each
item is scored on a scale of 0 (not at all) to 4 (always),and the maximum score is 80 points. The higher thescore, the stronger the trend of dysexecutive function.
Memory was assessed using the Rivermead Behavioral
Memory Test (RBMT). The RBMT is designed to tap
the participant’s memory in performing daily tasks. The
RBMT assesses different types of memory, such as associative memory, prospective memory, visual memory,
verbal memory, topographic memory, control, and recognition strategies [25]. RBMT produces a global scorefrom 0 to 24 points.
2.3.5 Psychological function
Depression was assessed using the self-rated, 15item, Geriatric Depression Scale (GDS). The GDS includes 15 items on depression, asked over several weeks.
Subjects answer each question with “Yes” or “No,” andscores on the GDS range from 0 to 15. A score < 5indicates no depression, a score from 5 to 10 indicatessuspected depression, and a score > 10 indicates probable depression. The GDS is a reliable and valid selfrating depression screening scale for older individuals
and stroke survivors [26]. Self-efficacy was assessedusing the 13-item Stroke Self-Efficacy Questionnaire(SSEQ). SSEQ was developed by Jones et al. [27]. This
self-report questionnaire comprises 13 items regarding
common functional tasks (e.g., getting comfortablein bed, walking, and dressing) and self-management(e.g., coping with frustration of the consequences ofstroke). Subjects answer each question between 0 (notat all confident) and 10 (extremely confident), and total
scores range from 0 to 130. The SSEQ has face validity,
excellent internal consistency (Cronbach alpha, .90),
and criterion validity with the Falls Efficacy Scale [28](Table 1).

12

FACTORS ASSOCIATED WITH THE DOMESTIC CHORES AFTER STROKE

Table 1 List of outcome measures
Demographics

Age, Sex, Family

Clinical characteristics
Physical function

Cognitive function

Pshychological function

FunctioningaStroke type, Affected hemisphere,
severity of paralysis

Stroke Impairment Assessment Set (SIAS-M)

balance ability

Berg Balance Scale (BBS), Timed up and Go Test (TUG)

attention

Trail Making Test A and B (TMT-A and TMT-B)
Symbol Digit Substitution Test (SDMT)

executive function

Tower of Hanoi (ToH),
Dysexecutive Syndrome Dysexecutive Questionnaire (BADS-DEX)

memoryRevermed Behaviral Memory Test (RBMT)

depression

Geriatric Depression Scale-15 (GDS-15)

self efficacy

Stroke Self Efficacy Questionnaire (SSEQ)

ADL

Functional Independence Measure (FIM)

IADL

Frenchay Activities Index (FAI)bca; collected from the medical records of our hospital, b; assessed during the participants were in the hospital, c; Pre-stroke FAI wasassessed by retrospectively recalling the performance before stroke onset. Post-stroke FAI was assessed by face-to-face interviews intheir home 1 month after discharge from the hospital.

2.4 Statistical analyses
All analyses of data were conducted using R 3-5-0
software. A significance level of .05 was established.
Descriptive statistics were used to describe the demographic data of age, sex, and family. The stroke characteristics included stroke type, affected hemisphere,score in the National Institute of Health Stroke Scale(NIHSS) at onset, assessment time from onset, functioning, and other outcomes. The post-stroke FAI score ofeach item of the domestic chores domain was presented.
To investigate the relationship between post-stroke
scores of domestic chores domain and other variables,
the Spearman’s rank-order correlation was used.

3 Results
Twenty-nine participants were enrolled in thisstudy. The mean age of participants was 72.5 ± 7.8
years, ranging from 57 to 86 years. Seven participants(24.1%) were male. Moreover, 16 participants (55.2%)
had cerebral infarction, 10 (34.5%) had cerebral hemorrhage, and 3 (10.3%) had subarachnoid hemorrhage. The
right hemisphere was affected in 12 participants (41.4%),
while the left hemisphere was affected in 16 participants(55.2%). The median NIHSS score at stroke onset was
5.5 (3–11.3), and the FIM summary score upon hospitaldischarge was 121 (117–123). This indicated that participants were mild to moderate stroke survivors, and their
independence rate of ADL was relatively high (Table 2).
The proportion of participants rating themselves at
the highest level of actual participation was 58.6% for

Table 2 Description of demographic data, stroke characteristics andpre- and post- stroke FAI summary score of participants (n =29)
Demographic data
Age (years)
Sex - Male (n)Family - Living alone (n)72.5 ± 7.8
7 (24.1%)
22 (75.9%)

Stroke characteristics
Stroke type - Cerebral Infarction (n)- Cerebral Hemorrhage (n)- Subarachnoid Hemorrhage (n)Affected hemisphere - Right (n)- Left (n)- Middle (n)NIHSS score at stroke onset
Assessment time from stroke onset (days)

16 (55.2%)
10 (34.5%)
3 (10.3%)
12 (41.4%)
16 (55.2%)
1 ( 3.4%)
5.5 (3–11.3)
121.6 ± 62.3

Functioning
FIM summary score at discharge from the hospital
FIM-M score at discharege from the hospital
FIM-C score at discharge from the hospital
pre-stroke FAI summary scorepost-stroke FAI summary score

121 (117–123)
88 (85–90)
33 (31–35)
32 (29–34.3)
23 (15.5–27)

Values given as mean ± SD for ratio scale and median (Q1–Q3) for
ordinal scale and n (%) for normal data NIHSS, National Institute of
Health Stroke Scale; FIM, Functional Independence Measure; FIM-M,
FIM motor domain; FIM-C, FIM cognitive domain; FAI, Frenchay
Activities Index

preparing meals, 65.5% for local shopping, 69.0% forcleaning, and 82.8% for washing dishes and clothes. In
contrast, the proportion of participants who never participated in these activities was 27.6% for preparing meals,
24.1% for cleaning and local shopping, and 13.8% forKusuda K et al.

Asian J Occup Ther 17: 9−16, 2021

13

Table 3 The post-stroke score of each item of the domestic chores domain of the FAI (n = 29)
Median (Q1–Q3): 13 (9–15)
min-max: 0–15

Preparing meals
Washing dishes

Washing clothes
Cleaning
Local Shopping

Never

Under once weekly

1–2 times a week

Most days

8 (27.6%)
4 (13.8%)

2 (6.9%)0 (0.0%)2 (6.9%)1 (3.4%)17 (58.6%)
24 (82.8%)

Never

1–2 times in 3months

3–12 times in 3months

At least weekly

4 (13.8%)
7 (24.1%)
7 (24.1%)

1 (3.4%)2 (6.9%)2 (6.9%)0 (0.0%)0 (0.0%)1 (3.4%)24 (82.8%)
20 (69.0%)
19 (65.5%)

Values given as n (%)

washing dishes and clothes (Table 3).
The average SIAS-M score was 22.9 ± 4.2. The
FIM-M score was 86.9 ± 3.9, and pre-stroke FAI score
was 31.5 ± 3.7. The TUG test (r = 0.41, p = 0.03), SSES(r = 0.54, p < 0.01), and FIM-M (r = 0.57, p < 0.01)
results were significantly associated with the domestic
chores domain of the FAI. The SIAS-M (r = 0.36, p =0.06), TMT-B (r = −0.34, p = 0.07), TOH (r = 0.35,
p = 0.08), BADS-DEX (r = −0.37, p = 0.07), and RBMT
(r = 0.37, p = 0.06) scores had a mild but insignificant
association the domain (| r | > 0.3). Other outcome measures were not significantly associated with the domestic
chores domain of the FAI (Table 4). Of the 29 participants, two were missing data for TUG, one for SDMT,
three for ToH, four for BADS-dex, three for RBMT, one
for GDS-15, and one for SSEQ.

4 Discussion
The current study investigated post-stroke frequency of domestic chores using the FAI. By using a criterionof pre-stroke score of domestic chores domains on FAI
was the maximum. We also investigated the participant’s
demographics, clinical characteristics, physical function,
cognitive function, psychological function, and pre- andpost-stroke functioning and their relationship to the frequency of post-stroke domestic chores. The strengths of
our study are as follows: First, because our participants
had been independent of domestic chores before stroke
onset, we could analyze the impact of stroke on domestic chores purely. Second, it is easy, accurate, or precise
to consider the influence of each factor by focusing on“domestic chores” in various IADL.
Blomgren et al. [4] investigated IADL in 237 young
and middle-aged stroke survivors using FAI, with theproportion of participants rating themselves at the highest level of actual participation from a low of 43.9% forpreparing meals to a high of 81.9% for local shopping.
Our sample shows a similar trend for preparing meals.

This implies that preparing meals was the most difficult
to resume for patients with stroke in the domestic chores
domain. This is because preparing meals is a complex
activity that needs high cognitive functions, such as executive function [14] and practical balance ability, compared to washing dishes, washing clothes, and cleaning.
Clearly, preparing meals is important for independent
living [29] and an individual’s sense of life satisfaction[30]. In contrast, washing dishes and washing clothes
were activities that can be resumed after stroke. This implies that interventions for washing dishes and washingclothes are relatively easy to improve the independenceof domestic chores after stroke.
The median FIM-M score of our sample was 88,
but pre- and post-stroke median FAI scores were 32 and23, respectively. This indicates that IADL can decrease
despite full independence in BADL, as measured by the
FIM. In a previous study, Edwards et al. [31] investigated stroke-related symptoms in patients with mild stroke.
The results showed that, although 95% of participants
had FIM scores of 110, approximately 40% and 35%
reported problems on social integration and household
management, respectively. There are several studies thatshowed similar results on ADL and IADL of patientswith stroke [32]. Despite the difference in the assessment tools between this and previous studies, our results
highlight the importance of assessment of IADL inpatients with stroke, particularly those who can perform
ADL independently.
The results of this study showed that the TUG test(r = −0.41, p < 0.01), SSEQ (r = 0.54, p < 0.01), and
FIM-M (r = 0.57, p < 0.01) scores were significantly
associated with frequency of domestic chores. The
TUG test evaluates gait and balance performance [33].
Because the TUG test can be performed easily, it can beused as a screening tool for reflecting domestic chores
after stroke. The concept of self-efficacy is describedas the confidence in one’s ability to perform a task or
specific behavior. Thus, the strongest way of influencing

14

FACTORS ASSOCIATED WITH THE DOMESTIC CHORES AFTER STROKE

Table 4 Descriptive statisitics and spearman’s correlation with the domain of domestic chores of FAI after
stroke (n = 29)naverage or Median

Spearman’s Correlation

p-value

Demographics
sex - Maleage
family - Living Alone

29
29
29

7 (24.1%)
72.5 (7.8)
22 (75.9%)

0
−0.13
−0.23

1
0.49
0.22

Physical function
SIAS-M (min-max: 0–25)
BBS (min-max: 0–56)
TUG (second)

29
29
27

25 (23–25)
53 (50–55)
11.9 (8.4)

0.36
0.29
−0.41

0.06
0.13
0.03*

29
29
28

193.3 (126.8)
239.1 (129.8)
39 (32–51)

−0.22
−0.34
0.3

0.26
0.07
0.12

26
25

4.5 (2–6)
17 (9–24)

0.35
−0.37

0.08
0.07

26

18 (15–20)

0.37

0.06

Psychological function
GDS-15 (min-max: 0–15)
SSEQ (min-max: 0–130)

28
28

5 (3–8)105 (83.3–117)

−0.07
0.54

0.73
< 0.01*

Functioning
FIM-M (min-max: 13–91)
pre-stroke FAI (min-max: 0–45)

29
29

88 (85–90)
32 (29–34.3)

0.57
0.21

< 0.01*
0.28

Cognitive function
attention
TMT-A (second)
TMT-B (second)
SDMT (min-max: 0–133)
executive function
ToH (min-max: 0–9)
BADS-DEX (min-max: 0–80)
memoryRBMT (min-max: 0–24)*p < 0.05. Values given as mean (SD) for ratio scale and median (Q1-Q3) for ordinal scale and n (%) for normal
data
SIAS-M, the Stroke Impairment Assessment Set Motor function; BBS, the Berg Balance Scale; TUG, the Timed
Up and Go test; TMT-A and TMT-B, the Trail-Making Test part A and B; SDMT, the symbol digit substitution
test; ToH, the Tower of Hanoi; BADS-DEX, the Behavioral Assessment of the Dysexecutive Syndrome Dysexecutive Questionnaire; RBMT, the Rivermead Behavioral Memory Test; GDS-15, the self-rated 15-item GeriatricDepression Scale; SSEQ, the 13-item Stroke Self-Efficacy Questionnaire; FIM-M, the Functional Independence
Measure Motor function; FAI, the Frenchay Activities Index

self-efficacy is a mastery experience through successful
performance of a task [34]. These results imply thatpatients with stroke should improve not only physicalor cognitive function but also self-efficacy to resume
domestic chores after stroke. While participants of thisstudy had a high independence rate of BADL with ahigh FIM-M score, it is still significantly correlated withdomestic chores. This suggests that ADL is the basis ofdomestic chores, and it is important to evaluate BADL
to reflect IADL.
Blomgren et al. showed that stroke survivors who
are older, men, and living with a partner report low
frequencies of performing IADL using FAI. However,in our study, age, sex, and living alone were not associated with domestic chores. This is possibly because
participants of the current study had been independent
in domestic chores before the onset of stroke comparedto those in other studies. Adjustment for pre-stroke
functioning should provide a better insight into possible

mechanisms for such age and sex differences [35].
Unlike previous studies, cognitive function did notshow a statistical relationship with domestic chores after
stroke. Our study found similar trends with those ofprevious studies [36] that executive function or memory,rather than attention, with the more complex tests(TMT-B rather than TMT-A) had associations withdomestic chores, while there were no significant associations between cognitive functions and domestic chores.
In previous studies that examined the patient’s ability toperform IADL, cognitive assessments were performed in
the acute phase [14, 15] and the pre-morbid performanceof IADL was not considered [14–16]. In the current
study, cognitive assessments were performed in the subacute phase where the pre-morbid frequency at which
patients performed IADL was considered in participants
who were mild to moderate stroke patients and had been
independent of domestic chores before the stroke. For
these reasons, the cognitive function of our participantsKusuda K et al.

Asian J Occup Ther 17: 9−16, 2021

did not affect the frequency of domestic chores strongly.
While most previous studies that examined the patient’s ability to perform IADL showed a significant relationship between post-stroke depression and functioning[15, 18], depression was not related to the frequency atwhich patients performed domestic chores in this study.
LeBrasseur et al [18] demonstrated that the GDS scoreof chronic stroke participants living in the community
was significantly associated with the management roledomain (the organization and management of socially)
and without the instrumental role domain (the ability toperform activities in the home and in the community).
The instrumental role domain in their study is similar to
the role of domestic chores in our study. Unlike previous
studies, assessment time of depression and performanceof domestic chores was slightly different in our study.
Besides, our samples showed relatively low median
GDS score of 5 points and the GDS is a dichotomous
measure and was not sufficiently sensitive. Moreover,
we investigated the frequency at which patients performdomestic chores, while previous studies have investigated the patient’s ability to perform domestic chores. As
stated, it is possible that depression was not related todomestic chores in this study.
4.1 Study limitations
The current study has several potential limitations.
Samples were included if they were independent ofwalking after stroke and did not have severe hyper-brain
dysfunction. These inclusion criteria resulted in selection of only patients with mild stroke (FIM-M medianscore, 85) without severe hyper-brain dysfunction. The
sample size was relatively small, and the term from thestroke onset was not consistent. Given the small sample
size, the results from this study provide a preliminary
overview of the relationship between the different possible factors influencing the frequency at which patients
perform domestic chores. Besides the small sample size
made it difficult to use predictive or multivariate models
for assessing the relationship between the possible factors for domestic chores and predictive power of thosefactors.
Future studies should include more participants anduse predictive or multivariate models to look for factors
predicting the frequency at which patients performdomestic chores after stroke. Besides, future studies
should collect acute, sub-acute, and chronic phase dataof stroke patients and conduct longitudinal research to
improve the prediction accuracy.
4.2 Conclusion
We found that balance ability, basic ADL, andself-efficacy were statistically associated with post-15

stroke frequency of domestic chores. Our study extends
these findings to include the domestic chores domain.
Our results imply that stroke patients should improve
not only physical or cognitive function but also selfefficacy to resume domestic chores.

Acknowledgements
We would like to thank all participants of the present study. We would like to thank Editage (www.editage.
com) for English language editing.

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■ORIGINAL ARTICLE

A Concept Analysis of Clinical Reasoning
in Occupational Therapy
Sho Maruyama1, 2, Satoshi Sasada3, Yohei Jinbo4, Peter Bontje5
1

Department of Occupational Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan University
Department of Rehabilitation, Shonan-Keiiku Hospital3
Department of Occupational Therapy, School of Rehabilitation, Kanagawa University of Human Services
4
Department of Occupational Therapy, Chigasaki-Rehabilitation College
5Department of Occupational Therapy, School of Health Science, Tokyo Metropolitan University
2

Abstract: Introduction: Acquiring competence in clinical reasoning is regarded as key to meet the challenges of integrating knowledge into one’s practice. Learners and educators need a shared understanding of what is clinical reasoning because they need appropriate means for reflection and feedback. However, the clinical reasoning concept needs
revisiting in the current context, which is becoming increasingly diverse and complex. The purpose of this study was toanalyse the clinical reasoning concept and develop a common framework.
Methods: Rodgers’ concept analysis was selected for this theoretical study. Accordingly, a systematically search ofmultiple databases yielded 903 articles and 135 articles that met the inclusion criteria were extracted, and of these 30
articles randomly sampled for analysis. Data analysis was done following Rodgers’ method of thematic analysis.
Results: The attributes were four ‘therapeutic thinking processes’ and two ‘professional thinking skills.’ The application
contexts were ‘clinical and non-clinical practice settings,’ and ‘professional education.’ Moreover, the antecedents were
‘professional factors’ and ‘practice factors,’ and the consequences were ‘professional developments’ and ‘professional
attitudes and behaviours.’
Conclusion: The resulting framework of clinical reasoning can be the basis for developing pedagogies and assessmentof clinical reasoning competence acquisition.
Keywords: allied health occupations, clinical competence, clinical reasoning, concept analysis, occupational therapy(Asian J Occup Ther 17: 17−25, 2021)

Introduction
Clinical reasoning (CR) in occupational therapy is acore-ability [1] that occupational therapists and students
develop with clinical experience [2]. Acquiring competence in CR is regarded as key to meet challenges of integrating knowledge into one’s practice in the changing
practice contexts [3]. CR has become key now students
and practitioners need to learn to deal with challenges
such as meeting expectations of clients who are better
informed than in the past; adapting to increasing diversity in the delivery of services and practical contexts
outside the traditional institutional settings; and how to
Received: 6 May 2020, Accepted: 29 September 2020
Corresponding to: Sho Maruyama, Rehabilitation dept., ShonanKeiiku Hospital, 4360 Endo, Fujisawa-city, Kanagawa, Japane-mail: ot1985sho@gmail.com©2021 Japanese Association of Occupational Therapists

master an increasing body of knowledge [4].
However, CR includes tacit knowledge embedded
into the experience of a practice, which is difficult toverbalise and to teach [5]. More recently, educatorsand learners alike started considering CR as an intersubjective process in which educators and learners
co-construct CR [6]. For these reasons, they need ashared understanding of what CR is. Previous studies
attempted to clarify what CR might be and its types
through mainly qualitative researches [5, 7]. However,while scholars have re-conceptualized these understanding, the CR concept has not been sufficiently confirmed,
expanded, or refuted through empirical studies [8].
In addition, Unsworth and Baker [9] argued thatdeveloping a standardized assessment scale is urgently
needed. Developed in the past, the Self-Assessment ofClinical Reasoning and Reflection (SACRR) and theCalifornia Critical Thinking Skills Test (CCTST) were
designed for the assessment of students’ reasoning and18

A CONCEPT ANALYSIS OF CLINICAL REASONING

reflection skills [10, 11]. However, these two scales were
not developed based on the CR concept in occupational
therapy. Also, the items of SACRR and CCTST are limited to scientific reasoning aspects of CR. Since a review
of research literature did not reveal any other assessment
tools, it appears that no valid, reliable assessments of
CR exist [12]. Therefore, in addition to educational reasons, it is necessary to fully establish the recent evolving
understandings in the profession regarding CR the future
development of valid assessment methods [13].
Adding further complexity to this lack of clarity on
how to operationalise and assess CR, some have started
to reframe the concept in terms of professional reasoning and therapeutic reasoning [14, 15]. Professional
reasoning broadens the CR concept to include the reasoning that occurs in non-medical environments, suchas schools and community settings, as well as including
reasoning done by occupational therapy teachers, clinicaleducators, and occupational therapy managers as they
conceptualise their practice [15]. However, despite this
proposed new terminology, research has not progressedon clarifying different features of CR concept. These
evolving insights about the CR concept lend further support to the need to revisit the concept in the context ofcurrent occupational therapy practices that are becoming
more diverse and complex [12]. In this paper, we will
use the term CR, albeit including the professional andtherapeutic reasoning that occurs in the non-traditional
diversifying practice contexts, being mindful of theintersubjective process in which educators and learners
co-construct CR [6].
In conclusion, based on the uncertainties in how
CR is understood, we argue there is a need for analysing
the concept of CR. While CR in occupational therapy
is typified as scientific, narrative, pragmatic, ethical,
interactive, and conditional reasoning [15], there is aneed for developing a common framework that not only
integrates the different types of CR, but one that also explains how CR occurs. Analysing the CR concept is essential, not only for supporting educators and learners in
the development of learners’ CR skills but clarifying theconcept is also fundamental to the future developmentof assessment tools of CR. It is well known that concept
analysis is well suited to such a double challenge [16].
Accordingly, the purposes of this study were to analyse
the concept of CR and to develop a common frameworkthat integrates the different types of CR in occupational
therapy.

Methods
Study design
Rodgers’ concept analysis [17] was selected for thefollowing reasons [18]. First, the assumption of Rogers’
methodology that concepts are dynamic lends itself tounderstanding the concept of CR, which is sensitive totemporal changes [8]. Secondly, Rodgers’ methodology
is an interpretive method and, particularly suited to
study the CR concept, which explains processes taking
place in persons’ minds [5]. Finally, Rodgers’ concept
analysis provides a strategy suited for more fully explaining how concepts occur by identifying and defining
their essential components, antecedents and consequences, and application contexts [16, 17].
Data gathering
Data gathering consisted of systematically searching and screening for relevant literature [17]. Searchterms were ‘occupational therapy,’ and ‘clinical reasoning,’ or surrogate terms of ‘professional reasoning,’‘therapeutic reasoning,’ and ‘narrative reasoning.’ The
searched databases were PubMed, Cumulative Index to
Nursing and Allied Health Literature (CINAHL), Health
Source, SocINDEX, Education Resources Information
Center (ERIC), OTseeker, Ichushi (Japan Medical Abstracts Society), J-STAGE (Japan Science and Technology Agency) and Medical online, using advanced search
processes. The searches spanned the years 1983–2017,
because CR as a concept was introduced into occupational therapy in 1983 [19]. The first author (SM)accessed the databases on October 23, 2017.
Figure 1 shows the flow for identifying and screening extracted papers in line with the PRISMA guidelines[20]. From the 903 studies identified, 504 were omitted
because of double selection. A further 264 papers were
excluded after titles and abstracts were screened for thefollowing criteria: (a) the subject of articles is not CR; (b)not reported by occupational therapists; (c) not related
to occupational therapy practice and education. Rodgers[17] suggests that 20% or about 30 articles of the retrieved literature be included in the sample. Accordingly,
with 135 papers remaining, we randomly sampled 30 by
Excel’s random number table (see Table 1).
Data analysis
Thematic analysis was conducted in the followinginteractive back-and-force process: generating initialcodes, searching for themes, reviewing themes, generating a thematic map of the analysis, and generating
names for each theme [17, 21]. First coding the data wasguided by using the following questions: What are thefeatures of the concept? What factors are preceding theconcept? What are the significant consequences of theconcept? Moreover, what kind of situation and scope
does the concept apply?
Subsequently, we identified (a) attributes and appli-

Maruyama S et al.

Asian J Occup Ther 17: 17−25, 2021

19

Fig. 1. The number of studies identified and screened for concept analysis. Diagram flow refers to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and data gathering methods of Rodgers’ concept analysis.

cation contexts, (b) antecedents, and (c) consequencesof the concept. (a) Attributes and application contexts
comprised of the definition of the concept. (b) Antecedents were multiple conditions, behaviours, or attitudes
that occurred before the concept. (c) Consequences were
events or phenomena that occurred afterwards to theconcept. This phase of analysis was an inductive coding
process of continually organizing and reorganizing data
until a cohesive, comprehensive, and relevant systemof descriptors was generated [17]. MAXQDA 2018
(VERBI) software was used to support the qualitative
data analysis. Besides, to reduce the bias of the authors(SM, YJ, PB) doing the analysis, records of the data
analysis were audited by an author (SS) of this study
team who was not involved in the actual data analysis.

Results
We clarified the attributes, preconditions, results,
and application context of the concept through Rodgers’
concept analysis of the CR literature. The attributes
were four ‘therapeutic thinking processes’ and two‘professional thinking skills,’ the application contexts

were ‘clinical and non-clinical practice settings’ and‘professional education of occupational therapists(pre-qualification and continuing education).’ Moreover,
the antecedents were ‘professional factors’ and ‘practicefactors,’ and the consequents were ‘professional developments’ and ‘professional attitudes and behaviours’ (seeFigure 2). The numbers inserted in brackets in the below
text correspond to numbers of the analysed articles listed
in Table 1.

Attributes
Therapeutic thinking processes‘Therapeutic thinking processes’ were an essenceof CR in occupational therapy, in which occupational
therapy practitioners and students used to organise andsupport clinical thinking [42]. It included the following four therapeutic thinking processes: (a) scientificevidence-driven thinking process, (b) professional ethicsdriven thinking process, (c) practical contexts-driven
thinking process, and (d) client’s narrative-driven thinking process. Practitioners and students used these fourtypes of therapeutic thinking processes together in their

20

A CONCEPT ANALYSIS OF CLINICAL REASONING

Table 1 List of articles included for the analysis[26]

Gee BM, Strickland J, Thompson K, Miller LJ. Exploring the influence of an e-learning sensory processing-based module for graduatelevel occupational therapy students on clinical reasoning: A pilot study. Occupational Therapy International. 2017; 24: 1–8.

[27]

Unsworth C, Baker A. Systematic review of professional reasoning literature in occupational therapy. British Journal of Occupational
Therapy. 2016; 79(1): 5–16.

[28]

Robertson D, Warrender F, Barnard S. The critical occupational therapy practitioner: How to define expertise? Australian Occupational
Therapy Journal. 2015; 62(1): 68–71.

[29]

Shafaroodi N, Kamali M, Parvizy S, Mahraban AH, O’toole G. Factors affecting clinical reasoning of occupational therapists: aqualitative study. Medical Journal of the Islamic Republic of Iran. 2014; 28(19): 50–9.

[30]

Kristensen HK, Borg T, Hounsgaard L. Aspects affecting occupational therapists’ reasoning when implementing research-based evidence
in stroke rehabilitation. Scandinavian Journal of Occupational Therapy. 2012; 19(2): 118–31.

[31]

Parkinson S, Shenfield M, Reece K, Fisher J. Enhancing professional reasoning through the use of evidence-based assessments, robustcase formulations and measurable goals. British Journal of Occupational Therapy. 2011; 74(3): 148–52.

[32]

Coker P. Effects of an experiential learning program on the clinical reasoning and critical thinking skills of occupational therapy students.
Journal of Allied Health. 2010; 39(4): 280–6.

[33]

Mu K, Coppard BM, Bracciano A, Doll J, Matthews A. Fostering cultural competency, clinical reasoning, and leadership throughinternational outreach. Occupational Therapy in Health Care. 2010; 24(1): 74–85.

[34]

Carrier A, Levasseur M, Bedard D, Desrosiers J. Community occupational therapists’ clinical reasoning: identifying tacit knowledge.
Australian Occupational Therapy Journal. 2010; 57(6): 356–65.

[35]

Taylor B, Robertson D, Wiratunga N, Craw S, Mitchell D, Stewart E. Using computer aided case-based reasoning to support clinicalreasoning in community occupational therapy. Computer Methods and Programs in Biomedicine. 2007; 87(2): 170–9.

[36]

Falk-Kessler J, Ciaravino EA. Student reflections as evidence of interactive clinical reasoning skills. Occupational Therapy in HealthCare. 2006; 20(2): 75–88.

[37]

Scaffa ME, Wooster DM. Effects of problem-based learning on clinical reasoning in occupational therapy. The American Journal of
Occupational Therapy. 2004; 58(3): 333–6.

[38]

Mitchell R, Unsworth CA. Role perceptions and clinical reasoning of community health occupational therapists undertaking home visits.
Australian Occupational Therapy Journal. 2004; 51(1): 13–24.

[39]

Leicht SB, Dickerson A. Clinical reasoning, looking back. Occupational Therapy in Health Care. 2002; 14(3–4): 105–30.

[40]

Lyons KD, Crepeau EB. Clinical Reasoning of an Occupational Therapy Assistant. The American Journal of Occupational Therapy.
2001; 55(5): 577–81.

[41]

Gibson D, Velde B, Hoff T, Kvashay D, Manross PL, Moreau V. Clinical reasoning of a novice versus an experienced occupational
therapist: a qualitative study. Occupational Therapy in Health Care. 2000; 12(4): 15–31.

[42]

Neistadt ME. Teaching clinical reasoning as a thinking frame. The American Journal of Occupational Therapy. 1998; 52(3): 221–9.

[43]

Fisher GS. Health care reform, manage care, and clinical reasoning: implications for ethical occupational therapy practice. Occupational
Therapy in Health Care. 1997; 11(1): 27–37.

[44]

Neistadt ME. Teaching strategies for the development of clinical reasoning. The American Journal of Occupational Therapy. 1996; 50(8):676–84.

[45]

Munroe H. Clinical reasoning in community occupational therapy. British Journal of Occupational Therapy. 1996; 59(5): 196–202.

[46]

Alnervik A, Sviden G. On clinical reasoning: patterns of reflection on practice. The Occupational Therapy Journal of Research. 1996;
16(2): 98–110.

[47]

Roberts AE. Clinical reasoning in occupational therapy: Idiosyncrasies in content and process. British Journal of Occupational Therapy.
1996; 59(8): 372–6.

[48]

Creighton C, Dijkers M, Bennett N, Brown K. Reasoning and the art of therapy for spinal cord injury. The American Journal of
Occupational Therapy. 1995; 49(4): 311–17.

[49]

Schell BA, Cervero RM. Clinical reasoning in occupational therapy: An integrative review. The American Journal of Occupational
Therapy. 1993; 47(7): 605–10.

[50]

Burke JP, DePoy E. An emerging view of mastery, excellence, and leadership in occupational therapy practice. The American Journal of
Occupational Therapy. 1991; 45(11): 1027–32.

[51]

Mattingly C. The narrative nature of clinical reasoning. The American Journal of Occupational Therapy. 1991; 45(11): 998–1005.

[52]

Mattingly C. What is clinical reasoning? The American Journal of Occupational Therapy. 1991; 45(11): 979–86.

[53]

Fleming MH. Clinical reasoning in medicine compared with clinical reasoning in occupational therapy. The American Journal of
Occupational Therapy. 1991; 45(11): 988–96.

[54]

Cohn ES. Fieldwork education: Shaping a foundation for clinical reasoning. The American Journal of Occupational Therapy. 1989;
43(4): 240–4.

[55]

Rogers JC. Eleanor Clarke Slagle Lectureship–1983; clinical reasoning: the ethics, science, and art. The American Journal of
Occupational Therapy. 1983; 37(9): 601–16.

Maruyama S et al.

Asian J Occup Ther 17: 17−25, 2021

Fig. 2.

21

Result of concept analysis of clinical reasoning in occupational therapy

daily practice, amounting to complex, multifaceted, anddynamic thinking processes [34, 38].
The scientific evidence-driven thinking process.
Practitioners and students used the scientific evidencedriven thinking process to inform problem-definition,
problem-analysis, and problem-solving in practice [28,49, 53, 55]. This therapeutic thinking process was considered to professionalise occupational therapy practice[49], because it included a logical process based on
hypothesis formulation and testing [55], facilitatedsystematic information gathering and interpretation [53],and selecting the best intervention to address clients’performance problems [42]. The scientific evidencedriven thinking process, conventionally called scientificreasoning, included diagnostic and procedural reasoning
as used in medicine [49, 53]. Also, it was often mainly
relied on by novice practitioners. The scientific evidence-driven thinking process reflected the scientificparadigm of the profession. In the modern occupational
therapy paradigm, practitioners and students focusedon the health condition, activity level/balance, andparticipation in daily occupations and/or occupational
performance of clients [39, 44, 53].
The professional ethics-driven thinking process.
Practitioners and students used the professional ethicsdriven thinking process for focusing not on ‘what could
be done’ in a therapy session, but on ‘what should bedone’ [55] to determine priorities for execution in prac-

tice where a myriad of potential ethical dilemmas exists[43]. They used this therapeutic thinking process tofind solutions when they were challenged with multiple
ongoing and complex issues [43], or when clinical data
contradicted their expectations and experience [43, 54].
A more recent phenomenon, the professional ethicsdriven thinking process was used for decisions of professional ethics, because of changes within the structureof health care service delivery (e.g., the need to a focus
on reducing costs), with competing interests of thehealth care system (e.g., prioritise the care given toclients), right of clients, and complicated choice of treatment (e.g., balance of benefit and risk) [39, 43]. Thus,
the professional ethics-driven thinking process included
dilemma recognition, dilemma analysis, self-monitoring
to given standards and norms, and self-reflection [28].
Finally, it was used by practitioners and students tomanage the influences of their personal contexts (e.g.,values, knowledge, experiences, skills, and routines) [34,39, 42, 49].
The practical contexts-driven thinking process.
Practitioners and students used the practical contextsdriven thinking process to manage the influences ofpractical contexts when considering the therapeutic
possibilities within a given occupational therapy setting[42, 48, 49]. Practical contexts included such aspects astime resources (e.g., time available for therapy sessions,an overall length of therapy programs, a therapist’sschedule), space resources (e.g., physical environment,

22

A CONCEPT ANALYSIS OF CLINICAL REASONING

availability of equipment and tools, client familiarity
with space), and social resources (e.g., social support
network, health care insurance, rules within the facility)[34, 39, 42, 49]. These factors were the starting pointof this thinking process. The practitioners and students
used this therapeutic thinking process to integrateconsiderations of practical contexts into their decisions
about intervention decisions or recommendations toclients [48, 49].
The client’s narrative-driven thinking process. Practitioners and students used the client’s narrative-driven
thinking process when understanding clients as occupational beings and interpreting stories told by clients.
They used this therapeutic thinking process to focus on
the clients’ life story and the meanings of occupations
to clients. The client’s narrative-driven thinking processfacilitated creating prospects for and with clients andoften together with clients’ families [49, 51–53], topromote participation of clients and their families in occupational therapy [49, 53], and to revise interventions
to meet the clients’ needs [42, 44, 46]. In other words,
occupational therapy students and practitioners used thistherapeutic thinking process when they were focused onunderstanding clients’ temporality (their past, present,
and future), client’s subjectivity and inter-subjectivity
between clients and their families [42, 46, 49, 52, 53].
Professional thinking skills‘Professional thinking skills’ of practitioners andstudents were core skills of occupational therapy practice [29, 30], and these skills were composed of (e)individual’s thinking skills and, (f) interactive thinking
skills.
Individuals’ thinking skills. Practitioners and students used one’s individual thinking skills for synthesizing or combining types of therapeutic thinking processes[45, 46, 49], which in the analysed articles were also referred to as mental manipulation or information processing skills [42, 45]. Differences in individuals’ thinking
skills were related to occupational therapists’ accumulation of clinical experience [27, 41, 44], enhancing theirvarious thinking directions (inductive and deductive
approaches) and range, depth, precision, and speedof reasoning [39, 41, 55]. For example, while novice
therapists were able to describe their CR, it appeared
to be confined to the scientific thinking process [41].
Also, students could note clients’ concerns but lacked
an in-depth understanding of how disability had an
impact on the life of individuals [47]. On the other hand,experienced therapists frequently weaved subjective andintersubjective perspectives into their understanding ofclients [47], and they used intuitive thinking and complex reasoning types [39, 41, 45, 53]. Also, experienced
therapists shifted rapidly and effortlessly from one formof CR to another (e.g., scientific to narrative reasoning)[44, 53].
Interactive thinking skills. Practitioners and students
used the interactive thinking skills to plan, conduct andreflect on their practice [26, 50, 52, 55]. The interactive
thinking skill was considered essential to interact withand better understand clients during face to face encounters [50]. It was ‘know-how’ that therapists used in
the conduct of their work and how they derived a ‘best’course of action with a client [38]. For example, experienced practitioners facilitated the delivery of meaningful
occupational therapy experiences for clients throughcommunication and collaboration with clients and otherprofessionals in complex practice situations [35, 39, 42,46]. Establishing these effective relationships were considered crucial to the success of the occupational therapy
process [39, 50]. Besides, this thinking skill was basedon individual knowledge and tacit knowledge, because
it was also based on tacit understanding and habitual
knowledge gained through experience [26, 41, 52].

Application contexts
The CR concept applied to clinical and non-clinical occupational therapy practice settings that include
schools, workplaces, and communities. Practitioners
and students used the CR concept as the language forthe professional education of occupational therapists(pre-qualification education, continuing education). For
example, using a CR-frame to organise clinical observations was an effective way to help entry-level occupational therapy students learn and apply the CR concept[42, 54]. Also, it was said that understanding and articulation of CR were desirable to facilitate the learner andeducator communication and sharing of knowledge [28].
Thus, CR was recognised as having significant implications for occupational therapy practice and education[27, 41, 49]. However, the scope of the CR concept waslimited to occupational therapy for clients as individuals
and groups, but its application to practices for populations was not included in the analysed articles.

Antecedents
Antecedent included professional factors of occupational therapists and practical factors (see Figure 2). The
professional factors included professional education,
occupational therapists’ expertise levels and personal
contexts. Professional education included e-learning,Maruyama S et al.

Asian J Occup Ther 17: 17−25, 2021

experiential learning, and reflections in/on occupational
therapy practice, which enhanced CR skills [26, 32, 36,37]. Expertise levels included the knowledge and use ofknowledge, perceived capability, and accumulated clinical experiences in specific areas [33, 34, 39, 41]. For
example, CR was influenced by individuals’ experiences, which different models of intervention with similar
clients [55]. Expertise levels which related to the clinicalexperience in a specific area, influenced the types of
CR preferred and the depth of understanding [38, 54].
Personal contexts included motivation, self-efficacy,beliefs, values routine, use of theory, and therapists’paradigms/world views [34, 39, 41, 49]. These personal
contexts might affect the specific types of CR used
individually, or of multiple CR types simultaneously[34]. The thinking processes used thus highly reflected
personal contexts [27, 34].
The practical factors included clients’ beliefs andvalues, relationships between clients and occupational
therapy practitioners (or students), and characteristics
of practical realities [29, 34]. Thus, CR was neither
context-free nor value-free because it was influenced
by a wide range of environmental, interpersonal, andintrapersonal factors and resources [45]. For example,
factors affecting CR included client perceptions of what
constitutes ‘good therapy’ [29]. The characteristics ofpractical realities included organizational, cultural,
economic, social resources within occupational therapy
practice [29, 34, 49], such as the power relationships ofoccupational therapy within the organization, reimbursement resources for treatment services, and the kinds ofavailable space and equipment [49]. The client-therapist
relationship and interaction were another important antecedent of CR because this affected the client’s active
participation in the therapeutic process and the use ofnarrative and interactive reasoning [34].

Consequences
Consequences included professional development
and enhanced professional attitudes and behaviours
as occupational therapists (see Figure 2). Professional
developments consisted of professional excellence andproficiency, and awareness of the complexity of professional practice. This was mainly reported as the growthand development of students and novice therapists oras being different between novices versus experts [27,44]. The use of CR language helped them develop more
precise thought processes sooner and provided a vocabulary for self-assessment and improvement of their CR
skills [44], and to communicate and share knowledge[28, 44]. Finally, CR helped to improve job satisfaction
by making students and practitioners more aware of23

the complexity and depth of their work [44]. Thus, theusage of CR language was essential to professional development [50].
Professional attitudes and behaviours were includedin the occupational therapy processes (e.g., implementation, modification, and explanation of occupational
therapy plan, and collaboration with other professions),
communication with clients in occupational therapy
situations, and establishment of therapeutic relationships[28, 35, 42, 54]. CR helped practitioners and students
understand the meaning of illnesses and disorders to clients [42], and enabled them to see possibilities for creating essential experiences for the client and to build onthese experiences by showing clients a possible future[51]. So, professional attitudes and behaviours facilitated meaningful occupational therapy experiences withclients [39]. In other words, the use of CR enhanced theperception of the effectiveness of interventions [28].
Besides, the use of CR language helped to explain therationales behind therapists’ decisions to clients, family
members, team members, and insurance carriers [44],and it helped to negotiate complex practice issues [35].

Discussion
A framework of the clinical reasoning concept
In light of the three historical phases of CR studies,as classified by Márquez et al., the data included in thisstudy covered the exploratory phase (7 articles), transition phase (10 articles), and consolidation phase (13articles) [8]. Therefore, we argue that the results of thisconcept analysis are valid from a historical perspectiveof CR research. The results of Rodgers concept analysis,
which identifies attributes (‘therapeutic thinking processes’ and ‘professional thinking skills’), antecedents(‘professional factors’ and ‘practice factors’), and consequences (‘professional developments’ and ‘professional
attitudes and behaviours’) were identified (see Figure 2),
taken together provide a framework for the CR conceptthat not only explains types of CR but also explains how
CR occurs.
As one dimension of the CR framework this study
identified CR attributes as four ‘therapeutic thinking
processes’ (Figure 2). These are comparable to previous
studies that identify the types of thinking process as answers to the question ‘what is CR’ [9]. Schell theorizes
eight types (scientific, diagnostic, procedural, narrative,
pragmatic, ethical, interactive, and conditional reasoning) as forms of CR [15]. Based on our analysis of literature we propose that our four types of CR (four typesof thinking processes) as an authoritative classificationof the various CR types.
Also, we clarified a new dimension of CR, namely

24

A CONCEPT ANALYSIS OF CLINICAL REASONING

the attributes ‘professional thinking skills’ (Figure 2). To
the best of our knowledge this is at best under-reported
in CR literature. That we could produce this result of
thinking skills may be reflective of recent professional
issues in occupational therapy such as evaluation ofinternationally developed competencies, and promoting
awareness among members of the public and otherprofessional groups of what the profession does [22]. In
relation to this, previous studies describe the difference
between novice and expert as a difference in the types ofreasoning used by therapists [15], but not as a differencein skill. However, it is important to distinguish expert
and novice in terms of skills in addition to ‘what’ experts
and novices perform [23]. The identified CR individuals’
and interactive thinking skills affords one an additional
dimension to clarify the development of CR skills fromnovice to expert.
In addition, the professional and practical factors,
the CR antecedents, not only affect individuals, but also
these affect the quality of CR [24]. Also, we clarified theprofessional developments and professional attitudes/behaviours that are CR consequences. On the other hand,conventional CR research topics focused on ‘what CR is’and ‘what promotes CR’ [9, 25]. Thus, the antecedents
and consequences identified in this study can be basic
knowledge for informing educational approaches promoting the acquisition of CR.
Finally, the framework resulting from this study
may be used to inform future research producing evidence of the efficacy of educational approaches and theauthors are planning the development of a sufficiently
reliable and valid assessment scale.
Limitations
The systematic search included English and Japa­
nese articles, but because of random sampling byRodgers’ methodology [17], the analysed sample did
not include Japanese articles (Table 2). However, as thenumber and scope of CR studies in Japan are still limited [12], we believe this did not affect the results of thisstudy. Another methodological limitation was that we
could not identify from the data, as per Rodgers’ method
for concept analysis [17], the exemplar as a typicalexample of CR. One possible reason is that the diversityof practice contexts in recent years [3] may have further
affected the complexity of CR concepts identified inpractice [25].

Conclusion
Our results identified that CR attributes were ‘therapeutic thinking processes’ and ‘professional thinking
skills,’ the antecedents were ‘professional factors’ and‘practice factors’, and the consequences were ‘professional developments’ and ‘professional attitudes and behaviours.’ The resulting framework of clinical reasoning
can be the basis for developing pedagogies and assessment of clinical reasoning competence acquisition.

References[1] Chapparo C, Ranka J. Clinical reasoning in occupational
therapy. In Higgs J, Jones MA, Loftus S and Christensen
N. (Eds.), Clinical reasoning in the health professions 3rd
ed. Oxford: Butterworth Heinemann, 2008; 265–78.
[2] Slater DY, Cohn ES. Staff development through analysis
of practice. The American Journal of Occupational Therapy. 1991; 45(11): 1038–44.
[3] World Federation of Occupational Therapists. Minimum
standards for the education of occupational therapists revis­
ed 2016. https://www.wfot.org/resources/new-minimumstandards-for-the-education-of-occupational-therapists2016-e-copy, 2016.
[4] Dent JA, Harden RM, Hunt D, Hodges BD. A practicalguide for medical theaters (5th ed). New York, Elsevier,
2017.
[5] Mattingly C, Fleming MH. Clinical reasoning: Forms ofinquiry in a therapeutic practice. Philadelphia, Pennsylvania: F. A. Davis, 1994.
[6] Faber RS, Koenig KP. Facilitating clinical reasoning infieldwork: The relational context of the supervisor andstudent. In Schell BAB and Schell JW (Eds.), Clinicaland professional reasoning in occupational therapy. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins,
2008; 335-367.
[7] Unsworth CA. How do pragmatic reasoning, worldview
and client-centredness fit? British Journal of Occupational Therapy. 2004; 67(1): 10–9.
[8] Márquez-Álvarez LJ, Arenillas J, Talavera M, MorunoMillares P. Professional Reasoning in Occupational
Therapy: A Scoping Review. Occupational Therapy International. 2019; 1–9.
[9] Unsworth CA and Baker A. Systematic review of professional reasoning literature in occupational therapy. British
Journal of Occupational Therapy. 2016; 79(1): 5–16.
[10] Royeen CB, Mu K, Barrett K, Luebben AJ. Pilot investigation: Evaluation of clinical reflection and reasoning
before and after workshop intervention. In P Crist (Ed.),
Innovations in Occupational Therapy Education. Bethesda, Maryland: American Occupational Therapy Association, 2000; 107–14.
[11] Facione PA. California critical thinking skills test: Form
2000. Millbrae, California: Insight Assessment, 2000.
[12] Maruyama S, Nagatani R. A literature review on theapplication of the clinical reasoning concept –comparison
between pre-2005 and post-2006 in Europe, the UnitedStates and Japan– (in Japanese). Japanese Clinical Occupational Therapy Research (rinsyousagyouryouhoukenkyuu). 2016; 3(1): 39–46.

Asian J Occup Ther 17: 17−25, 2021

[13] Young M, Thomas A, Gordon D, Gruppen L, Lubarsky
S, Rencic J, Durning SJ. The terminology of clinical reasoning in health professions education: Implications andconsiderations. Medical Teacher. 2019; 41(11): 1–8.
[14] Kielhofner G. Model of human occupation: Theory andApplication (4th ed.). Philadelphia, Pennsylvania: Lippincott Williams and Wilkins, 2008.
[15] Schell BAB. Professional reasoning in practice. In Schell
BAB and Gillen G (Eds.), Willard and Spackman’s Occupational Therapy 13th. Philadelphia, United States ofAmerica, Wolters Kluwer, 2019; 482–97.
[16] Meleis AI. Theoretical nursing: Development and progress (4th ed.). Philadelphia, Pennsylvania: Lippincott
Williams and Wilkins, 2007.
[17] Rodgers BL. Concept development in nursing: foundations, techniques, and applications (2nd Ed), Philadelphia, Pennsylvania: W. B. Saunders Company, 2000.
[18] Hupcey JE, Penrod J. Concept analysis: examining thestate of the science. Research and Theory of Nursing
Practice. 2005; 19(2): 197–208.
[19] Rogers JC. Eleanor Clarke Slagle Lectureship–1983; clinical reasoning: the ethics, science, and art. The American
Journal of Occupational Therapy. 1983; 37(9): 601–16.
[20] Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses:
the PRISMA statement. PLOS Medicine. 2009; 6(7):Maruyama S et al.

25e1000097.
[21] Braun V, Clarke V. Using thematic analysis in psychology, Qualitative Research in Psychology. 2006; 3(2): 77–
101.
[22] World Federation of Occupational Therapists, Mackenzie
L, Coppola S, Alvarez L, Cibule L, Maltsev S, Loh SY,
Mlambo T, Ikiugu MN, Pihlar Z, Sriphetcharawut S,
Baptiste S, Ledgerd R. International occupational therapy
research priorities: A Delphi study. Occupational Therapy Journal of Research: Occupation, Participation and
Health. 2017; 37(2): 72–81.
[23] King G, Currie M, Bartlett DJ, et al. The developmentof expertise in paediatric rehabilitation therapists: The
roles of motivation, openness to experience, and types ofcaseload experience. Australian Occupational Therapy
Journal. 2008; 55(2): 108–22.
[24] Maruyama S, Jinbo Y, Saito Y. Pilot study on novice
occupational therapists’ experience of using narrative reasoning for elderly clients in Japan (in Japanese). Japanesejournal of research for the occupational therapy education(sagyouryouhoukyouikukennkyuu). 2019; 18(2): 23–8.
[25] Carrier A, Levasseur M, Bedard D, Desrosiers J. Community occupational therapists’ clinical reasoning: identifying tacit knowledge. Australian Occupational Therapy
Journal. 2010; 57(6): 356–65.

■CASE REPORT

Occupational Therapy in Integrative Visual Agnosia
and Memory Disorder: A Case Report
Masahiro Tanaka
Department of Rehabilitation, Faculty of Health Science, Nihon Fukushi University

Abstract: Visual agnosia is a rare symptom in which the patient cannot recognize objects by visual perception. We report a case of integrative visual agnosia and memory disorder. A 70-year-old, right-handed man was diagnosed with cardioembolic stroke affecting the proximal left posterior cerebral artery. He had a short-term memory disorder. He could
not name and explain how to use objects, or read characters, but could discriminate between objects to some extent
and draw copies of simple figures. His recognition by tactile sense was comparatively preserved. He needed complete
assistance with his life in the hospital ward. We provided him with training using preserved tactile sensation by errorless learning. We arranged the environment around him to promote his memory of the position of objects and to avoid
misuse of daily objects. Improvement in the visual agnosia and memory disorder was slight. He became independent
with his life in the hospital ward. However, he needed assistance in a new environment, such as an unfamiliar lavatory.
The results suggest that a patient with visual agnosia may become independent early by appropriate training, despite
insufficient visual perception and memory function. In our patient, the intervention period was too short to generalize
the effects of training. Additionally, the memory disorder might have become an obstacle for generalization. Further
improvement in visual perception, independence in daily activities, and quality of life, will need continuous support.
Keywords: visual agnosia, memory disorder, occupational therapy(Asian J Occup Ther 17: 27−30, 2021)

Introduction
Visual agnosia is a form of cognitive deficit inwhich the patient cannot recognize objects by visual
perception. Visual agnosia is traditionally divided into
two types, apperceptive visual agnosia and associativevisual agnosia [1]. Humphreys advocated another type,
integrative visual agnosia [2].
Integrative agnosia is thought to be an impairmentof the perceptual integration that shapes elements into
coherent wholes [2]. A patient with integrative visualagnosia can discriminate and draw copies of objects
they see, but they cannot recognize them [2].
Visual agnosia is a rare symptom with few reports
about the rehabilitation process. Here, we describe apatient with integrative visual agnosia and memory disReceived: 26 May 2020, Accepted: 22 December 2020
Corresponding to: Masahiro Tanaka, Department of Rehabilitation,
Faculty of Health Science, Nihon Fukushi University, 26-2, Higashihaemi-chou, Handa, Aichi, Japane-mail: tmasahir@n-fukushi.ac.jp©2021 Japanese Association of Occupational Therapists

order induced by cardioembolic stroke.
The publication of this report was explained to thepatient and his family with a written document, andinformed consent was obtained from a family member.

Case Report
The patient was a 70-year-old, right-handed man
who complained of headache and vision problems when
he presented to our hospital. He was not paralyzed anddid not have a sensory disorder. He had right homonymous hemianopsia, slight aphasia, memory disorder, andvisual agnosia. His language was fluent, and he could
have daily conversations with mild difficulty in findingwords. He was diagnosed with cardioembolic stroke atthe proximal left posterior cerebral artery by magnetic
resonance imaging (Fig. 1).
He had a short-term memory disorder where hecould not remember recent events but could partiallylearn repeated information. His visual perception was
generally impaired and Visual Perception Test for Agnosia (VPTA) [3] results are shown in Fig. 2 left half. He
could not name or explain how to use objects, or read

28

OCCUPATIONAL THERAPY IN INTEGRATIVE VISUAL AGNOSIA AND MEMORY DISORDER

were unchanged. He could independently eat, maintainpersonal hygiene, and recognize objects on the tablewithout touching. He was able to reach the predetermined lavatory and excrete without requiring tactile
sensation for recognition or assistance. While he became
independent in his daily life in the limited environmentof the hospital ward, assistance was needed in new environments such as an unfamiliar lavatory.
The patient was transferred to a rehabilitation hospital 36 days after initial admission for further treatment.
Fig. 1. The diffusion weighted image of brain

characters, but could partially discriminate objects anddraw copies of simple figures after a long time. Recognition by tactile sense was comparatively preserved,
as he could occasionally use objects properly when hetouched them. He needed assistance and guidance witheating and personal hygiene since he could not recognize
or use the appropriate objects, and with using the toilet
because he could not reach the lavatory and wandered in
the ward. Before the onset of stroke, he was completely
independent in his daily life.
We started occupational therapy on the second dayof admission. We focused on his preserved tactile function and that he could learn information with repetition.
We provided him with therapy so he could perform
activities of independent daily living by compensatingwith tactile sensation. We helped him learn how to eat,maintain personal hygiene, and toileting by repeatedly
practicing in the hospital ward. We made him touch objects required for eating and personal hygiene, and learn
strategies to aid recognition (Fig. 3 left). Further, we
identified the position of objects needed for eating andpersonal hygiene at the table to promote memory andavoid misuse (Fig. 3 middle). For toileting, we madehim touch the toilet bowl, toilet paper, and flush button
repeatedly so he could recognize and use them by tactile
sensation (Fig. 3 right). We identified the location of the
toilet early in his therapy so the effect of therapy could
be generalized to an early period in his hospital stay. We
used errorless learning so whenever he made a mistake,we would stop as soon as possible and guide him to thecorrect way. His symptoms and assistance required were
described to the nursing staff so he could continue hispractice. We provided occupational therapy, physicaltherapy, and speech and language therapy 5 days a week.
His word finding difficulties improved, while thememory disorder remained. He was able to roughly
recall daily events and practice the contents during
therapy. His VPTA score improved (Fig. 2 right half),
although visual agnosia persisted and other parameters

Discussion
Based on the medical evaluation and symptoms, thepatient was considered to have integrative visual agnosia, and his damaged lesion corresponded with previous
studies of integrative visual agnosia [2, 4].
While there are few studies about rehabilitation ofpatients with visual agnosia, compensatory strategies are
beneficial [5]. Further, errorless learning is an effective
approach for patients with memory disorders [6]. Basedon the patient’s spontaneous functional recovery, weused a compensatory approach and errorless learning
to improve his independence in daily life. Our results
suggest that patients with visual agnosia can become
independent early through appropriate training, despite
impaired visual perception and memory function.
However, the patient needed assistance in a new environment. Zihl reported a patient with integrative visualagnosia who trained for a visual search task and could
generalize the effect to untrained tasks [7]. In contrast,
Behrmann reported a patient who trained for a visual
recognition task and could generalize to other tasks [8].
The current intervention period was limited to an acutephase, which could be considered too short to generalize
the effect of training on his long-term recovery. Memory
disorders may also be an obstacle for generalization in a
new environment.
Few reports exist on the improvement in daily
object recognition during long-term follow-ups [9, 10].
While our patient became independent in his daily life in
the hospital ward, he needed further improvement. Afterdischarge from the rehabilitation hospital, continuous
support will be needed to improve his visual perception,
independence in daily activities, and quality of life.

Conclusion
We have described a patient with integrative visualagnosia and memory disorder. The patient became
independent early in his hospital ward stay by usingpreserved tactile function training. While the effects ofthis training did not generalize to a new environment,

Verbal-visual task
Verbal-verbal task

Discrimination of shapes
Inclination of lines
Overlapping figures

Judgment about gender
Judgment about age

Line cancellation, lower left
Line cancellation, upper rightLine cancellation, lower right

Description of expressions

Judgment about gender

Judgment about age

Fig. 2. The results of VPTA

Description of expressions

Line cancellation, upper left

Matching faces simultaneously

Topographical orientation
Topographical orientation, daily life
Individual topographical memory
Blank map

Topographical orientation
Topographical orientation, daily life

Individual topographical memory
Blank map

Drawing pictures, left half
Drawing pictures, right half

Drawing pictures, left half
Drawing pictures, right half

Reading numbers from left to right, left half
Reading numbers from left to right, right half

Reading numbers from left to right, left half

Reading numbers from left to right, right half

Reading numbers from right to left, left half
Reading numbers from right to left, right half

Reading numbers from right to left, left half

Reading numbers from right to left, right half

Copying of the flower, left
Copying of the flower, right

Copying of the flower, rightLine cancellation, lower rightLine cancellation, upper rightLine cancellation, lower left

Line cancellation, upper left

Line bisecting, shift to rightLine bisecting, shift to left

Visual space recognition and operation

Matching letters

Reading letters by tracing them

Copying of letters

Kana words

Kanji words

Numbers

Kanji letters

Hiragana letters

Katakana letters

Recognition of symbols

Symbol recognition

Selection of colored pencils

Copying of the flower, left

Fig. 2. The results of VPTA

Matching faces simultaneously

Discrimination of same and different faces

Faces of family members

Line bisecting, shift to left

Pointing out famous persons

Line bisecting, shift to right

Visual space recognition and operation

Pointing out famous persons

Face recognition
Naming famous persons

Faces of family members

Matching letters

Pictures of situations

Naming objects using auditory stimulation

Naming objects using tactile stimulation

Pointing to objects by instructions

Sketching objects

Explain how to use objects

Naming objects

Object and picture recognition

Discrimination of same and different faces

Reading letters by tracing them

Face recognition

Kanji words

Naming objects using tactile stimulation

Naming famous persons

Numbers

Pointing to objects by instructions

Kana words

Kanji letters

Sketching objects

Copying of letters

Hiragana letters

Pictures of situations

Categorizing pictures

Katakana letters

Naming objects

Explain how to use objects

Naming objects using auditory stimulation

Naming pictures

Symbol recognition
Recognition of symbols

Naming pictures

Categorizing pictures

Copying of figrures

Verbal-verbal task

Selection of colored pencils

Copying of figrures

Object and picture recognition

Pointing to colors

Categorizing hues

Matching hues

Naming colors

Color recognition

Pointing to colors

VPTA second time

Verbal-visual task

Disturbed

Inclination of lines

normalOverlapping figures

Length of lines

Changes in visual experience

Basic function of visual perception

Counting dots with eyes

Disturbed

Matching hues

normalCategorizing hues

Color recognition

Counting dots with eyes

VPTA first time

Discrimination of shapes

Disturbed
Naming colors

normalLength of lines

Basic function of visual perception

normalDisturbed

Asian J Occup Ther 17: 27−30, 2021
Tanaka M
29

30

OCCUPATIONAL THERAPY IN INTEGRATIVE VISUAL AGNOSIA AND MEMORY DISORDER

Fig. 3. The scene of occupational therapy and environmental arrangement

Fig. 2. The scene of occupational therapy and environmental arrangement

this could be due to the short intervention period and his
memory disorder.

Declaration of Conflicting Interests
est.

The author declares that there is no conflict of inter-

Funding
The author received no financial support for the
research, authorship, and/or publication of this article.

References[1] Lissauer H. Ein Fall von Seelenblindheit nebst einem
Beitrage zur Theorie derselben. Archiv für Psychiatrie
und Nervenkrankheiten. 1890; 21(2): 222–70.
[2] Riddoch MJ, Humphreys GW. A case of integrativevisual agnosia. Brain. 1987;110(Pt 6): 1431–62.
[3] Japanese Society of Aphasiology. Visual Perception Testof Agnosia. Tokyo: Shinko Igaku Shuppan; 1997 (inJapanese).
[4] Hirayama K, Suzuki Y, Inoue K. Integrative visual (object)agnosia. Clinical Neuroscience. 2012; 30(10): 1090–1 (inJapanese).
[5] Heutink J, Indorf DL, Cordes C. The neuropsychologicalrehabilitation of visual agnosia and Balint’s syndrome.
Neuropsychol Rehabil. 2019; 29(10): 1489–508.
[6] Jean L, Bergeron M-È, Thivierge S, Simard M. Cognitive
Intervention Programs for Individuals With Mild Cognitive Impairment: Systematic Review of the Literature.
Am J Geriatr Psychiatry. 2010; 18(4): 281–96.
[7] Zihl J. Rehabilitation of Visual Disorders After Brain
Injury, 2nd Edition. 2011.
[8] Behrmann M, Marotta J, Gauthier I, Tarr MJ, McKeeff
TJ. Behavioral change and its neural correlates in visualagnosia after expertise training. J Cogn Neurosci. 2005;
17(4): 554–68.
[9] Rubens AB, Benson D. Associative visual agnosia. Arch
Neurol. 1971; 24(4): 305–16.
[10] Wilson BA, Davidoff J. Partial recovery from visualobject agnosia: a 10 year follow-up study. Cortex 1993;
29(3): 529–42.

■CASE REPORTS

Analysis of Responses of a Healthy Subject
and Subjects with Cerebellar Hemorrhage
and Parkinson’s Disease in Eye–Hand Coordination
Pointing with Pencil Test
Kazuo Saito1, Maki Koyama2, Atsuko Ishida3, Toshiko Futaki4
1

Department of Rehabilitation, Faculty of Health Sciences, Tokyo Kasei University, Saitama City, Japan
Office for Promotion of Regional Collaboration, River Basin Research Center, Gifu University, Gifu, Japan3
Department of Rehabilitaion, Grado Sakaehigashi, Nagoya City, Japan
4
Faculty of Health Sciences, Okayama Healthcare Professional University, Okayama City, Japan
2

Abstract: Purpose: The objectives of this study were to quantitatively analyze the reaction patterns of ataxia andParkinson’s disease cases that are cognitively harmless and to examine the characteristics of pathological reactions,such as ataxia, rigidity, and motor control, compared to the patterns of a healthy subject.
Methods: An eye–hand coordination pointing with pencil test (EHCPPT) app was developed that requires patients to
tap a bullseye target with a pencil for screening testing. This app is intended to be used during regular check-ups of theelderly to help them maintain their home lifestyle through self-management of health. The EHCPPT consists of two
tasks, both of which require the patient to tap a bullseye target as a test of eye–hand coordination in response to a stimulus sound. In one task, the sound is repeated rhythmically; in the other, it is generated irregularly and infrequently. The
EHCPPT app is based on the “oddball paradigm” experimental design and can be administered in just a few minutes tomeasure the time lag between the sounds and taps as well as the distance between the target and tapped locations automatically.
Results: The data generated when the app was used by a healthy subject, an ataxia patient, and a patient with Parkinson’s disease were analyzed. In each case, the data exhibited a distinctive pattern.
Conclusion: The EHCPPT app is simple and fast and shows potential as a screening test.
Keywords: eye–hand coordination, pointing test, tapping test

(Asian J Occup Ther 17: 31−35, 2021)

1. Introduction
A finger-tapping test [1], a type of tapping task,
is used in neurophysiological research and for thesimple clinical evaluation of Parkinson’s disease [2, 3]
and cerebrovascular disorders [4, 5]. In recent years,
researchers have begun exploring how finger-tapping
relates to age and cognitive function as well as to themotor control functions of the hand and arm; studies
Received: 16 July 2020, Accepted: 27 December 2020
Corresponding to: Kazuo Saito, Department of Rehabilitation, Facultyof Health Sciences, Tokyo Kasei University, 2-15-1, Inariyama, Sayama,350-1398, Japane-mail: saito-kaz@tokyo-kasei.ac.jp©2021 Japanese Association of Occupational Therapists

have also reported relationships with attention capacity
and short-term memory [6, 7]. A center-of-target tappingtask is, by its nature, highly sensitive to coordinatedmovement; therefore, we believe that it can be used toevaluate poor physical yield and cognitive function.
However, during examinations of elderly people, thistest may produce poor or widely varying results causedby patient unfamiliarity or nervousness.
According to Kropotov, the oddball paradigm isgenerally considered an “active paradigm.” In otherwords, it is a behavioral task that requires an action fromthe subject, such as pressing a button in response todeviants or silently counting the number of deviants [8].
Unlike the traditional speed test, which is administeredunder strict conditions, we opted for a bullseye-targettapping task. Therefore, we created an eye–hand coor-

32

ANALYSIS OF RESPONSES OF THREE SUBJECTS IN ECPPT

Table 1 Subject characteristics (case 2: ataxia; case 3: Parkinson’s)

Case 2
Case 3Right Grip

Left Grip

TUG

GDS

SF8

MMSE

CDT

TMT-A

TMT-B

BI

Lawton11.5 kg
11.4 kg

10.5 kg
8.7 kg

14 s
10 s

3
3

9
10

28
27

9
9

250 s
269 s

321 s
350 s

80
75

2
3

TUG: Timed up to go test; GDS: Geriatric depression scale 15; SF8: MOS 8-Item Short-Form Health Survey; MMSE: Mini-Mental State Examination 0 (severe) to 30 (normal), cutoff 23 points; CDT: Clock drawing test, 0 (severe) to 5 (normal), dementia at 3 points or less; TMT-A, TMT-B:
Trail Making Test age 64 years and under, A 84.5 s, B 117.0 s; BI: Barthel Index; Lawton: Lawton’s IADL (instrumental activities of daily living).

dination pointing with pencil test (EHCPPT) app. Thisapp is available in both iOS and Android versions. The
study investigated the usefulness of the test based on thecontrast in performances between a healthy individual
and patients with ataxia and Parkinson’s disease.

2. Methods
2.1 Subjects
Case 1: Healthy subject: 23-year-old man; 16 yearsof education; working in the medical field.
Case 2: Ataxia patient: 69-year-old man; 16 years ofeducation; 3 years since onset of cerebellar hemorrhage;
scale for the assessment and rating of ataxia (SARA)
score [9] of 11/40 points.
Case 3: Parkinson’s disease patient: 70-year-old
woman; 15 years of education; 5 years since Parkinson’s
onset; Hoehn and Yahr IV, Life Disability Classification
II.
Cases 2 and 3 received regular home care from visiting nurses. No dementia was observed. A small levelof assistance was required in their activities of dailyliving (ADLs) and instrumental activities of daily living(IADLs).
2.2 Measurement methods
2.2.1 Patient position during examination and measurement
The examination was conducted with the subject
seated in a chair or wheelchair. The subject sat with theirnondominant hand in a fist on the desk, forming a fistsized barrier between their body and the top of the desk,
and then performed the test with the dominant arm resting on top of the nondominant hand. The subject practiced tapping the tip of the stylus pen from a distanceof at least 10 cm from the screen for each tap. During
the examination, the bullseye-target tapping task waspresented to the subject via the EHCPPT app running onan Apple iPad tablet (MP2F2 J/A). The subject held astylus, which was used as the input device, in their dominant hand and tapped the bullseye target at the centerof the concentric circles on the screen in synchrony
with the stimulus sounds. Before the measurement, theresearcher ran the application several times and madepractice measurements.
2.2.2 EHCPPT app
The EHCPPT is an eye–hand coordination test that
requires the subject to tap a bullseye at the center of six
concentric circles in synchrony with stimulus sounds
played at regular intervals. The details of the task are as
follows. In Task A, the subject must tap in time with alow-pitched (1 kHz) tone played 60 times in 1 s intervals. In Task B, 65 low-pitched (1 kHz) tones and 35
high-pitched (2 kHz) tones are played at random, andthe subject must tap only after hearing the high-pitched
tone. Prior to this measurement, five healthy people intheir 20s were measured, and the test–retest reliability
was 0.95 on average (0.91–0.97).
2.2.3 Measurement data and processing
The app obtains the (x, y) coordinates (in pixels)of the iPad screen location at which the subject taps
the stylus and converts them into (X, Y ) coordinates (inmm) relative to the origin at the center of the bullseye.
The coordinates are then stored along with the time atwhich the stylus makes contact. The measurement data
are saved as a CSV file. For each tap of the stylus, theapp measures the “deviation from target” (in mm), thatis, the distance of the tap from the center of the bullseye,and the “simple reaction time” (in seconds), that is, thetime lag between the tap and stimulus sound.
The experimenter counts an “omission error” (OE)
if the subject fails to tap when the stimulus sound isplayed and a “commission error” (CE) if the subject taps
by mistake.
2.3 Ethical considerations
This study was conducted with the consent of thesubjects and the approval of the ethics review boardsof Kyoto University Medical Center (approval number
R1379) and Fuchinobe General Hospital (approval
number 19-006).

3. Results
Table 1 shows the background data for cases 2 and3. Figures 1-1, 2-1, and 3-1 summarize the data obtainedSaito K et al.

Asian J Occup Ther 17: 31−35, 2021

33

(1)

(2)

Fig. 1. (1) Results summary, task A, task B. (2) Results of deviation from target (mm).

using the EHCPPT app and the number of omission andcommission errors for each task. Figures 1, 2, and 3
show the results over time for cases 1, 2, and 3, respectively.
As the results show that OE was 0 in all cases intask A, but CE was 15 and 5 in cases 2 and 3, respectively. In contrast, in task B, OE was 24 in both cases 2 and3, and CE was 2 and 3 in cases 2 and 3, respectively (Fig.
1-1). Regarding the deviation from target, in case 2, thepatient results in tasks A and B were observed to spreadby two to three times more than those of the healthy
subject, and in case 3, the task B results were spread by
about two times more (Fig. 1-2). Regarding the degreeof deviation from the target of cases 1 and 2, the initialdeviation in patient results was small in task A compared
to in those of the healthy subject, but increased in thelatter half, resulting in more CE. The results were large
at the beginning of task B and had many OEs (Figs. 1-1,
2-1). Regarding simple reaction time, in task A, this wasa characteristic measurement result that repeated a cycle
in which the deviation increased with each iteration.
In task B, the measurement results were quite difficult(Figs. 1-1, 2-2).
Regarding the degree of deviation from the targetof cases 1 and 3, there was a deviation in the patient results in task A compared to those of the healthy subject,
and the deviation was large, especially in the latter half.
There was little deviation from task B (Figs. 1-1, 3-1).
Regarding simple reaction time, in task A, there was alarge fluctuation in the first half, but subsequently there
was a constant deviation. In task B, there was a large
deviation and there were many OEs (Figs. 1-1, 3-2).

4. Discussion
SARA is a semiquantitative evaluation method thatis easy to use in daily medical practice; however, its
upper-limb ataxia outcome measures have been reported
to vary widely across evaluators [9]. For Parkinson’s
disease, the severity classification of Hoehn and Yahr
is widely used; further, the Unified Parkinson’s Disease
Rating Scale (UPDRS) is a standard evaluation index
the reliability and validity of which have been verified,although this evaluation is time-consuming [10].

34

ANALYSIS OF RESPONSES OF THREE SUBJECTS IN ECPPT

(1)

(2)

Fig. 2. (1) Degree of deviation from target (mm). (2) Simple reaction time (s) (case 1: healthy and case 2: ataxia).

(1)

(2)

Fig. 3. (1) Degree of deviation from target (mm). (2) Simple reaction time (s) (case 1: healthy and case 3: Parkinson’s).

In contrast, the EHCPPT measurements performedin this study were simple and rapid. Furthermore, ourresults suggest that the test may reveal disease-specificcharacteristics. In the ataxia case (Table 1, Fig. 2), thedeviation from the target in task 2 was around twice thatin task A, and the time lag was around 1.5 times greater.
Task A requires movement control to match a constantrhythm. Because the patient suffered from a rhythm
disorder, we expected them to show more erroneous
reactions, difficulty with time control, and longer simple
reaction time. Furthermore, we noticed that they tried tocontrol their deviation from the target using strategies
such as pressing their elbow to their body for stability,
which resulted in a certain amount of deviation andSaito K et al.

Asian J Occup Ther 17: 31−35, 2021

early tapping. Task B required reaction to one sound at atime and therefore was less susceptible to the effects ofrhythm disorders. However, the subject seemed to have
faced difficulties in controlling the initiation of eachmotion and was unable to react in time before the next
stimulus sound.
In the Parkinson’s case (Table 1, Fig. 3), the deviation from the target in task B was less than that in task
A, whereas the time lag (including standard deviation)
was around 1.5 times greater. In task A, no omission
errors were recorded, and the tapped area was smaller
than that in the ataxia case. This patient may have faceddifficulties in initiating motions independently but not
in reacting to the stimulus sound. In task B, their muscle
rigidity may have led to decreased deviation from thetarget but increased lag time from detection to reaction.
The study results suggest that disease-specific characteristics exist; however, the small sample size and thelikelihood of individual differences in the use of spatiotemporal and spatial strategies to tap the target make thissuggestion difficult to prove. In future work, in addition
to increasing the number of cases, we will examine
different parameters, for example, by calculating the
average double product or comparing the tapped areas.
We would also like to perform further investigations
regarding whether the developed app can be used as adrug efficacy index, for example, for describing disease
severity or on–off syndrome.

5. Conclusion
We developed an EHCPPT app as a screening test
that requires patients to tap a bullseye target and performed measurements for three cases: a healthy subject,
an ataxia patient, and a patient with Parkinson’s disease.
This app enables the assessment of disease-specificcharacteristics, suggesting that it may be useful as ascreening test.

Conflict of interest disclosure
There are no conflicts of interest that need to bedisclosed in connection with this research.

35

Acknowledgement
This research was supported by JSPS Grants-in-Aid
for Scientific Research (JP18K10707).

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test: a quantitative analysis. Arch Neurol. 1990; 47(6):681–4.
[2] Kosaka K, Nagasaki H, Nakamura R. Finger tapping test
as a means to differentiate olivo-ponto-cerebellar atrophy
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[3] Opara J, Małecki A, Małecka E, Socha T. Motor assessment in Parkinson’s disease. Ann Agric Environ Med.
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[4] Axelrod BN, Meyers JE, Davis JJ. Finger tapping test
performance as a measure of performance validity.
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[5] Hubel KA, Reed B, Yund EW, Herron TJ, Woods DL.
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[6] Zhang L, Zhao Y, Shen C, Lei L, Dong J, Zou D, et al.
Can long-term regular practice of physical exercises
including taichi improve finger tapping of patients presenting with mild cognitive impairment? Front Physiol.
2018; 9: 1396. doi:10.3389/fphys.2018.01396.
[7] Petilli MA, Trisolini DC, Daini R. Sustained-paced finger
tapping: a novel approach to measure internal sustained
attention. Front Psychol. 2018; 9: 881. doi:10.3389/fpsyg.
2018.00881.
[8] Kropotov JD, editor. Neuronal Networks and EventRelated Potentials. In: Quantitative EEG, Event-Related
Potentials and Neurotherapy. Cambridge: Academic Press;
2009; 325–65.
[9] Schmitz-Hübsch T, Tezenas du Montcel S, Baliko L,
Berciano J, Boesch S, Depondt C, et al.: Scale for theassessment and rating of ataxia: Development of a newclinical scale. Neurology. 2006; 66(11): 1717–20.
[10] Fahn S, Elton RL. UPDRS Development Committee:
United Parkinson’s Disease Rating Scale. In: Fahn S,
Marsden CD, Calne DB, Lieberman A, editors. Recent
Developments in Parkinson’s Disease. Florham Park:
Macmillan Healthcare Information; 1987; 153–63.

■ORIGINAL ARTICLE

Effectiveness of the Parent-Child Social Skills Training
Program for Children with Developmental Disorders:
A quasi-experimental design
Kimiko Shibata1, Hirokazu Nishikata2, Sayoko Kawabata3,
Hiroko Miyadera4, Yohei Kuriki2
1

Saitama Prefectural University
Bunkyo Gakuin University
3
University of North Carolina Chapel Hill
4
Gunma Paz University
2

Abstract: Purpose: This study explored the effectiveness of a new parent-child social skills training program
addressing social skills and parenting stress among children with developmental disabilities and their parents.
Methods: Participants were 15 children (14 boys, 1 girl; 7–9 years old) with diagnoses related to developmental disability and a Full Scale IQ ≥ 70 and 17 parents (2 fathers, 15 mothers; 34–51 years old). Each session of this program
lasted 110 minutes and occurred every 1–3 weeks for about 2 months. Social skills were measured by self-evaluation(Social Skills Scale for Elementary School Children, Social Skills Self-Rating Scale for Adults: SS-A), information provider’s evaluation (Vineland Adaptive Behavior Scales, Second Edition, Japanese version: VABS-II), and practitioner’s
evaluation (Role-Play Test for Children and Parents: RPT-CP), and parenting stress was measured with the Parenting
Stress Index (PSI) before, immediately after, and at a 3-month follow-up after intervention.
Results: VABS-II scores were significantly lower after the intervention (z = −2.58, p = .011, r = −.65). Children’s RPTCP scores also improved (z = 1.705, p = .08). The scores on SS-A, parents’ RPT-CP, and PSI improved significantly atfollow-up (z = 2.832, p = .005, r = .71; z = 2.91, p = .004, r = .71; z = −2.34, p = .019, r = −.57), and parents’ RPT-CPscores were significantly higher at follow-up than post-intervention (z = 2.333, p = .02, r = .58).
Conclusions: This program effectively improved parents’ social skills after the intervention, and parenting stressdecreased at follow-up.
Keywords: developmental disorder, social skills training, parent, communication, elementary school(Asian J Occup Ther 17: 37−44, 2021)

Introduction
The Manual for the Diagnosis and Statistics ofMental Disorders, 5th Edition [1] classifies attention
deficit hyperactivity disorder, autism spectrum disorder(ASD), and developmental coordination disorder as
neuro­developmental disorders described as “hidden”
neuro-biological developmental disorders with highmorbidity. Their prevalence is 5–6%, and they are someof the most common disorders affecting children of
Received: 27 February 2020, Accepted: 6 January 2021
Corresponding to: Kimiko Shibata, Saitama Prefectural University,
820 Sannomiya, Koshigaya-shi, Saitama 343-8540, Japane-mail: kimishiba@icloud.com©2021 Japanese Association of Occupational Therapists

school age [1]. Approximately 6.5% of Japanese children have neurodevelopmental disorders [2], and manyare enrolled in regular classes. Their social skills may beslightly below average in preschool, but difficulties establishing interpersonal relationships become evident inelementary school [3]. As a result, children with neuro­developmental disorders experience isolation and rejection from peers, often leading to learning difficulties,
interpersonal difficulties, school refusal, and depression.
Some core deficits associated with ASD improve, butsocial deficits show relatively little improvement as thechild ages [4]; therefore, social skills are prioritized astreatment targets [5, 6].
Parents of children with neurodevelopmental disorders, including ASD and mild intellectual disability,
experience substantial childcare stress resulting from

38

EFFECTIVENESS OF THE PARENT-CHILD SST PROGRAM

the child’s behavior [7, 8] and are more depressed thanparents of typically developing children [9, 10]. Parental
mental health is related to parenting behavior [11],which in turn affects child development [12]. A study
on the resilience of mothers of children with ASD [13]found that those with good social adaptation showedsimilarities in parenting, indicating that mothers cancommunicate with their children, find strengths in theirchildren, and help them improve their skills. Kurani
reported that when parents of children with severe intellectual disabilities actively worked with their children
with an emphasis on social skills, children’s development was promoted [14]. In other words, it is necessary
to provide a program for the parents to promote thedevelopment of children with neurodevelopmental
disorders and help them acquire more effective communication skills. Parents and children can use social skills
at home to communicate with each other, and can it also
be applied at school as the next step.
Social skills training (SST) can help children withneurodevelopmental disorders manage difficulties ininterpersonal relationships and acquire social skills[15, 16]. The role of parents in SST for children withneurodevelopmental disorders has often been indirect,
such as helping children use their learned skills [17, 18].
To enhance the effects of SST interventions, it has beensuggested that parents be included in SST [19].
We have developed a parent-child SST program
for learning social skills [20] for parents and children tolearn the same target skills, do homework, and role-play
to improve the target skills. This study aimed to examine
the effects of this parent-child SST program on children
with neurodevelopmental disorders and their parents,
focusing on social skills and parenting stress.

Methods
Study Design
A quasi-experimental design (one group, beforeand-after design) was used, and assessments were conducted at three time periods: before and immediately
after the intervention, and at 3-month follow-up. Fiveoccupational therapists at Bunkyo Gakuin University
conducted the trial from August 2016 to March 2019.
Ethical approval was granted from the ethics committeeof the Faculty of Health Science Technology, Bunkyo
Gakuin University.
ParticipantsParticipants were children with developmental
disabilities and their parents. Inclusion criteria included
children in grades 2–4 with diagnoses related to neurodevelopmental disorders, with a Full Scale Intelligence

Quotient (FSIQ) ≥ 70 on the Wechsler Intelligence Scale
for Children-Third Edition. Participation was available
to all parents. Open recruitment was conducted throughthe Bunkyo Gakuin University website, which included
a program overview. Applicants filled out an application
submitted by fax or email. The contents of the application form were age, grade, gender, diagnosis, FSIQ, andelementary school type. Those meeting the inclusion
criteria were notified by email of the pre-intervention
evaluation schedule. At the time of the pre-intervention
evaluation, parents provided informed written consent.
Information on the study was also given to the children,
who provided written assent. Participants were free towithdraw from the study without consequence, in linewith ethical considerations in research with human subjects in Japan.
A total of 16 children and 18 parents initially participated in the SST program. One child and one parent
only participated twice and were excluded. Consequently, the participants were 15 children (14 boys, 1 girl; 7–9
years old) and 17 parents (2 fathers, 15 mothers; 34–51
years old) who completed the whole program (Table2). Before the parent-child SST program, children werereported to have problems communicating with peers,
cried, and were isolated. The age range was chosenbecause children around age 9 can objectively perceive
themselves, but do not yet have a positive awarenessof themselves, and tend to have a sense of inferiority.
Therefore, promoting children’s understanding of the
viewpoint of others, respect for oneself and others,
and compassion for others is important in this age.
Therefore, we targeted children around age 9 (2nd–4th
graders), in accordance with national guidelines by the
Ministry of Education, Culture, Sports, Science andTechnology [21].
Parent-Child SST Program
The program was conducted with six groups oftwo to four children. Each session lasted 110 minutes
and occurred every 1–3 weeks for about 2 months (sixsessions per group). The SST for children comprised
two parts: learning time (to learn skills) and playtime (toapply skills). After observing children’s learning time,
the parents participated in a session for themselves.
There were five SST target skills: seeing and recognizing, expressing positive feelings, making requests,
expressing unpleasant feelings, and listening to others(Table 1), based on previous studies implementing programs for parents and children [17, 18, 22], basic skills
in social skills education [23], and four basic skills by
Bellack [16]. The first author, an occupational therapist
certified as instructor of the Japanese Association ofSocial Skills Training (JASST), was in charge as theShibata K et al.

Asian J Occup Ther 17: 37−44, 2021

39

Table 1 Content and Target Skills for the Six Sessions of the Parents-Children Social Skills Training Program
SessionChildren SST
Leaning Time

Parents SST

Playtime

1

Orientation
Looking closely and noticing

Picking up plastic bottle

Orientation
Looking closely and noticing

2

Expressing positive feelings

Giant trump nervous breakdown

Expressing positive feelings

3

Making requests

Borrowed games

Making requests

4

Expressing unpleasant feelings

Pretending

Expressing unpleasant feelings

5

Listening to others

Exploration games

Listening to others

6

Production activities using skills with parents and children, farewell party

Note. SST, social skills training.

Table 2 Children and Parents Demographic Characteristics

Children’s age (years)
Boys
Girls
Diagnosis
ASD
PDD
ADHD
Mild intellectual disability
Down’s syndrome
Soto’s syndrome
No diagnosis
WISC-II FSIQ
SchoolNormal classUse of program of resource rooms
Parents’ age (years)
Mothers
Fathersn

M (SD)

Range

15
14
1

7.6 ( 0.8)

7–9

95.3 (15.3)

76–12244.1 ( 5.1)

34–51

6
3
2
1
1
1
1
15
3
17
15
2

Note. ASD, autism spectrum disorder; PDD, pervasive developmental
disorder; ADHD, attention-deficit hyperactivity disorder; WISC-III
FSIQ: Wechsler Intelligence Scale for Children-Fourth Edition

leader of the learning time in the SST for children and
the SST for parents, and the co-leaders of the sessions
were two occupational therapists who had completed a
beginner training course in the JASST. In the children’s
program, three to four occupational therapists who specialized in the treatment of children with developmental
disabilities participated as auxiliary staff.
Each session of the learning time involved a warmup exercise, reporting homework, target skill learning,and explanation of the next homework. As a warm-up,
children engaged in light exercise such as tug-a-war
aimed at enhancing concentration for learning. To learn
the target skill, an explanation of the skill’s significancewas given, and then a “bad model” (i.e., unfavorable behavior) was performed by staff. The children confirmed

the points to be improved, and then a “good model” (i.e.,
preferable behavior) was presented. After the model presentations, children performed the role-play themselves,received feedback on the good points, and advice for
improvement from the participants and staff. They thenengaged in another role-play. Finally, homework was set
up to use the target skill every day. The children were topractice the skills at home first, and then at school and in
the community. Records were maintained on homework
sheets, and parents were encouraged to help their children complete them.
The leader of the SST playtime for children was
the co-leader of the learning time who also specializes
in treatment of children with developmental disabilities.
During the SST playtime for children, the staff actively
reinforced and encouraged the use of the target skill in
play, particularly when it was not being used. Furthermore, a table was presented on a large sheet of paper toprovide visual feedback regarding the usage of the target
skill in play.
In the parent program, after observing the children's
learning time for the purpose of preparing them forskill learning, they practiced the skills in the same waythat the children learned them. The differences in thelearning time were the content of the warm-up (parents
talked about what made them happy recently to have apositive focus), model presentation (only “good model”
presentation), and homework (helping with the child’s
homework and recording the responses and impressionsof using the learned skills in their life). The staff actively
provided positive feedback after homework reports androle-plays, and praised the challenge of acquiring skills.
In the final session, the target skills were reviewed,
and craft activities were completed by parents and children using these skills. To reinforce skill usage, children
received a sticker as a token from their parent when theyused learned skills; when skills were used by parents,

40

EFFECTIVENESS OF THE PARENT-CHILD SST PROGRAM

they received stickers from the staff.
Outcome Measures
In the evaluation of social skills, it is necessary tomeasure the learned target skills accurately and assess
general social skills widely and comprehensively [24].
Therefore, we selected methods for measuring social
skills by referring to Aikawa’s [25] three types of social
skill evaluation: self-evaluation (e.g., self-report andself-monitoring), information provider’s evaluation (e.g.,parents and peers related to children), and practitioner’s
evaluation (e.g., interview, behavior observation, androle-play methods). In this study, children’s social skills
were measured through self-evaluation, information
provider’s evaluation, and practitioner’s evaluation,
while parents’ social skills were assessed through selfevaluation and practitioner’s evaluation. Evaluations
were performed at three time points: before and immediately after the intervention, and at 3-month follow-up.
Self-Rating Scale of Social Skills for Elementary
School Children. The Social Skills Scale for Elementary School Children (SSS-E) [26], a 15-item self-rating
questionnaire using a 4-point Likert scale, was used
for self-evaluation of social skills by the children. The
SSS-E focuses on two main aspects of social behavior:
the extent to which the respondent has acquired the actions necessary to maintain smooth human relationships
and the extent to which he/she has not acquired actions
hindering human relationships. Higher scores on the
SSS-E indicate greater skills. The SSS-E was created
for typically developing elementary school children;the instruments’ validity and reliability were verified by
Shimada [26].
Social Skills Self-Rating Scale for Adults. The
Social Skills Self-Rating Scale for Adults (SS-A) [27],a 35-item questionnaire using a 4-point Likert scale toassess social skills, was used to evaluate the social skillsof the parents by self-evaluation. Higher scores on the
SS-A indicate greater skills. The SS-A was created foruniversity students, and Aikawa et al. [27] examined its
validity and reliability.
Vineland Adaptive Behavior Scales, Second Edition. The Japanese version of the Vineland Adaptive Behavior Scales, Second Edition (VABS-II) [28] was used
for the information provider’s evaluation of the social
skills of children. It involves a semi-structured interview
with parents, and scores are calculated on a 3-point
Likert scale. The regional standard score of VABS-II has
a mean of 100, a standard deviation of 15 and is normally distributed. The adaptive behavior subscale (VABSA) evaluates three areas: interpersonal relations, play/leisure time, and coping skills. The higher the score, themore desirable the behavior. The maladaptive behavior

subscale (VABS-MA) examines internalized and externalized maladjusted behavior. The higher the score, theless desirable the behavior.
Role-Play Test for Children and Parents. The
Role-Play Test for Children and Parents (RPT-CP),developed by the authors based on a role-play test forindividuals with schizophrenia [29], was used for practitioners’ evaluations of social skills. The test evaluates
participants’ social skills through interaction with the examiner. The RPT-CP comprises five scenarios, including
one practice item and four skills—listening to others,
making requests, expressing positive feelings, and expressing unpleasant feelings—for each child and theirparents. The evaluation consists of 13 items in the areasof situational recognition (e.g., place, partner, facial
expression, purpose of the scene), coping skills (e.g.,
proposing coping method, correcting coping method),subjective evaluation (e.g., self-efficacy, anxiety), andtransmission skills (e.g., gaze, facial expression, voicechange, social validity, achievement of purpose). The
RPT-CP is acted out between an examiner and the child/parent and videotaped for subsequent scoring. The
RPT-CP typically takes 15–20 minutes for each participant. The examiner was the first author, but in order toavoid information bias, we asked another occupational
therapist and two clinical psychologists to be evaluators.
The evaluators were selected based on their experience
as SST leaders. They watched the video to evaluate
situation recognition and coping skills using a 3-point
Likert scale, and subjective evaluation and transmission
skills on a 5-point Likert scale. A total score for 11 items
was calculated, excluding the subjective evaluationfrom the analysis because the purpose of the evaluation
was to obtain objective data regarding skills. When theinter-rater reliability of the RPT-CP was assessed, theintraclass correlation coefficient was .858, confirming
high inter-rater reliability.
Parenting Stress Index-Japanese Version. The
Japanese version of the Parenting Stress Index (PSI) [30]was used to assess parental stress. It is a 78-item questionnaire using a 5-point Likert scale that assesses twodomains of parental stress: child domain (PSI-C), which
evaluates the adaptability of the child and how much he/she annoys the parents, and the parent domain (PSI-P),
which measures the competence of the parents and their
attachment to the child. A total score can also be calculated by adding the two domain scores, and the higher
the score, the higher the stress.
Statistical Analysis
The total scores on the RPT-CP, SSS-E, VABS-A,
VABS-MA, and SS-A, and the total score and subscalescores of the PSI before and after the intervention and at

Shibata K et al.

Asian J Occup Ther 17: 37−44, 2021

41

Table 3 Outcome Measures at Pre/Post Treatment and 3-Month Follow-Up
MeasureSSS-E
SS-A
VABS-II
VABS-A
VABS-MA
RPT-CPChildren
Parents
PSI total
PSI-C
PSI-P

Pre-treatment
M (SD)

Post-treatment
M (SD)

Follow-up
M (SD)Pre to post
p-value

Post to follow-up
p-value

36.4 ( 5.8)
86.4 (14.1)

37.5 ( 5.3)
87.8 (15.0)

36.9 ( 6.9)
93.2 (12.5)

.343
.244

.932
.004

75.3 (10.4)
20.1 (2.99)

72.9 ( 9.3)
20.3 ( 3.0)

72.3 ( 9.4)
19.5 ( 3.1)

.011
.596

.550
.204

94.6 (20.5)
122.8 ( 8.4)
234.2 (33.4)
113.2 (14.6)
121.1 (26.3)

105.5 (14.6)
130.1 (10.7)
235.3 (32.9)
111.4 (12.3)
123.9 (26.3)

110.7 (18.2)
135.4 ( 8.6)
225.6 (37.1)
106.2 (14.4)
119.4 (26.0)

.088
.005
.776
.463
.394

.209
.020
.019
.052
.058

Note. M, mean; SD, standard deviation; RPT-CP, Role-Play Test for Children and Parents; RPT-C, Role-Play Test forChildren; RPT-P, Role-Play Test for Parents; SSS-E, Social Skills Scale for Elementary School Children; VABS-A,
Vineland Adaptive Behavior Scales, Second Edition, Japanese version, Adaptive Behavior Subscale; VABS-MA,
Vineland Adaptive Behavior Scales, Second Edition, Japanese version, Maladaptive Behavior Subscale; SS-A, Social Skills Self-Rating Scale for Adults; PSI, Parenting Stress Index; PSI-C, Parenting Stress Index, Child Domain;
PSI-P, Parenting Stress Index, Parent Domain.

follow-up were calculated. Because of the small sample
size and use of ordinal scales, the Wilcoxon test waschosen to compare scores before and after the intervention, and scores after the intervention and at follow-up.
Statistical significance was set at two-tailed p < .05. Statistical analyses were performed using SPSS version 25
for Microsoft Windows. Mizumoto’s method was used
was to calculate the effect size [31].

Results
Children’s Social Skills
Table 3 shows the results of the evaluation performed in this study. The SSS-E score, which wasa self-evaluation, showed no significant differences
after the intervention or at follow-up. The information
provider evaluations, the VABS-II and VABS-A scores
decreased significantly after the intervention (z = −2.58,
p = .011), and the effect size was moderate (r = −.65);
however, there was no significant difference in the
VABS-MA scores. At follow-up, neither the VABS-A
nor VABS-MA scores changed. Regarding the RPT-CP,
which was the practitioner’s evaluation, the target skills
scores after the intervention showed a tendency to rise(z = 1.71, p = .088), but they did not change at follow-up.
Parents’ Social Skills
The SS-A score, which was a self-evaluation,
showed no significant changes after the intervention, but
increased significantly at follow-up (z = 2.91, p = .004),
and the effect size was moderate (r = .71). The RPT-CPscores indicated that the parents’ target skills increased
significantly after the intervention (z = 2.83, p = .005),
and the effect size was moderate (r = .71). Moreover, atfollow-up, the target skills scores increased significantly(z = 2.33, p = .020), and the effect size was moderate(r = .58).
Parental Childcare Stress
After the intervention, there were no significant
differences in total PSI, PSI-C, or PSI-P scores. At follow-up, the total PSI scores decreased significantly (z =−2.34, p = .019), and the effect was moderate (r = −.57),
but there were no significant differences in the PSI-C
and PSI-P scores.

Discussion
In this study, we explored the effectiveness of anew parent-child SST program to determine if there wasan improvement in parental and child social skills anda reduction in parenting stress, and whether the effects
were maintained. As a result, in the case of children,
the social skills showed a tendency to improve after theintervention, as indicated by the RPT-CP scores, butscores decreased on the VABS-A and did not change on
the SSS-E. At follow-up, no changes were seen in the
SSS-E, VABS-A, VABS-MA, and RPT-CP scores. For
parents, social skills after the intervention improved asmeasured by the RPT-CP but did not change according
to the SS-A scores. At follow-up, both RPT-CP and
SS-A scores improved, indicating that parents’ social
skills further improved. Parental stress did not decrease
after the intervention, but a significant reduction wasseen at follow-up.
Interestingly, parents’ self-evaluation did not show
improvement in general social skills immediately after
intervention but did at follow-up, even though the

42

EFFECTIVENESS OF THE PARENT-CHILD SST PROGRAM

RPT-CP score indicated immediate improvement. Thissuggests that there was a time lag between the practitioners’ evaluation and self-awareness. The experienceof receiving praise from the staff and other parents
during the program could have shifted the parents’ focus
of attention from wanting to enhance children’s behavioral changes to wanting to improve their own social
skills. The parents did not immediately recognize theirimprovement but were able to continue using the target
skills in their daily life until they were able to realize theeffects. To reduce mothers’ stress and anxiety about parenting, it is effective to consider childcare and acquireparenting skills [32]. The decreased PSI score indicatedthat the improvement in the parents’ self-assessmentof social skills led to enhanced parenting skills, which
resulted in a reduction in parenting stress.
Regarding the social skills of the children, thepractitioner’s evaluation showed a significant tendency
to improve after the intervention, but the information
provider’s evaluation worsened, and the self-evaluation
showed no change. The reason may be that the evaluator’s subjectivity may have influenced the scores: theparents’ expectation or changes of perception from theprogram experience for the information provider evaluation and the desires of the child for the self-evaluation[25]. Additionally, in a study in which SST was provided
to children with ASD and psychological education wasgiven to their parents, there was no change in children as
indicated by the information provider evaluation using
the Child Behavior Checklist [18]. However, improvement in the target skills according to the practitioner’s
evaluation is required. Thus, it may be necessary torevise the program to examine whether this goal is met.
Many of the previous studies on SST for neurodevelopmental disorders involved training programs withmore than 10 sessions [33–35]. Improvement in social
skills may be difficult to achieve in such a short period.
Currently, in Japan, programs aiming to support parents
must be provided over a short period of time becauseof difficulty in maintaining parents’ motivation andattendance to all the sessions [36]. As mentioned earlier,given that the social skills of parents improved after thisshort-term intervention, if parents use social skills in
the home and become a good model, the social skills of
their children may improve. Furthermore, a modificationin the presentation of homework and its step-to-stepstages may lead to the improvement of target skills. In
the future, we would like to verify the effects by setting
a long-term follow-up, such as 6 months and 1 year.
The participants in this study responded to open
recruitment, and it can be predicted that the parents werehighly motivated, for example, wanting their children
to acquire social skills, or perhaps parents themselves

seeking to improve their skills. Therefore, the observed
effects of the parent-child SST program may have been
limited to the parents, namely the improvement in parents’ social skills and reduction in parenting stress. It is
not clear whether the children were highly motivatedeven in open recruitment.
In this study, a scale had to be developed to evaluate
the role-play of children with neurodevelopmental disorders and their parents. The RPT-CP is an important scalethat can be used to evaluate whether the skills targetedin SST have been acquired [25]. This fact indicatesthat not only social skills training but also social skills
evaluation measures in this area are lacking. It may not
be possible to accurately evaluate all the target skills
using practitioners’ evaluation of behavior. Social skills
include social cognition (receiving skills) to recognize
oneself and the present situation; social problem solving
and decision-making (processing skills) to consider options for achieving personal goals in specific situations;and expressive skills (sending skills) exchanged in
actual situations [15]. The RPT-CP involves these three
information-processing processes, and we would like todevelop it for standardization in the future.
This study had several limitations. First, the sample
size was small, and there was no control group in thisstudy. In the future, the effects of the program shouldbe verified using a controlled research design. Second,the criteria for selecting children in this study was only
having neurodevelopmental disorders and their FSIQ.
During this program, some children were joking andunable to concentrate. Furthermore, the target children
had various diagnoses of neurodevelopmental disorders.
We would like to consider adaptation criteria for thisprogram in future studies, such as limiting target children to those having ASD.

Conclusions
The features of the parent-child SST program implemented in this study were that parents and children
learned the same skills using SST, playtime for thegeneralization was set up in accordance with the target
skills, and homework was performed at home. This
study showed that parents’ social skills improved after
the intervention and at follow-up, and parenting stressdecreased at follow-up. Since this program can be implemented over a short period in six sessions, it is considered easy to implement in clinical settings. However,in order to improve children’s social skills, it may benecessary to modify the program in ways such as how topresent homework. By implementing this program, it isexpected that the skills learned will be used in the home
and that communication between parents and children

Asian J Occup Ther 17: 37−44, 2021

will increase.

Acknowledgments
We would like to express our deep appreciation
to the parents and children who cooperated in implementing this program. We are also grateful to the staff
members who participated in the program from earlymorning: Rina Kobayashi, Kenya Kobayashi, Misako
Mitanoya, Maki Uchizawa, Hanae Hayashi, and thestudent staff. The abstract of this paper was presented at
the 50th the Japanese Occupational Therapy Congress in
Sapporo, Japan.

Conflict of Interest
The authors disclose no conflict of interest.

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■ORIGINAL ARTICLE

Effectiveness of Metacognitive Training
for Long-Term Hospitalized Patients with Schizophrenia:
A Pilot Study with a Crossover Design
Kyohei Fujii1, Masayoshi Kobayashi2, Koji Funasaka1,
Suguru Kurokawa1, Koji Hamagami1
1
2

Murai Hospital
Graduate School of Medicine, School of Health Science, Shinshu University

Abstract: Objective: This study aimed to explore the efficacy of metacognitive training (MCT) with long-term hospitalized patients with schizophrenia.
Methods: Patients admitted to a hospital’s long-term care ward were randomly allocated to Groups A or B, and a crossover trial was performed. As intervention, 16 weekly MCT sessions were performed for 4 months as part of standard
occupational therapy, and the participants’ cognitive functioning, psychiatric symptoms, overall functioning, and cognitive bias were assessed at baseline, 4 months later, and 8 months later.
Results: Twenty-two patients participated. Those who were discharged midway through the course, and those who
withdrew their consent were excluded, and 17 individuals (Group A: n = 9; Group B, n = 8) completed their assessments 8 months later. No significant differences were seen in inter-group comparisons of the scores of various scales atthe baseline. Four months and eight months later, a comparison between before and after MCT showed improvement
tendencies for both groups in the participants’ cognitive function and psychiatric symptoms. A comparison of scores
before and after the MCT intervention period, from all participants, showed significant improvement tendencies in theirverbal memory and attention.
Conclusion: MCT can be used for long-term hospitalization in patients with chronic-stage schizophrenia, and this study
showed its potential to improve neurocognitive function. Going forward, there is a need to increase the sample size andexamine the efficacy of MCT in more detail.
Keywords: schizophrenia, long-term hospitalization, cognitive rehabilitation, metacognitive training(Asian J Occup Ther 17: 45−52, 2021)

Introduction
In recent years, cognitive impairment has been considered the core impediment of schizophrenia [1, 2], andcognitive rehabilitation aimed at improving this is
attracting attention. Schizophrenia’s cognitive impairments include (a) disorders of neurocognitive function,such as attention, memory, working memory, verbal
fluency, executive function, and processing speed; and(b) cognitive biases such as tending to seek causes in
Received: 6 December 2020, Accepted: 4 February 2021
Corresponding to: Masayoshi Kobayashi, Graduate School of Medicine, School of Health Science, Shinshu University, 3-1-1, Asahi,
Matsu­moto, Nagano 390-8621, Japane-mail: mkobaya@shinshu-u.ac.jp©2021 Japanese Association of Occupational Therapists

external factors, rushing to conclusions, and passing
judgment with only minimal information and becomingstrongly convinced of it. Patients with schizophrenia are
liable to hold erroneous beliefs due to these cognitive
impairments that are deemed to affect their social functioning, such as daily living, interpersonal relations, andemployment [3, 4].
Moritz and Woodward [5] developed metacognitive
training (MCT) to correct cognitive bias in schizophrenia. MCT regards metacognition as “thinking about
thinking” or “cognition about cognition,” and positions
it as the ability to monitor one’s own cognitive bias andcontrol it [5–8]. MCT is a psychoeducational program
conducted individually or in groups, using the basic
theory of cognitive behavioral therapy as the background, with learning tasks presented, using a PowerPoint file. Participants complete their learning tasks and46

METACOGNITIVE TRAINING FOR SCHIZOPHRENIA PATIENTS

engage in group discussions while enjoying them, andaim to generalize the lessons gained in the sessions totheir daily lives and expand their problem-solving repertoires [5]. It includes 8 modules prepared in 2 cycles,
which are implemented over 16 weeks or 4 months.
A series of studies conducted by Moritz et al. confirmed that MCT is effective in mitigating the positive
symptoms of schizophrenia patients [5–8]. The Japanese
language edition of MCT was developed in 2012 by
Ishigaki [9], and is currently at the stage of having theeffects verified in Japan. Until now, improvements inthe stress handling of those with schizophrenia andmitigation of positive symptoms have been reported as
its training effects [10, 11]. Ishikawa et al. stated that theJapanese edition of MCT helped improve schizophrenia
patients’ positive symptoms (especially delusion) as well
as overall functioning and cognitive bias [12]. Improvement of elemental neurocognitive functions, such asattention and memory, is believed to be related to theimprovement of positive symptoms and cognitive bias.
However, no reports have thus far been published about
MCT’s effectiveness in improving neurocognitive
function in schizophrenia; its efficacy against long-term
hospitalized schizophrenia patients [13] has not been investigated, either. Therefore, this study aimed to explore
the possibility of using MCT with long-term hospitalized patients with schizophrenia in Japan as well as its
efficacy in improving their neurocognitive function.

Methods
ParticipantsParticipating in this study were patients who werediagnosed with schizophrenia by a psychiatrist, based on
the diagnostic criteria of the Diagnostic and Statistical
Manual of Mental Disorders 5th edition (DSM-5) [14],were admitted to a psychiatric hospital’s long-term careward, and were undergoing occupational therapy. As
part of the enrollment criteria for participation, individuals had to be between the ages of 20 and 65 years.
The following individuals were excluded: those withintellectual disability and a history of substance abuse
and/or dependence, dementia, epilepsy, head injury, andcerebrovascular diseases. Those with unstable disease
condition, e.g. those with refusal and/or significant lossof motivation, and those whom either a psychiatrist oran occupational therapist had determined as unfit forthe study were also excluded. We explained the purposeof the study to all the participants, both in writing andorally, and obtained their consent to participate. This
study was conducted after receiving the approval of
Shinshu University’s Medical Ethics Committee (Approval No. 3517).

Study design
A crossover trial was performed, with the participants
being allocated to two groups (A and B) via stratified
randomization that took their sex and age into consideration. In the first half of the follow-up period, GroupA had MCT added to their occupational therapy (OT)
sessions, while Group B received the usual OT only. In
the latter half of the follow-up period, MCT was added
to Group B’s OT sessions, while Group A received theusual OT only. Because the carryover effects of MCTs
were anticipated from the outset, no washout period
was established in this crossover design. The start of
the follow-up was based on the baseline assessment ofoutcome indicators. Assessment 2 was implemented inboth groups four months after Group A had completed
their MCT, and Assessment 3 was implemented in bothgroups eight months after Group B had completed their
MCT.
Interventions
MCT was conducted in a group setting. A 60-minuteweekly session was conducted 16 times over a period offour months. MCT modules included tasks that handled“causal attribution (simplistic attribution),” “jumping toconclusions,” “correction of beliefs,” “taking perspectives of others (the theory of mind),” memory (erroneous
overconfidence),” and “self-esteem.” In each session,
two occupational therapists assumed the role of a leader
and a co-leader, and used a projector to present PowerPoint teaching materials, encouraged verbal interactions
among the participants in accordance with the MCT
implementation manual [9], and ensured that the participants could tackle the tasks while enjoying them. By
way of information, in the usual OT, either an individual
or a group program lasting 1 to 2 hours per session wasoffered 4–5 times a week according to the participants’
individual wishes and goals. The program included lightphysical exercises, arts and crafts, psychoeducation, andother subjects.
MeasuresAt baseline, an occupational therapist used the participants’ medical records to gather data including basic
information: age, sex, number of years of education, ageof onset, disease duration, length of hospital stay, and thedose of antipsychotic drug(s) being taken (“medication”).
At the baseline, four measures were used: the Brief
Assessment of Cognition in Schizophrenia (BACS),
the Positive and Negative Syndrome Scale (PANSS),
the Global Assessment of Functioning (GAF), and theBeck Cognitive Insight Scale (BCIS). The BACS is acognitive function evaluation scale developed by Keefeet al. [15]. It comprises six sub-tests that measure verbal

Fujii K et al.

Asian J Occup Ther 17: 45−52, 2021

memory, working memory, motor speed, verbal fluency,
attention and processing speed, and executive function.
The results were evaluated using a standard score(z-score) that used 0 as the typically functioning participants’ population mean. The larger the z-score, thehigher is the person’s cognitive function. As a yardstickfor severity, −0. 5 ≤ −1.0 was judged as mild disorder,−1. 0 ≤ −1.5 was judged as a moderate disorder, and −1.
≤ 5 was judged to be a severe disorder. In this study, theJapanese language edition standardized by Kaneda et al.
[16] was used and evaluated by occupational therapists.
The PANSS, created by Kay et al. [17], is a scale
for assessing the mental state during schizophrenia. A
total of 30 items comprising 7 positive symptom items,
7 negative symptom items, and 16 general psychopathology items were evaluated, ranging from 30 to 210(1 = the mildest and 7 = most severe). The PANSS wasassessed by occupational therapists and psychiatrists.
The GAF is a scale featured in DSM-IV-TR [18],and evaluates a participant’s mental health and disease
condition based on the degree of severity and functional
level (the role played in society and occupation), using
a score ranging from 1 to 100. The higher the score, thehealthier one’s functional level is judged to be. The GAF
was evaluated by occupational therapists. The BCIS,
created by Beck et al. [19], is a self-report evaluation
scale that measures cognitive bias. The respondents
were asked to rate how much they agreed with each of
the 15 items by using a 4-point scale, (0 = do not agree
at all and 3 = agree completely). Self-Reflectiveness(SR) was compiled from nine items (range: 0–27), andSelf-Certainty (SC), from six items (range: 0–18). The
higher the SR score, the higher-level insight a person
has toward their thoughts, and the higher the SC score,
the stronger a person is convinced of their own thinking.
A composite index is calculated by subtracting the SC
score from the SR score (range: −18~27), and the higher
the score, the more appropriate a person’s cognitive
tendencies are judged to be. In this study, the Japanese
language edition of the BCIS produced by Uchida et al.
[20] was used, and was evaluated by occupational therapists.
Statistical analyses
An inter-group comparison was made among thedemographic characteristics and evaluation scale scoresat baseline as well as the scores of scales at Assessments
2 and 3. These scores of Groups A and B were also compared before and after MCT. Because the Shapiro-Wilk
test showed no normality of population, a nonparametricmethod was adopted. The Mann-Whitney U test wasused to compare Groups A and B, the Friedman test wasused for making before and after MCT comparisons in47

each group, the Scheffe method was used for multiple
comparisons, and the Wilcoxon signed-rank test wasused to compare the scores before and after MCT. Effectsize® was also calculated to confirm the size of thedifferences that were not affected by sample size. Bell
Curve for Excel Ver.3.21 was used for statistical analysis, and the significance level was less than 5%.

Results
Of the 43 patients hospitalized inside the long-termcare ward, 22 took part in this study. Eleven individuals
were randomly allocated to Groups A and B. During thefollow-up period, one individual in Group A was discharged from the hospital, and another individual withdrew their consent, while two individuals in Group B
were discharged, and another individual withdrew theirconsent. In the end, nine individuals in Group A (maleto-female ratio = 6 : 3), and eight in Group B (male-tofemale = 4 : 4) were analyzed (Figure 1).
Table 1 compares the two groups’ demographic data
and the results of assessments at baseline. No significant
differences were seen in a comparison between Groups
A and B in terms of the demographic data and the scalescores of the baseline, and Assessments 2 and 3.
Table 2 shows a comparison of Group A’s assessmentscores before and after MCT. Compared to baseline
scores, Assessments 2 and 3 (Friedman test), a significant increase in scores was seen in the BACS’ verbal
memory ( p < .05, r = .75), attention ( p < .05, r = .81),
executive function ( p < .05, r = .75), and composite
scores ( p < .01, r = .81). In the post-hoc test, a significant increase was seen between Assessments 2 and 3 inthe score for executive function ( p < .05, r = .84). In a
comparison of the PANSS scores via repeated measurement, a significant decrease in score was seen in positive
symptoms ( p < .01, r = .84), negative symptoms ( p <.05, r = .89), general psychopathology ( p < .05, r = .75),
and the PANSS total scores ( p < .01, r = .89), and, in the
post-hoc test, a significant difference was seen between
baseline and Assessment 2 in positive symptoms ( p <.05, r = .84), negative symptoms ( p < .05, r = .67), general psychopathology ( p < .05, r = .77), and the PANSS
total scores ( p < .01, r = .89). No significant differenceswere seen between medication and the scores for the
GAF and BCIS.
Table 3 shows Group B’s comparison of assessmentscores between before and after MCT. In a comparison
among baseline, Assessments 2 and 3, a significant
increase in scores was seen in the BACS verbal memory( p < .01, r = .84) and attention ( p < .05, r = .84), and,in the post-hoc test, a significant increase was seen
between Assessments 2 and 3 in both verbal memory ( p48

METACOGNITIVE TRAINING FOR SCHIZOPHRENIA PATIENTSEnrolment

Assessed for eligibility (n = 43)

Randomized (n = 22)

Excluded (n = 21)
・Not meeting inclusion
criteria (n = 13)
・Declined to participate (n= 8)Allocation
Group A (n = 11)・Received allocated intervention (n = 11)
・Did not received allocated intervention(n = 0)Group B (n = 11)・Received allocated intervention (n = 11)
・Did not received allocated intervention(n = 0)
Follow-up

OT + MCT
Lost to follow-up (n = 1)
・Withdrew consent (n = 1)
・ Discharge (n = 0)

OT alone
Lost to follow-up (n = 2)
・Withdrew consent (n = 1)
・ Discharge (n = 1)

OT alone
Lost to follow-up (n = 1)
・Withdrew consent (n = 0)
・ Discharge (n = 1)

OT + MCT
Lost to follow-up (n = 1)
・Withdrew consent (n = 0)
・ Discharge (n = 1)
AnalysisAnalysed (n = 9)

Analysed (n = 8)

Fig. 1. A1.CONSORT
flow diagram
crossoverdesignfor a randomized
trial
FigureA CONSORT
flowwith
diagramwithcrossoverdesign controlled
for a randomized
controlled trial< .05, r = .89) and attention ( p < .05, r = .74). Moreoverin a comparison of the PANSS scores via repeated measurement, a significant decrease in scores was seen in
negative symptoms ( p < .05, r = .57), and, in a multiple
comparison, a significant decrease in scores was seen
between baseline and Assessment 1 in negative symptoms ( p < .05, r = .78), general psychopathology ( p <.05, r = .84), and total score ( p < .05, r = .89). No significant differences were seen among dosage, the GAF, andBCIS.
The scores of various scales were compared before
and after MCT implementation for all participants (Table
4). A significant increase in scores was seen in the
BACS verbal memory ( p < .01, r = .73), attention ( p <.01, r = .64), and composite scores ( p < .05, r = .63), but
no significant differences were seen in the GAF, PANSS,BCIS, or medication.

Discussion
The participants were patients with schizophrenia
whose disease duration exceeded 30 years, and who had
been hospitalized for a long time in a psychiatric department’s long-term care ward. At baseline, the BACS
composite score was below −2.0 for both groups, show-

ing severe cognitive impairment. Moreover, from their
GAF, PANSS, and BCIS scores, the participants wereassumed to have low-level psychosocial functioning,
relatively severe psychiatric symptoms, and low SR.
The large dosage of antipsychotic drugs was believed
to reflect the participants’ unstable mental and physicalfunction. During the follow-up period, of the 19 participants a total of 17 individuals, or 89.47%, managed
to complete the OT program that included MCT. This
relatively high completion rate indicates the potential ofusing MCT in patients with chronic-stage schizophrenia
who are being admitted to a psychiatric hospital’s longterm care ward. There is a possibility that the advantagesof MCT, allowing the participants to tackle the tasks
while enjoying them, may have contributed to maintaining the participants’ motivation.
Past studies have reported improvement of positive
symptoms and cognitive bias with the use of MCT [5–8,
10–12], but no reports have thus far focused on the
improvement of neurocognitive function. Our study’s
repeated measurements performed at baseline, Assessments 2 and 3, showed improvement tendencies forverbal memory, attention, executive function, and composite score in Group A, and improvements for verbal
memory and attention in Group B (Tables 2 and 3). The

Fujii K et al.

Asian J Occup Ther 17: 45−52, 2021

49

Table 1 Demographic characteristics and baseline assessments results by treatment group (A; B)
Group A (n = 9)

VariableAge (years)
Sex• Male, n (%)• Female, n (%)
Age at onset (years)
Disease duration (years)
Education (years)
Length of hospital stays (months)
Medication (mg/day)
The BACS• Verbal memory• Working memory• Motor speed• Verbal fluency• Attention• Executive function• Composite score
The GAF
The PANSS• Positive• Negative• General psychopathology• PANSS total
The BCIS• Self-reflectiveness• Self-certainty• Composite index

Group B (n = 8)

Mean

(SD)

Mean

(SD)

Statistic
(U)

p

r

54.00

(7.60)

54.50(8.63)

33

0.77

0.07

6
3
22.22
31.78
12.17
71.67
1117.24(66.67)(33.33)(4.71)(6.16)(1.97)(89.79)(686.94)

4
4
21.13
33.38
12.63
103.751033.25(50.00)(50.00)(4.23)(10.43)(1.80)(106.87)(419.74)

χ = 0.48

0.49

0.17

30.5
29.5
32.5
30
36

0.59
0.53
0.72
0.56
1.00

0.13
0.15
0.09
0.14
0.00

−2.29
−2.47
−2.55
−1.18
−3.68
−2.11
−2.38
18.89

(1.13)(1.47)(1.60)(1.40)(1.49)(2.42)(1.15)(4.84)

−1.74
−2.55
−3.15
−1.69
−3.90
−1.44
−2.41
21.63

(0.69)(0.87)(0.83)(1.00)(1.01)(1.35)(0.37)(5.17)

25
32.5
24
27
36
31.5
32
26.5

0.29
0.74
0.25
0.39
1.00
0.66
0.70
0.36

0.11
0.07
0.15
0.41
0.14
0.01
0.05
0.41

28.00
27.33
53.33
108.67(5.98)(9.82)(10.56)(22.87)

23.50
28.75
54.75
107.00(6.26)(7.19)(11.71)(22.91)

21.5
33.5
35.5
30

0.16
0.81
0.96
0.56

0.20
0.16
0.08
0.02

11.00
6.11
4.89

(3.43)(2.47)(5.22)

12.38
6.25
6.13

(4.18)(4.15)(4.54)

29
35
35

0.50
0.92
0.92

0.16
0.20
0.18

2

Note. Mann-Whitney U test. SD, standard deviation. r, Effect size
BACS, Brief Assessment of Cognition in Schizophrenia; GAF, Global Assessment of Functioning; PANSS, Positive and
Negative Syndrome Scale; BCIS, Beck Cognitive Insight Scale; Medication, Antipsychotic medication (chlorpromazine
equivalence).

Table 2 Comparison of the BACS, GAF, PANSS, and BCIS Scores of Group A
Variable
The BACS• Verbal memory• Working memory• Motor speed• Verbal fluency• Attention• Executive function• Composite score
The GAF
The PANSS• Positive• Negative• General psychopathology• The PANSS total
The BCIS• Self-reflectiveness• Self-certainty• Composite index
Medication (mg/day)Baseline

Assessment 2

P

Assessment 3

Mean

(SD)

Mean

(SD)

Mean

(SD)

p0

−2.29
−2.47
−2.55
−1.18
−3.68
−2.11
−2.38
18.89

(1.13)(1.47)(1.60)(1.40)(1.49)(2.42)(1.15)(4.84)

−1.55
−2.18
−2.83
−0.70
−2.64±
−1.96
−1.98
20.78

(0.93)(1.31)(1.33)(1.27)(1.75)(2.77)(1.15)(3.94)

−1.31
−2.06
−2.64
−0.70
−2.59
−1.4
−1.78
22.44

(1.17)(1.27)(1.19)(1.25)(1.59)(1.82)(0.93)(4.06)

*

28.00
27.33
53.33
108.67(5.98)(9.82)(10.56)(22.87)

23.33
22.89
47.00
93.22

(5.64)(5.65)(11.59)(20.33)

22.78
22.89
46.56
92.22

(5.61)(8.27)(12.39)(22.89)

11.00
6.11
4.89
1117.2(3.43)(2.47)(5.22)(686.9)

11.33
6.00
5.33
985.9

(3.40)(2.21)(5.16)(629.5)

12.22
5.44
6.78
1039.1(4.26)(2.22)(5.59)(623.1)

p1

*
*
**
**
*
*
**

r
p2

*

*
*
*
**

r0

r1

r2

.75
.47
.10
.40
.81
.75
.81
.77

.65
.38
.30
.42
.65
.14
.61
.54

.22
.11
.57
.22
.30
.84
.57
.46

.84
.89
.75
.89

.84
.67
.77
.89

.23
.06
.14
.14

.16
.16
.21
.39

.02
.04
.08
.53

.23
.28
.42
.53

Note. n = 9. Friedman test. SD, standard deviation. r, Effect size
* p < 0.05, ** p < 0.01. p0 is a comparison of the three assessments by the Friedman test. p1 shows a comparison between baseline and assessment 2,
and p2 shows a comparison between assessments 2 and 3 (Scheffe). r0 represents the effect size for the comparison of the three assessments,
r1 represents the comparison between the baseline and the second assessment, and r2 represents the effect size for the comparison between thesecond and third assessments.
BACS, Brief Assessment of Cognition in Schizophrenia; GAF, Global Assessment of Functioning; PANSS, The positive and negative syndrome
scale; BCIS, Beck Cognitive Insight Scale; Medication, Antipsychotic medication (chlorpromazine equivalence).

50

METACOGNITIVE TRAINING FOR SCHIZOPHRENIA PATIENTSTable 3 Comparison of the BACS, GAF, PANSS, and BCIS Scores of Group B
Baseline

Variable
The BACS• Verbal memory• Working memory• Motor speed• Verbal fluency• Attention• Executive function• Composite score
The GAF
The PANSS• Positive• Negative• General psychopathology• The PANSS total
The BCIS• Self-reflectiveness• Self-certainty• Composite index
Medication (mg/day)Assessment 2

P

Assessment 3

Mean

(SD)

Mean

(SD)

Mean

(SD)

p0

−1.74
−2.55
−3.15
−1.69
−3.90
−1.44
−2.41
21.63

(0.69)(0.87)(0.83)(1.00)(1.01)(1.35)(0.37)(5.17)

−1.65
−2.47
−2.62
−1.99
−3.72
−1.42
−2.31
22.38

(1.01)(0.76)(1.14)(1.33)(1.15)(1.23)(0.39)(3.50)

−0.94
−2.19
−2.30
−2.03
−2.71
−1.52
−1.95
21.63

(1.13)(1.27)(0.92)(1.35)(1.00)(2.37)(0.78)(2.69)

23.50
28.75
54.75
107.00(6.26)(7.19)(11.71)(22.91)

21.88
23.75
47.25
92.88

(6.37)(4.84)(7.66)(15.28)

22.38
24.25
48.88
95.50

(4.72)(5.12)(6.81)(12.59)

12.38
6.25
6.13
1033.3(4.18)(4.15)(4.54)(419.7)

12.25
4.5
7.75
968.8

(4.41)(2.78)(4.84)(521.5)

12.50
3.88
8.63
1014.9(3.77)(2.89)(3.97)(521.1)

r
p2

r0

r1

r2

**

*

*

*

.84
.04
.78
.42
.84
.05
.64
.03

.24
.31
.48
.36
.24
.00
.35
.15

.89
.05
.24
.42
.74
.05
.50
.05

.06
.57
.42
.45

.27
.78
.84
.89

.11
.15
.30
.08

.05
.37
.15
.05

.03
.67
.47
.43

.00
.05
.27
.05

*

p1

*
*
*

Note. n = 8. Friedman test. SD, standard deviation. r, Effect size
* p < 0.05, ** p < 0.01. p0 is a comparison of the three assessments using the Friedman test. p1 shows a comparison between baseline andassessment 2, and p2 shows a comparison between assessments 2 and 3 (Scheffe). r0 represents the effect size for the comparison of the threeassessments, r1 represents the comparison between the baseline and the second assessment, and r2 represents the effect size for the comparison
between the second and third assessments.
BACS, Brief Assessment of Cognition in Schizophrenia; GAF, Global Assessment of Functioning; PANSS, Positive and Negative Syndrome
Scale; BCIS, Beck Cognitive Insight Scale; Medication, Antipsychotic medication (chlorpromazine equivalence).

Table 4 Changes in the BACS, GAF, PANSS, and BCIS Scores before and after the MCT period
Variable
The BACS• Verbal memory• Working memory• Motor speed• Verbal fluency• Attention• Executive function• Composite score
The GAF
The PANSS• Positive• Negative• General psychopathology• The PANSS total
The BCIS• Self-reflectiveness• Self-certainty• Composite index
Medication (mg/day)

Before (n = 17)

After (n = 17)

Mean

(SD)

Mean

(SD)

Statistic
(W )

−1.99
−2.47
−2.58
−1.56
−3.7
−1.78
−2.35
20.53

(1.12)(1.19)(1.41)(1.42)(1.34)(1.98)(0.88)(4.60)

−1.26
−2.19
−2.58
−1.33
−2.67
−1.75
−1.96
21.18

(1.07)(1.29)(1.18)(1.47)(1.45)(2.60)(1.00)(3.43)

13
59
68
62
21
66
22
30.5

0.003**
0.41
1.00
0.76
0.009**
0.62
0.01**
0.30

0.73
0.20
0.00
0.08
0.64
0.12
0.63
0.26

25.12
25.65
50.47
101.24(6.88)(8.08)(9.79)(21.19)

22.88
23.53
47.88
94.29

(5.25)(5.45)(9.68)(17.17)

27
33
48
35.5

0.11
0.13
0.13
0.05

0.39
0.37
0.33
0.47

11.59
5.35
6.24
1047.4(3.97)(2.74)(5.24)(619.1)

11.88
5.00
6.88
999.5

(3.63)(2.77)(4.92)(581.2)

66.5
50.5
57.5
62

0.94
0.90
0.59
0.76

0.02
0.03
0.13
0.08

P

r

Note. Wilcoxon signed-rank test. SD, standard deviation. r, Effect size
* p < 0.05, ** p < 0.01
In Group A, the score change from baseline to Assessment 2 was compared, and in Group B, the score change from
Assessment 2 to Assessment 3 was compared.
BACS, Brief Assessment of Cognition in Schizophrenia; GAF, Global Assessment of Functioning; PANSS, Positive and
Negative Syndrome Scale; BCIS, Beck Cognitive Insight Scale; Medication, Antipsychotic medication (chlorpromazine
equivalence).

Fujii K et al.

Asian J Occup Ther 17: 45−52, 2021

effect size, which represents the amount of changes inverbal memory, attention, and composite score, waslarge between baseline and Assessment 1 for Group A(r1 = .65, r1 = .65, r1 = .61), while it had a tendency to
be large between Assessments 2 and 3 for Group B(Table 3; r2 = .89, r2 = .74, r2 = .50). These results
show that, with the intervention of MCT, items such asverbal memory and attention, in particular, were liable
to become activated, and a comparison made between
before and after the MCT intervention period (Table4) also suggested MCT’s effects in improving verbal
memory and attention.
In the MCT learning program, tasks are presented repeatedly on PowerPoint slides. Participants are assumed
to turn their attention to the tasks that are being shown,
explore the detailed information, memorize information, and, by constructing a story or listening to otherparticipants’ opinions, see the activation and applicationof their cognitive functions. Improvement of verbal
memory and attention may have been affected by the activation of cognitive functions such as these. Moreover,in Group A, even in Assessment 3, which took place
four months after the end of MCT, the participants’cognitive function was maintained or showed tendencies
toward improvement, suggesting the possibility thatthe improvement of neurocognitive function by MCT
may be maintained by the continuation of OT. Further
consideration of OT interventions will be needed to promote working memory, motor speed, verbal fluency, andexecutive function.
As shown in Tables 2 and 3, changes in the PANSS
scores tended to be large between the baseline andAssessment 1 for both Groups A and B. No significant
differences were seen in a comparison between before
and after the MCT intervention (Table 4). Participants inGroup B showed a reduction in the PANSS scores before
intervention with MCT, so there is a possibility that factors other than MCT may have worked to improve their
psychiatric symptoms. Previous studies have reported
that MCT is effective in improving delusion and otherpositive symptoms [21]. In this study, as shown in Table
4, although tendencies toward improvement for verbal
memory and attention were seen after intervention with
MCT, no significant changes were seen in psychiatric
symptom scores. Further investigation is therefore
needed to examine the relationship between the improvement of psychiatric symptoms and neurocognitive
function.
Cognitive bias governs a person’s judgment and decision-making, and affects their social functioning [19,20]. Lam et al. [22] performed MCT in patients withschizophrenia at a frequency of two times a week andreported that, compared to the control group, the MCT

51

intervention group saw a significant improvement in the
BCIS SR scale and comprehensive evaluation scores.
Ochoa et al. [23] implemented either MCT or psychoeducation with patients having recent-onset psychosis andreported that the BCIS performance results were superior in the group with which MCT had been implemented.
In our study, the composite index of the BCIS showed
an increasing tendency for both groups, suggesting the
mitigation of cognitive bias. However, no statisticallysignificant differences were seen in the changes in thescores. The participants of this study were patients withschizophrenia who were hospitalized in a long-termcare ward and suffered severe neurocognitive disorderand moderate psychiatric symptoms. A reduction inreactivity, frequently seen in schizophrenia patients who
follow a chronic course, may be related to the lack ofimprovements in cognitive bias.
Study limitations and future research
A limitation of this study is its small sample size.
Another limitation is that interventions and assessments
were not blinded. A third limitation is the possibility that
other psychiatric services, which included daily living
inside a ward during the follow-up period, were notcontrolled, so confounding factors may have influenced
the results. There is also a need to recognize that the tendency for verbal memory and attention to improve, seenby the intervention of MCT, is not the single-handed
effect of MCT, but was obtained by the concurrent use
of OT. It is therefore necessary to position this study asa preliminary research. Future studies should increase
the sample size, control the method of interventions to
the extent possible, and investigate, in detail, MCT’s
efficacy on neurocognitive functioning, psychiatric
symptoms, and cognitive bias, including the influenceof age, sex, length of hospital stay, disease duration, andother factors.

Conclusion
This study showed that MCT can be used with longterm hospitalized patients with schizophrenia. The useof MCT indicated a tendency for schizophrenia patients’neurocognitive function (especially verbal memory andattention) to improve, and the improvement effects continued even after four months. No significant improvements were seen in the PANSS, GAF, and BCIS scores
before and after MCT interventions. No improvements
in cognitive bias attributable to MCT were seen. Goingforward, there is a need to increase the sample size and,at the same time, control the confounding factors, andinvestigate in detail the efficacy of MCT in neurocognitive function, psychiatric symptoms, and cognitive bias.

52

METACOGNITIVE TRAINING FOR SCHIZOPHRENIA PATIENTS

Conflict of Interest
The authors declare no conflicts of interest.

Acknowledgements
The authors thank all the participants involved in thisstudy. They also thank the Medical Corporation Murai
Hospital for their support with this study. We would
like to thank Editage (www.editage.com) for English
language editing.

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■RAPID COMMUNICATIONS

Relationship between Emotional Peer Support Networks
and Subjective Recovery of People
with Mental Illness Living in the Community
Kazuki Yokoyama1, 2, Shigeya Yabe2, 3, Takafumi Morimoto1, Nozomu Ikeda1
1

Department of Occupational Therapy, School of Health Sciences, Sapporo Medical University
Hokkaido Peer Support Association
3
Multi-functional office: PEER + design
2

Abstract: Purpose: This study determined the relationship between having an emotional peer support network (i.e.
people experiencing similar mental health difficulties) and aspects of subjective recovery in people with mental illness.
Methods: In total, 37 participants with mental illness living in the community were divided into high/low emotional
peer support groups using the Emotional Support Network Scale. Subjective recovery was evaluated using the Recovery Assessment Scale (RAS). Total and individual factor scores of subjective recovery between the two groups werecompared with an unpaired t-test, and effect size were calculated.
Results: Participants were categorized into high (n = 18) and low (n = 19) emotional support (ES) network groups. For
demographic and clinical characteristics and the total score of RAS, the groups had no significant differences. However,high ES was significantly higher in “no domination by symptoms” and “willingness to ask for help”, showed medium
effect size.
Discussion: People with high levels of emotional peer support felt less affected by symptoms and were more willing to
ask for help, which affected their recovery. This result reflects elements of peer support, like using experiential knowledge and recovery role models. In occupational therapy, emotional support among clients through group therapy andenvironmental adjustment is critical for recovery.
Keywords: mental illness, social support, peer support, emotional support network, subjective recovery(Asian J Occup Ther 17: 53−56, 2021)

Introduction
Recovery involves developing new meaning andpurpose in life as one overcomes catastrophic effects ofmental illness [1]. This is supported when the resulting
treatment is person-centered, strengths-based, andcommunity-focused, and enhances natural support [2].
“Optimism,” “recognition of emotional support network,”and “hobbies and enjoyment” are factors that significantly promote subjective recovery [3]. Occupational
therapists should be conscious of such in psychiatricrehabilitation. Especially, the emotional support network
Received: 26 November 2020, Accepted: 4 February 2021
Corresponding to: Kazuki Yokoyama, Department of Occupational
Therapy, School of Health Sciences, Sapporo Medical University,
South-1, West-17, Chuo-ku Sapporo, Hokkaido, Japane-mail: k.yokoyama@sapmed.ac.jp©2021 Japanese Association of Occupational Therapists

composed of close persons like family, friends, andhealth care professionals, which is important in reducing
stress [4]. Because people with mental illness living in
the community are affected by symptoms, disorders,public stigma, and self-stigma [5], emotional support isimportant in reducing negative psychological responses
and participating in society.
Recently, peer support has garnered attention as acomponent of community mental health welfare. The
Ministry of Health, Labour and Welfare has indicatedits importance for people with mental illness [6]. People
experiencing similar mental health difficulties (i.e.
“peers”) obtain security and self-affirmation when sharing their emotions [6]. Thus, emotional peer support may
be included in the recovery of people with mental illness.
In occupational therapy, group programs encourage
clients’ emotional support. In addition, occupational
therapists must collaborate with and empower people
with mental illness, and utilize peer support. However,

54

EMOTIONAL PEER SUPPORT AND SUBJECTIVE RECOVERY

the aspects of recovery affected by emotional peer support networks have been unidentified. Thus, this study
explored the relationship between an emotional peer
support network and aspects of subjective recovery inpeople with mental illness. The basic assumption is thatparticipants with high levels of emotional peer support
from their networks have better outcomes in aspects ofsubjective recovery.

Methods
This was a cross-sectional study using a self-reported
questionnaire conducted from September 2018 to February 2019, approved by the institutional review board at
Sapporo Medical University (approval number 30-2-8).
Participants gave written informed consent.
ParticipantsParticipants were from two employment support
facilities and one mental health workshop in Hokkaido,
Japan. All were diagnosed with a mental illness bytrained psychiatrists according to the ICD-10. The inclusion criteria were: (i) aged over 20 years; (ii) livingin the community; and (iii) no history of head injury,
mental retardation, or serious medical disease like lossof consciousness. Participants who had difficulty understanding ethical considerations and/or questionnaire
items were excluded.
Measurements
1) Demographic and clinical data
Demographic variables were age, sex, residence
status, and employment status. Clinical variables comprised mental illness duration and diagnosis.
2) Emotional support network
Emotional support was measured using the Emotional
Support Network Scale (ESNS) [4], which has 10 items
like “someone who is always able to guess how I am
feeling,” and assesses perception of emotional support
from specified others, designated here as “people experiencing similar mental health difficulties.” Participants
rated each item using a yes/no scale (No = 0, Yes = 1).
Higher scores indicated a higher emotional support network.
3) Subjective recovery
The Japanese version of the Recovery Assessment
Scale (RAS) measured subjective recovery [7]. It has
five factors: (1) goal/success orientation and hope; (2)reliance on others; (3) personal confidence; (4) no domination by symptoms; (5) willingness to ask for help. It
includes items, like “I have a desire to succeed,” with
5-point Likert response options from 1 (strongly disagree) to 5 (strongly agree). Higher total scores indicate

more advanced states of recovery.
Data analysis
Descriptive statistics were calculated for demographic
and clinical characteristics, and the two scales. The
ESNS score was divided into high level (High ES)
and low level (Low ES); the former for eight points or
higher, and the latter for seven points or less , based on
criteria used in prior research [4]. The variable distribution normality was verified using the Shapiro-Wilk
test. All variables except for ESNS score conformed to atheoretical normal distribution. We used t-tests to compare the averages of continuous variables and chi-square
tests to compare the proportions of categorical variables
between the groups. Effect sizes were calculated using
Cohen’s d [8]. The effect size thresholds are small =0.20, medium = 0.50, and large = 0.80. Furthermore,
the Mann-Whitney U test was used on each quantitative
factor from the ESNS. IBM SPSS Statistics for windows,
version 25.0 J (IBM Corp., Armonk, N.Y., USA) wasused for statistical analyses, with significance level at
5% for all tests.

Results
ParticipantsParticipants were categorized into High ES (n = 18)
and Low ES (n = 19). Medians of the ESNS scale were9.50 (Interquartile Range = 9.00–10.00) for the former
and 5.00 (Interquartile Range = 1.00–6.00) for theformer. Their demographic and clinical characteristics
are shown in Table 1. The groups had no significant
differences on the variables.
Relationship between emotional peer support networkand subjective recovery
Table 2 presents the RAS scores differences between
the groups. For the total RAS score, there was no significant difference (t = 1.984, p = 0.055, Cohen’s d = 0.661).
Analyzing individual factors, High ES was significantly
higher in “no domination by symptoms” (t = 2.075, p =0.045, Cohen’s d = 0.687) and “willingness to ask forhelp” (t = 2.175, p = 0.036, Cohen’s d = 0.726), showed
medium effect size. However, in “goal/success orientation and hope” (t = 1.750, p = 0.089, Cohen’s d = 0.585),“reliance on others” (t = 0.274, p = 0.786, Cohen’s d =0.091), and “personal confidence” (t = 1.638, p = 0.110,
Cohen’s d = 0.545), no significant differences existed.

Discussion
High ES gave stronger ratings of “no domination by
symptoms” and “willingness to ask for help” in subjec-

Yokoyama K et al.

Asian J Occup Ther 17: 53−56, 2021

55

Table 1 Demograhics and clinical characteristics of participants
Emotional support network

Group differences

P-value5.00 (1.00–6.00)

U = 0.000< 0.001

41.11 ± 8.05

t = 0.281

0.781

2

High ES (n = 18)

Low ES (n = 19)

ESNS, Median (IR)9.50 (9.00–10.00)

Age, Mean ± SD

40.39 ± 7.24

Sex, n (%)

Male
FemaleOther

9 (50%)
9 (50%)
0 ( 0%)

7 (37%)
11 (58%)1 ( 5%)

χ = 1.424

0.491

Resident status, n (%)

SingleLiving with familyGroup home
Others7 (39%)
9 (50%)
1 ( 6%)
1 ( 6%)

8 (42%)
8 (42%)
2 (11%)
1 ( 5%)

χ2 = 0.432

0.934

Employment status, n (%)

Full-time job
Part-time job
Non-working

5 (28%)
6 (33%)
7 (39%)

4 (21%)
4 (21%)
11 (58%)χ2 = 1.374

0.503

13.00 ± 6.93

12.77 ± 9.57

t = 0.083

0.934

8 (44%)
7 (39%)
1 ( 6%)
2 (11%)

5 (26%)
11 (58%)2 (11%)
1 ( 5%)

χ2 = 2.441

0.486

Duration of illness in years, Mean ± SD
Diagnosis, n (%)

Schizophrenia
Mood disorders
Disorders of psychological development
Other

ES, Emotional Support; ESNS, Emotional Support Network Scale; IR, Interquartile Range; SD, Standard Deviation
Note: The results of the demographic and clinical characteristics data in High ES and Low ES groups were shown. The variables were matchedbetween the groups.

Table 2 The difference between the groups of RAS scores
Emotional support network

RAS

Total
Goal/success orientation and hope
Reliance on others
Personal confidence
No domination by symptoms
Willingness to ask for help

High ES (n = 18)

Low ES (n = 19)

Mean ± SD

Mean ± SD

90.67 ± 14.27
35.50 ± 6.60
15.11 ± 2.75
17.61 ± 4.04
7.89 ± 1.79
14.56 ± 2.54

80.95 ± 15.09
31.84 ± 5.91
14.84 ± 3.13
15.37 ± 4.17
6.32 ± 2.67
12.58 ± 2.89

Group differences

P-value

Effect size
(Cohen’s d)t = 1.984
t = 1.750
t = 0.274
t = 1.638
t = 2.075
t = 2.175

0.055
0.089
0.786
0.110
0.045
0.036

0.661
0.585
0.091
0.545
0.687
0.726

SD, Standard Deviation; RAS, Recovery Assessment Scale
Note: The results of the difference between the groups of RAS total and five factors scores were shown. There were significant differences in “Nodomination by symptoms” and “Willingness to ask for help” of RAS factors between the groups.

tive recovery, suggesting that participants who perceived
high levels of emotional peer support felt less affectedby symptoms and were more help-seeking. According toa previous study, psychiatric symptoms were not associated with network size and satisfaction of social support[9]. Open peer support providers who shared their experiences built trust with clients and served as recoveryrole models [10]. They gave experience-based advice
and conveyed information better [11]. Such characteristics of peer support may be related to these results.
This study has limitations. First, due to cross-sectional
design, causality cannot be determined. Thus, the op-

posite relationship (i.e. greater recovery leads to higher
emotional support) may exist. Second, small sample sizeand focus on Japan limit generalizability. Third, becauseof the self-reported questionnaire, instruments used
might not measure actual emotional support and recovery. In the future, we will investigate causal relationshipand use objective measures.

Summary and Conclusions
We determined the relationship between emotional
peer support networks and subjective recovery in people

56

EMOTIONAL PEER SUPPORT AND SUBJECTIVE RECOVERY

with mental illness, specifically in relation to no domination by symptoms and willingness to seek help. In
occupational therapy, it is critical for clients’ recovery
to naturally foster their emotional support. To illustrate,group programs allowing clients to share emotional
support is effective. However, since the pace of interpersonal relationship formation differs from one person toanother, the client’s individuality must be respected so
as not to impose the therapist’s agenda on clients but totailor treatment to individual needs.

Conflict of interest
No conflicts of interest.

Acknowledgments
This was supported by the Japan society for thepromotion of science KAKENHI (grant number JP18K
17753). The authors wish to thank all participants andstaff who facilitated data collection. This paper was
supported by Sapporo Medical University.

References[1] Anthony WA. Recovery from Mental Illness: The Guiding Vision of the Mental Health Service System in the
1990s. Psychosoc Rehabil J. 1993; 16(4): 11–23.
[2] Slade M. 100 ways to support recovery, 2nd edition.
[online]. 2013 London: Rethink Mental Illness [Cited
2018 June 13]. Available from: http://www.recovery.awh.
org.au/images/new/PDF_Documents_upload/100_ways_
to_support_recovery_2nd_edition1.pdf.
[3] Fujimoto Y, Fujino Y, Kusuba Y. Factors influencing therecovery of persons with mental disorder living in thecommunity (in Japanese). Jpn Bull Soc Psychiat. 2013;
22: 20–31.
[4] Munakata K. Emotional support network scale. In:
Public Health Research Foundation, editors. Stress scaleguidebook (in Japanese). Tokyo: Jitsumukyoiku-shuppan;
2004; 404–5.
[5] Yokoyama K, Kodama S, Morimoto T, Ichihara-Takeda
S, Ikeda N. The process of forming and coping with
self-stigma of people with mental disorders living in thecommunity: a qualitative study (in Japanese). The Japanese Occupational Therapy Research (sagyouryouhou).
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[6] Ministry of Health, Labour and Welfare. Support services
for persons with mental disorders [online]. [cited 2019
July 8]. Available from: https://www.mhlw.go.jp/file/05Shingikai-12601000-Seisakutoukatsukan-Sanjikanshitsu_
Shakaihoshoutantou/0000098140.pdf.
[7] Chiba R, Miyamoto Y, Kawakami N. Reliability andvalidity of the Japanese version of the Recovery Assessment Scale (RAS) for people with chronic mental illness:
Scale development. Int J Nurs Stud. 2009; 47(3): 314–22.
[8] Cohen J. Statistical power analysis for the behavioral sciences, 2nd ed. Hillsdale: Lawrence Erlbaum Associates;
1988.
[9] Corrigan PW, Phelan SM. Social support and recovery inpeople with serious mental illnesses. Community Ment
Health J. 2004; 40(6): 513–23.
[10] Miyamoto Y, Sono T. Lessons from peer support amongindividuals with mental health difficulties: a review ofthe literature. Clin Pract Epidemiol Ment Health. 2012; 8:
22–9.
[11] Proudfoot G, Jayawant A, Parker G, Manicavasagar V,
Smith M, Nicholas J. Mechanisms underpinning effective peer support: a qualitative analysis of interactions
between expert peers and patients newly-diagnosed withbipolar disorder. BMC Psychiatry. 2012; 12: 196.

■ORIGINAL ARTICLE

Examining the Linguistic Equivalency andCross-Cultural Adaptation of the Sensory Processing
and Self-Regulation Checklist- Tagalog Version
Ivan Neil Benitez Gomez1, 2, Pauline Grace G. Morato-Espino1, 2,
Cynthia YY Lai3
1

Center for Health Research and Movement Science, University of Santo Sto. Tomas, Manila, Philippines
Department of Occupational Therapy, College of Rehabilitation Sciences, University of Santo Sto. Tomas, Manila, Philippines
3
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR
2

Abstract: Children’s ability to adequately process sensory information from their environments contribute to the development of self-regulation. The increasing prevalence of sensory processing difficulties in both clinical and normative
childhood population underscores the need for assessment. However, in the Philippine context, there is no crossculturally validated tool that measures sensory processing and self-regulation among children. Both language equivalency and cultural-relevance should be addressed when translating health-related outcomes. In this study, the accuracyof linguistic equivalency and cultural relevance of the Tagalog version of the Sensory Processing and Self-Regulation
Checklist (SPSRC) was validated. Using a multi-step process of forward translation, equivalence of translation testing,backward translation, face, and content validation, and cross-cultural adaptation inquiry, the SPSRC-Tagalog was examined. Adaptation of colloquial English terms was incorporated, and several items whose examples were deemed notculturally relevant were modified to reflect the language and culture it is intended for. The findings in this study support
the linguistic equivalency and cultural-relevance of the SPSRC-Tagalog as a single measure of sensory processing
and self-regulation abilities of Tagalog-speaking Filipino children that can be used by Filipino occupational therapists.
Future studies should further examine its psychometric properties in the target population.
Keywords: linguistic equivalence, cross-cultural adaptation, Tagalog version of the Sensory Processing and Self-Regulation Checklist, translation(Asian J Occup Ther 17: 57−63, 2021)

Introduction
Sensory processing refers to the ability to detectand organize sensory information from the environment
and integrate them in order for appropriate responses tobe generated [1, 2]. The prevalence of sensory processing difficulties among children has been seen in bothclinical and general populations. For example, children
with neurodevelopmental disabilities, sensory processing difficulties were seen in as much as 80% [3]; while
Received: 2 July 2020, Accepted: 15 April 2021
Corresponding to: Ivan Neil Benitez Gomez, Rm. 124 St. Martin dePorres Building, University of Santo Tomas, España Boulevard, Sampaloc, Manila, 1015 Philippines
e-mail: ibgomez@ust.edu.ph©2021 Japanese Association of Occupational Therapists

records have been documented to be between 5–28%
among typically developing children [4, 5]. Sensory
processing difficulties affect children’s ability to participate in occupations [1, 2], and the developmentof self-regulator abilities necessary for higher orderfunctional skills [6]. This underscores the importancemeasuring sensory processing and self-regulation amongchildren. However, in the Philippine context, there is no
known cross-culturally relevant and validated tool thatmay do so.
The adaptation of health-related measurement tools
developed in Western countries has been a common
worldwide clinical practice [7]. A similar trend can also
be observed among developing countries, such as thePhilippines [8, 9]. The pressure to adopt an evidencebased practice, the use of psychometrically tested outcome measures, lack of financial and temporal resourc-

58

SPSRC-TAGALOG TRANSLATIONes, and growing interest in cross-cultural comparisonsamong normative and clinical groups have motivatedthis paradigm shift [7, 10].
The most basic process of cross-cultural adaptationof health-related measurement tools involves translationfrom the original text to the intended language of use[11–13]. However, this mere translation may pose to be
more problematic than helpful. The existence of culturedependent concepts may lead to misinterpretation whenitems on a tool are translated into the target language[8, 10]. Literal translations may disregard language
form and content. Thus, when a translation is hastily
performed, the original meaning behind the items maychange, alongside its intended constructs and its psychometric properties [7, 10–13].
Translation of health-related measurement tools
entails the careful translation of their meaning into thetarget language. Language equivalency is a suggested
criterion that should be mindfully integrated into thetranslation procedures. Several translation procedures
can be seen in the literature, but the most common
methods involve forward and backward translation. In
forward translation, a bilingual expert translates theoriginal instrument from the original language to thetarget language. In the backward translation procedure,an independent bilingual expert translates the instrument
back to its original form. Experts are then recruited tocompare the backward translated instrument with theoriginal one to detect inconsistencies [14–16]. Morerecently, the use of an expert panel to determine language equivalency has been suggested [16]. This may
take several forms. One approach recruits an expert
panel that evaluates the forward translated instrument
and looks at whether the translated items contain thesame meaning within the target language [11, 17].
While these approaches are useful, they might belimited to the form and content of the language, and noton the cultural relevance of the items. The physical objects or materials, and the level of familiarity, meaning,and value an individual places on them are not explicitly
addressed [18, 19]. Language and culture, while different
constructs, should be considered jointly when adapting
health-related measurement tools [11, 13]. Determining
the cultural appropriateness and relevance of the itemson the translated instrument should be an implicit procedure towards the adaptation of an instrument.
Cross-cultural validation may be performed during
the process of translation. For example, Beaton and collegues [11] suggests that translators should be oriented
to both language and culture of the target language inorder for equivalency of the translation and adaptation.
During cross-cultural translations, equivalence of theconcept, items, semantics, context, measurement, andfunction should be considered [12]. This can be achievedby a consensus panel of experts who are knowledgeableof the assessment construct, language, and culture [11].
In determining cross-cultural adequacy, authors may
consider the use of quantitative (i.e. survey instruments)
and qualitative (i.e., focus group discussions) methods[7, 10–17].
In this study, we examine the linguistic equivalency
and cross-cultural adaptation of the Sensory Processing
and Self-Regulation Checklist-Tagalog version (SPSRCTagalog) after going a multi-process of translation andlanguage equivalency. In the Philippines, there is no
known outcome measure similar to the constructs of the
SPSRC-Tagalog. We further employed initial attempts
to validate the translated tool using face and content
validation tests. Establishing the linguistic equivalency
and cross-cultural adaptation of the SPSRC-Tagalog will
be useful for Filipino occupational therapists in understanding sensory processing difficulties among Filipino
children.

Methods
Before conducting this research, ethical approval
was sought from the University of Santo Tomas- College
of Rehabilitation Sciences- Ethics Review Committee.
This study reports the preliminary findings on the
SPSRC-Tagalog, which is limited to examining its linguistic equivalency and cross-cultural adaptation.
The Sensory Processing and Self-Regulation Checklist(SPSRC)The Sensory Processing and Self-Regulation
Check­list was developed as a singular tool that cansimultaneously measure self-regulation and sensory
processing skills among children ages 3–8 [18, 20]. It
was developed through a rigorous process that involved
child development experts that resulted in the current
132-item checklist. The SPSRC has undergone psychometric property testing, and results indicate satisfactoryreliability (internal consistency, intrarater reliability)and validity (factor analysis, convergent validity, discriminant validity) [18, 20]. It is divided into two parts:
Self-regulation ability (Part 1) and Sensory processing
ability (Part 2). Part 1 is subdivided into three scales(physiological, social/cognitive/emotional, facing changes or challenges), while Part 2 has six sensory-related
subscales (auditory, visual, tactile, gustatory/olfactory,
vestibular, proprioceptive). Parents are instructed to rate
their child’s typical performance on the items within thepast three months using a 5-point Likert scale (never = 5,
seldom = 4, sometimes = 3, most of the time = 2, always= 1; reversed scoring for some), where a lower score in-Asian J Occup Ther 17: 57−63, 2021

dicating performance that is less favorable. The original
version is in Chinese [18, 20], but a translated English
version is likewise available [21]. The SPSRC-English
is a translation of the original version by the authors that
underwent a rigorous process of forward translation,
backward translation, and review by an expert panel.
ProceduresThis research underwent several phases to reporton the cross-cultural and linguistic equivalency of the
SPSRC-Tagalog version, guided by the recommendations of the World Health Organization [17] and its
original author (Lai, personal communication, February2018).
Forward Translation
The Philippines is mostly a bilingual (English andFilipino) nation, with Tagalog being one of the mostwidely spoken languages. The Tagalog translation of
the SPSRC was carried out using the recent English
version [21]. Two Filipino occupational therapists(OT) performed the forward translation. Both werelicensed OTs with > 5 years of experience in the fieldof pediatrics, familiar with sensory processing and selfregulation, and knowledgeable of the English language,
but whose mother tongue is Tagalog. The translation
was performed independently. A consensus meeting
between the forward translators and the research teamwas conducted to review the initially translated tool.
During this meeting, each item on the riginal tool waspresented, while the individual forward translators presented their translations. The translations for each item
were discussed in order to reach consensus. Diverging
translation were deliberated, with the research team’s
primary investigator mediating the discourse. At the endof the meeting, converging and diverging translations, aswell as questionable items endorsed by the translators,
were resolved and revised to produce the initial draft of
the Tagalog version.
Equivalence of Translation
The equivalence of translation into the Tagalog version was reviewed out by eight panel members, which
included 7 OTs and 1 speech-language pathologist. All
expert panel members were licensed (or in the case of
the speech-language pathologist, carries the certification
to practice) Filipino professionals with > 3 years ofcurrent and continued pediatric practice, familiar withsensory processing and self-regulation, and knowledgeable of the English language, but whose mother tongue
is Tagalog. These participants were asked to commenton the equivalence of translation of the SPSRC fromEnglish to Tagalog using the Equivalence of Transla-

Gomez INB et al.

59

tion Tool by Flaherty [22]. Each item was rated using
a 3-point scale (a score of 3 means that the item had
precisely the same meaning in both versions, a score of
2 means that the item had almost the same meaning inboth versions and a score of 1 means that there are different meanings in each language) and commented on by
the experts. Items which scored 1 or 2 by any memberof the expert panel were reviewed by the research teamconsidering the specific comments and suggestions andwere reworded for the purposes of enehancement ofclarity of the Tagalog version.
Backward Translation
The Tagalog version was then translated back to
English by two independent Filipino OTs (different
from the OTs who performed the Tagalog translation but
sharing similar characteristics) who were naïve of theoriginal version. The translation was conducted independently of each other but was subsequently integrated.
Items deemed questionable were revised following thesuggestions made by the backward translators and by
the study team. In order to avoid biased information language ambiguitites, the research team concorded withauthor of the original SPSRC in order to address determine whether the translated items retained their original
constructs. A consensus was reached between the study
team the original author on the Tagalog version of the
SPSRC.
Face, Content and Cross-cultural Adaptation Validation
The SPSRC-Tagalog version was evaluated on its
face, content, and cross-cultural adaptation validity byfifteen Tagalog-speaking Filipino expert panel members,
which consisted of three OTs, three physical therapists,
three speech-language pathologists, and three parents.
All professionals were licensed therapists with > 3
years of current and continued pediatric practice. Face,
content and cross-cultural adaptation validation can beaccomplished using quantitative and qualitative methods[7, 10–17]. In this study, face, content and cross-cultural
adaptation validity were measured using the questionnaire by Yaghmaei [23], and comments from theexperts. The questionnaire allows for measuring andanalyzing the extent of a measurement tool’s ability tomeasure what it intends to measure. General face andcontent validity were determined by asking yes or noquestions. Criteria items with > 80% were retained,
while those with lower ratings were considered for revisions. Each scale on the questionnaire was evaluated on
its relevance, clarity, simplicity, and ambiguity, using a
4-point Likert scale (the higher the rating, the better thevalidity score). Items with a mean score of > 3.00 werenoted and revised based on the comments of the experts,

60

SPSRC-TAGALOG TRANSLATION

Table 1 Summary of Culturally-Adapted Terms in SPSRC-Tagalog
Part

SectionItem NoSPSRC-English

A

6

Radio broadcast at MTR

Anunsyo sa tren

B

2, 6

Torch lightFlashlightC3, 95, 12, 18
15

Rough mat or grass mat
Ice or hot-water pad
Hand cream

Carpet o banig
Yelo o mainit na bimpo
LotionD

2
3

Markers
Lemon juice

Pentel pen
Calamansi juice

E

12Roundabout

Merry-go-round (tsubibo)F

14Play-dohClay2and subsequently integrated into the final draft of the
SPSRC-Tagalog.

Results
Language Equivalence
We recorded and tallied the individual responsesof the participants on each of the items on the SPSRCTagalog and their rating on its cross-cultural adaptation
appropriateness. All items on Part 1 (Self-regulation
ability) scored a grade of 3 on the Equivalence ofTranslation Tool [22] and did not receive any dissenting
comments, which suggests its endorsement as crossculturally appropriate for the Tagalog-speaking Filipino
population. Across all items, there were no commentson the use of colloquially-adapted terms (using English
words in due to lack of existing equivalent word or theword loses its meaning when translated into the Filipino language). The experts also endorsed the adapted
Tagalog translation, which used non-direct translation.
However, we noted eleven items (nine examples) thatscored a 1 on language equivalence (means that there aredifferent meanings in each language) and their respective comments across participants in Part 2 (Sensoryprocessing ability), specifically on the objects used as
an example. We found that the process of consesnsus
between the translators and the study team, the invaluable comments from the expert panel, and discussions
with the tool’s original authors are useful practices thatallowed us to translate them into the target language
and culture [11–13]. It was not that the translation was
flawed, but rather the experts commented on its cultural
relevance. In this research, we refer to these as nonculturally relevant objects. The participants provided
similar suggestions on how these objects used in theitems may be more culturally relevant. We modified thenine examples and integrated them into the SPSRCTagalog version. In order to retain the original construct

SPSRC-Tagalog

and meaning of these items, discussions between the
study team and the original authors proved useful andmeaningful [13].
For example, Part 2 Section C Items 3, 9 used“rough mat or grass mat” in its colloquial English form
(English form retained in the Tagalog version). The
suggestion made by the participants was to omit theadapted colloquial term and replace it with “carpet obanig,” a more culturally-relevant and familiar object
that can be understood by the target audience. Anothercomment raised by the participants pertain to the objects
depicted in Part Section C Item 18 “ice or hot-waterpad.” The suggestion was to replace it with “yelo omainit na bimpo.” In this example, we see “ice” directlytranslated into its Tagalog equivalent, “yelo.” However,the “hot-water pad,” an item that is somewhat familiarin the Filipino culture (closest equivalence is “hotpacks”), is not most accessible or widely-used. Instead,the suggestion of using “mainit na bimpo” was made,which, when translated, refers to hot moist towels, traditionally used by parents on their children. These, among
other examples, were suggested by the participants, anda summary of these can be seen in Table 1.
Face Validity
All participants deemed the SPSRC-Tagalog as aquestionnaire that can be easily read and understood(Table 2). A consensus agreed that it is easy to understand (92.86%) and administer (92.86%). However,more than half of the participants (57.14%) noted thepresence of grammatical errors.
Content Validity
Generally, all participants rated the SPSRC-Tagalog
as a tool that covers major critical areas in sensory processing and self-regulation that are related to each otherwith appropriate rating scales (Table 3). However, someparticipants (14.29%) questions whether items underGomez INB et al.

Asian J Occup Ther 17: 57−63, 2021

Table 2 Summary of SPSRC-Tagalog Face Validation

61

Table 3 Summary of SPSRC-Tagalog General Content Validation

Criteria

RatingCriteria

RatingText can easily be read
Instructions are easy to understandFree from grammatical error
Layout is properly arranged
Can easily be administered
Can easily be answered
Can easily be administered within a reasonable amountof time100%
92.68%
57.14%
85.71%
92.68%
100%
85.71%

Covers the necessary major areas needed to be measured
Major areas covered by the tool relate to each otherItems under each are adequately represent the area it falls
under in
Items under each major area are related to each other
Rating scale used in the tool appropriate to the items it is
supposed to measure

100%
100%
85.71%
100%
100%

Table 4 Summary of SPSRC-Tagalog Section Validation
Sections

Relevance

Clarity

Simplicity

Ambiguity

Part 1. Self-regulation abilities
1. Physiological functioning
2. Social/Cognitive/Emotion Development
3. Facing Transition or Challenges

3.95 ± 0.14
3.98 ± 0.05
3.99 ± 0.03

3.91 ± 0.10
3.86 ± 0.21
3.90 ± 0.12

4.00 ± 0.00
3.94 ± 0.11
3.94 ± 0.16

3.95 ± 0.10
3.92 ± 0.11
3.98 ± 0.06

Part 2. Sensory processing abilities
1. Auditory
2. Visual
3. Tactile
4. Gustatory/olfactory
5. Vestibular
6. Proprioceptive

4.00 ± 0.00
3.98 ± 0.06
3.99 ± 0.02
4.00 ± 0.00
4.00 ± 0.00
4.00 ± 0.00

3.85 ± 0.20
3.93 ± 0.14
3.91 ± 0.14
3.92 ± 0.15
3.94 ± 0.08
4.00 ± 0.00

3.93 ± 0.03
3.99 ± 0.02
3.99 ± 0.22
3.92 ± 0.15
3.99 ± 0.02
4.00 ± 0.00

3.87 ± 0.27
3.99 ± 0.03
3.99 ± 0.02
3.95 ± 0.15
3.98 ± 0.04
4.00 ± 0.00

each area adequately represent the area it falls under in.
We rated each scale on the SPSRC-Tagalog on its
relevance, clarity, simplicity, and ambiguity (Table 4).
For the relevance criteria, items on four out of the ninescales (auditory, gustatory/olfactory, vestibular, proprioceptive) were rated as very relevant (4.00 ± 0.00), withthe rest ranging from a mean score of 3.95 to 3.99. Only
the items on the proprioceptive scale were perfectly
rated very clear (4.00 ± 0.00), while the rest ranged
from 3.85 to 3.94. Items on two scales (physiological
functioning, proprioceptive processing) were perfectly
deemed very simple in its presentation (4.00 ± 0.00),
and the rest ranged from 3.92 to 3.99. The meaning of
the items is most clear (ambiguity) for the proprioceptive scale (4.00 ± 0.00) compared to the rest, whichspanned between 3.87 to 3.99).

Discussion
The SPSRC-Tagalog has undergone a multi-processof translation and linguistic equivalency examination.
The Tagalog version of the SPSRC depicted in this study
has proven to be an excellent equivalent to the original
English version, and is seen to be appropriate for psychometric testing among Tagalog-speaking Filipinos.
In the translation of the SPSRC from English
and Tagalog, several English terms were retained andreceived no objections from the expert panel. The habitof using English integrated into the Tagalog language
is a cultural phenomenon observed in the Philippines,
a generally considered bilingual nation [24]. This formof communication, seen in both written and oral forms,
places standard English words or phrases with thestandard Tagalog. A kind of switching occurs between
English and Tagalog within and between sentences.
Several reasons may exist to explain such practice. Still,in this case, it surmised that the acceptance of the useof English colloquial words or phrases within a Tagalog
version of the questionnaire might likely be for precision. Communicative proficiency is preferred over literaltranslations, which may compromise construct-specificlexical terms from the original source language [25, 26].
This practice is not exclusive to the SPSRC-Tagalog andcan be seen in other Tagalog version of health-related
outcome measures, especially among the intended
constructs within [27, 28]. The Tagalog-English codeswitching seen in this study reflects the bilingual natureof the target population the questionnaire is designed
for. Further investigation is needed if SPRC is to betranslated into other international or local languages.
More than language equivalency, this paper places
importance on the cultural-relevance of items in a questionnaire. In the process of examining the equivalency oftranslation of SPSRC into Tagalog, our experts focused

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SPSRC-TAGALOG TRANSLATION

on recommending changing the objects of examples insome of the items. For the respondent to provide thebest response to a questionnaire item, the construct of
the question should be appropriate and relevant to them,in terms of culture and language [29]. Careful consideration of both physical and nonphysical characteristicsof the sensory stimulus depicted in the questionnaire
is essential to gather the appropriate response [18, 19].
Future researchers who intend to translate the SPSRC
in other languages should look beyond the languagetranslation, and likewise incorporate the relevance of theitems within the culture it is designed to be used for.
The preliminary findings on the linguistic equivalance and cross-cultural adapatation of the SPSRCTagalog reported herein are part of a larger study thatwill examine the psychometric properties of the said
tool. Nevertheless, in this research, we demonstrate thequality of the process of translating and determining thelanguage equivalency of the SPSRC-Tagalog. However,there are some limitations in methodology. Whereas we
used methods and strategies described in previous literature, the psychometric properties of the SPSRC-Tagalog
remain to be answered, an objective beyond the scopeof this study. There is a neeed for SPSRC-Tagalog toestablish its measurement properties, which includes
reliability (i.e., test-retest, internal consistency) andvalidity (i.e., criterion validity, construct validity) [30].
In the process of translating assessment tools fromone language to another, researchers often run the riskof altering the intended meaning of the test items andconsequently affecting the validity of the assessment
tool. Nevertheless, it is recommended that the SPSRCTagalog be subjected to an extensive sample field testing
to evaluate its reliability and validity. This includes ana priori examination of its ecological validity. For this,the bilingual approach suggested [19]. Both the English
and Tagalog versions of the SPSRC should be tested on
bilingual end users of the questionnaire (i.e. parents andcaregivers of children), and their responses compared todetermine the translation and language equivalency of
the SPSRC-Tagalog in a real-world setting.

Conclusion
To conclude, these findings in this study support
the linguistic equivalency and cultural-relevance of the
SPSRC-Tagalog as a single measure of sensory processing and self-regulation abilities of Tagalog-speaking
Filipino children. The methods described in this study
may serve as a guide in translating the SPSRC in otherlocal languages. Succeeding studies should evaluate
its psychometric properties. Using the SPSRC-Tagalog
may aid in a better understanding of sensory processing

for clinical and research purposes among occupational
therapists.

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■CASE REPORTAn Intervention to Overcome Eating Difficulties
in a Patient with Autism Spectrum Disorder-A Case Study
Masato Sato1, Yukio Mikami2, Yoji Asakura1, Kiya Katayama1,
Fumihiro Tajima2
1
2

Department of Rehabilitation, Hashimoto Municipal Hospital
Department of Rehabilitation Medicine, Wakayama Medical University

Abstract: Introduction: Patients with autism spectrum disorder (ASD) may present with problems related to eating
behaviors, including unbalanced diet, attention disruption, and poor tool manipulation. These problems are attributed to
the widespread sensory processing abnormalities associated with ASD. Therefore, it is important to consider interventions and support for eating behaviors in patients with ASD that address these sensory processing problems. However, todate, no studies have investigated interventions to aid eating behaviors in this population. Here, we describe an actionbased intervention to promote food ingestion in a young adult with ASD.
Methods: An A-B method with a single-system research design was implemented, with three main outcome measures:
goal attainment scaling (GAS), time required to eat, and functional independence measure (FIM). Following baseline
measures, the intervention was based on changes in eating actions and consisted of two phases. In Phase I, the eating
environment was adjusted. Phase II supported the manipulation of eating tools in addition to environmental adjustments.
Results: The eating action changed from needing complete assistance with eating to her own manipulation of eating
tools and the ability to ingest food orally. The time needed for eating was reduced, while the GAS and FIM scores both
improved.
Conclusion: The organization of the environment promoted eating, while the manipulation of eating tools promoted theflow of actions. When a person with ASD has eating difficulties, it is suggested that manipulating the eating tools may
be useful to promote oral ingestion in addition to environmental adjustments.
Keywords: autism spectrum disorder (ASD), eating action, eating environment, action-perception(Asian J Occup Ther 17: 65−68, 2021)

Introduction
Problems related to eating behaviors in patients with
Autism Spectrum Disorder (ASD) have been reported,
including unbalanced diets, attention disruptions, andpoor tool manipulation [1]. These problems are attributed to the widespread sensory processing abnormalities
associated with ASD [2]. Problems with sensory proReceived: 6 March 2020, Accepted: 30 May 2021
Corresponding to: Masato Sato, Department of Rehabilitation, Hashi­
moto Municipal Hospital, Ominedai 2-8-1, Hashimoto, Wakayama,648-0005 Japane-mail: sato.my1005@gmail.com©2021 Japanese Association of Occupational Therapists

cessing continue into adulthood and inconvenience in
activities of daily living (ADL) [3]. In adulthood, sensory processing problems contribute to hyperreactivity andhave been linked to the core symptoms of ASD [4, 5].
Therefore, it is important to consider support for eating
behaviors in patients with ASD presenting with sensory
processing problems. However, there is no report on
specific support for adults with ASD. The purpose ofthis study was to outline a specific intervention to aid
ADL; focusing on eating difficulties from an action-perception viewpoint [6].

66

AN INTERVENTION TO OVERCOME EATING DIFFICULTIES IN A PATIENT WITH AUTISM SPECTRUM DISORDER -A CASE STUDY

Table 1 Goal Attainment Scaling

GAS is a tool for respecting the values of patient and their family, incorporating therapist’s judgment, and conducting
patient-centered interventions. Her personal goal was stable oral ingestion.
GAS: Goal Attainment Scaling

Subject

MethodThe patient was a 23-year-old woman admitted tothe hospital for fever of unknown origin. She had been
was diagnosed with a pervasive developmental disorder (now diagnosed as ASD) at the age of nine. After
hospitalization, the fever resolved, but oral ingestions
continued to be difficult. She had a strong resistance
to exercising and was anxious. The Japanese Sensory
Inventory-mini (JSI-m) explores the possibility of sensory dysregulation. Her inventory result was red; hence,a diagnosis of hyperesthesia was presumed. Sensory
processing problems in childhood may persist into adulthood [3]. Therefore, behaviors that were scored duringchildhood on the JSI-m were used as clues to understand
adult tendencies. The patient communicated by nodding
only and all ADL required the assistance of her parents.

Procedure
An A-B method with a single-system research
design comprising three target outcomes was conducted
to assess the effects of the intervention. The baseline was
3 weeks without occupational therapy (OT). Thereafter,
the intervention was performed for 5 weeks. Signed
informed consent for this study was obtained from her
mother.

Eating action
The eating environment was on a bed in a privateroom. Around the time of eating, the body turned rigid,
and the patient became nervous due to visual and auditory stimuli from outside the room. A spoon was usedas the eating utensil. However, the patient was hesitant
to reach food and could not scoop the food. As a result,the consumption of the meal was fully assisted by her
mother.

1) GAS (Goal Attainment Scaling)
GAS was adopted to carry out patient-centered interventions, with the patient’s therapist and family’s help
in setting the goals [7]. The individual goal was stableoral ingestion (Table 1). We quantified changes in GASscores before and after baseline and OT interventions.
2) Eating; required time
The time required to eat, which can also be considered eating “efficiency,” was measured daily for up to
60 minutes.
3) FIM (Functional Independence Measure)
ADL performance was scored by FIM and measured at admission and before and after the OT intervention.
Therapy process
The intervention based on action-perception was
divided into two phases.

Sato M et al.

Asian J Occup Ther 17: 65−68, 2021

67

Fig. 1. Intervention scene by handling utensils and tableware.
a) Inserting the spoon into the food while keeping contact with the inner surface of the bowl. b) Scooping food while keeping
contact with the inner surface of the bowl. The spoon is held in a horizontal position. c) The spoon is moved from the bowl to thelips with constant contact.
Table 2 Effect of the Intervention on the Main Outcome Measures

GAS: Goal Attainment Scaling, FIM: Functional Independence Measure

Phase I: 1st week
The dining table was separated from the bed, andthe area was closed with curtains and doors. Only theutensils and tableware were placed on the table.
Her therapist scooped up food with a spoon andguided her head to encourage a relationship in which her
mouth and food approached each other. The spoon wasthen guided to a stable contact with her lower lip, andthe food was removed by her upper lip.
Phase II: 2nd to 5th weeks
From the 2nd week, the meal was changed to rice
porridge and soft food, and utensils and tableware werehandled by the patient (Fig. 1). Her therapist guided her
hand to assist in using the spoon and bowl. When scooping food, her therapist started by bringing the spoon into
contact with the inner surface of the bowl to stabilize it.
Then, her therapist’s guidance was shifted from a gathering manipulation to a scooping manipulation basedon the sense of food resistance. Spooning food into themouth continued while maintaining the spoon in contact
with her lower lip from the inside of the bowl.

Results
The patient was hospitalized for eight weeks. Table
2 shows the changes in target outcomes in each period.
GAS scores improved following the intervention. In the
final stage of the interventions, the patient was able toconsume all food with assistance in the use of eatingutensils. She was also able to self-feed for about 50%of her eating, and the required time to eat was reduced.
FIM was also improved after the intervention, and hermother reported that the patient’s eating action wasmaintained after discharge.

Discussion
Prior to the intervention, the patient was unable toorient herself to the layout of the dietary environment,
which was full of visual stimuli, and was overreacting
to auditory stimuli from surrounding noise and involvement of others. ASD is characterized by an overreaction
to sensory stimuli [4, 5], and hypersensitivity to sensory
processing tends to distract them from eating. The dis-68

AN INTERVENTION TO OVERCOME EATING DIFFICULTIES IN A PATIENT WITH AUTISM SPECTRUM DISORDER -A CASE STUDY

traction might lead to problems with eating behaviors [8].
For this reason, the patient had persistent tension during
mealtimes and could not progress to eating actions.
Persons with ASD tend to make decisions based on
rules [9]. Therefore, her therapist offered the patient an
action-based viewpoint, based on the perception oftactile sensation from the adjusted eating environment,
to the manipulation of eating tools, and the sensory
experience of food in the mouth. To promote eating,adjusting the eating environment and encourage behavioral changes offer promising results [6]. Therefore, it
is conceivable that the interdependent experience ofperception and action partly explains the improvementin ADL in general.

Conclusion
When adult patients with ASD have difficultyeating, it is suggested that in addition to environmental
adjustments, the manipulation of eating tools based on
the perception of tactile sensation may be useful to stimulate oral ingestion. However, the findings of this casereport must be tested in a larger group to establish thereal effectiveness.

Acknowledgments
We thank the client for their participation in thisstudy.

References[1] Lai MC, Lombardo MV, Baron-Cohen S. Autism. Lancet.
2014; 383(9920): 896–910.
[2] Crane L, Goddard L, Pring L. Sensory processing in
adults with autism spectrum disorders. Autism. 2009; 13:
215–28.
[3] Leekam SR, Nieto C, Libby SJ, Wing L, Gould J.
Describing the sensory abnormalities of children andadults with autism. J Autism Dev Disord. 2007; 37: 894–
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[4] Schauder KB, Bennetto L. Toward an interdisciplinary
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[5] Schaaf RC, Lane AE. Toward a best-practice protocol
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[6] Affolter FD. Tomita M, Nukaya K, translators. Perception: from the roots of development to the discovery oflanguage (in Japanese). Tokyo: Maruzen Publishing Co;
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scaling as a measure of clinically important change innursing-home patients. Age Ageing. 1999; 28: 275–81.
[8] Raiten DJ, Massaro T. Perspectives on the nutritional
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Couteur A, McConachie H, et al. Enhanced decision
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spectrum disorder. Neuropsychology. 2014; 28: 222–8.

■ORIGINAL ARTICLE

Effect of Daily Living Activities on the Needfor Long-Term Care in Older Adults
Akira Sagari1, Takayuki Tabira2, Michio Maruta3,
Hironori Miyata4, Takashi Hasegawa5, Masahiro Kawagoe6
1School of Health Science, Faculty of Medicine, Shinshu University
School of Health Sciences, Faculty of Medicine, Kagoshima University
3
Okatsu Hospital
4
Kumamoto Health Science University
5
Wazinkai Hospital
6
Saitama Prefectural University
2

Abstract: Background: Japan has become a super-aged society, resulting in an increased number of insurance certifications for long-term care needs. This study aimed to identify the effects of daily living activities on changes in certification among older persons with support needs classified by cognitive function.
Methods: The sample, sourced from the 2014 and 2016 Japanese long-term care insurance certification surveys, consisted of 6,219 individuals with support needs. Logistic regression analysis was performed to identify activities of dailyliving (ADL) associated with certification changes. Separate logistic regressions were performed to predict certification
changes based on participants’ cognitive functioning.
Results: Regarding levels of cognitive functioning, ADL associated with certification change among the highest functioning individuals were bathing, nail trimming, mobility, managing money, and decision-making ability. At the nextlevel of functioning, the activities included bathing, toilet hygiene (urinary), taking prescribed medications, managing
money, decision-making ability, and preparing meals. At the lowest level of functioning, only managing money was
associated with a certification change.
Conclusion: ADL affecting certification change varies with the level of cognitive functioning. Thus, managing money
was considered to be the most important activity as it influences change in certification in all cognitive categories.
When occupational therapists create interventions for older persons with support needs, they should use IADL abilities
such as managing money, which requires complex cognitive functions, from an early stage. This may lead to the reduction of the need for care in older persons with support needs.
Keywords: cognitive function, daily living activities, long-term care insurance, long-term care needs level, support
needs level(Asian J Occup Ther 17: 69−77, 2021)

1. Introduction
Japan became a super-aged society in 2016, when
the percentage of its older population exceeded 27% [1].
The population began to decline after peaking in 2008.
This, in turn, has caused a drop in the working-age
Received: 13 February 2020, Accepted: 4 August 2021
Corresponding to: Akira Sagari, School of Health Science, Faculty of
Medicine, Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano 3908621, Japane-mail: sagaria@shinshu-u.ac.jp©2021 Japanese Association of Occupational Therapists

population and an increase in the aging population [2].
As a result, with the increase in the number of persons
with long-term care needs certification under Japan’slong-term care insurance (LTCI) system [3], the LTCI
premium has more than doubled since its inception, andvarious initiatives emphasizing preventive long-termcare have been launched [4].
In preventive long-term care, efforts have been
focused on the phase prior to the support needs-certification stage; however, developing and applying effective
interventions in earlier studies were difficult becauseof small sample sizes [5]. Accordingly, developing andexecuting care management plans to promote the in-

70

EFFECT OF DAILY LIVING ACTIVITIES ON CERTIFICATION

dependence of individuals who have been certified ashaving support needs may deter the decline of their
physical health and postpone their need for long-termcare needs certification. In addition, care managers
and occupational therapists working in the community
should understand what activities of daily living (ADL)should be focused on, to deter a decline in certificationof care needs. This is because if occupational therapists
can appropriately predict ADL items that lead to careneeds certification and intervene accordingly, individuals with support needs could live happily without careneeds certification.
According to the Status of Basic Life Survey conducted in 2016 [6], although joint disease, frailty due
to old age, and fracture/fall were common reasons forsupport needs certification, the most frequent reason forcare needs was dementia, suggesting the importance ofpreventing cognitive impairment in persons with support
needs. The importance of such an approach was highlighted in a previous longitudinal study, which reported
an association between long-term care needs certification and dementia [7]. Recent studies have focused on
the association between dementia and ADL [8, 9]. It has
been reported that cognitive impairment causes limitations in instrumental ADL (IADL), gradually lowering
basic ADL (BADL) functioning (e.g., in the early stageof cognitive decline, individuals often need support withmanaging money and taking prescribed medications).
Previous reports on factors of long-term care needs
certification have included ADL, in addition to physical,
mental, and social factors [10, 11]. Although Germany
and South Korea, like Japan, have introduced LTCI [12,13], studies on factors of long-term care needs certification are limited [14, 15], and no studies have examined
long-term care needs certification based on ADL in older
persons with support needs. Determining which ADL
contribute to transition in certification (from support
needs to long-term care needs) will help provide effective occupational therapy interventions for older adults
with support needs. Since dementia is an importantfactor in the increase in the number of older adults withcare needs [6, 7], we propose a care plan to support thecognitive function of older adults with dementia after
analyzing their degree of independence in daily living.
Based on the analysis of certification data, thisstudy first aimed to elucidate whether gender, age, anddegree of independence in daily living among older
adults with disabilities or dementia affect their certification change (from support needs to long-term careneeds) after two years. The reason why the dependent
variable was “certification change from support needs
to long-term care needs” is that the recovery rate ofpersons with care needs is considerably lower than thatof persons with support needs [16].
Further, to provide suggestions for developing measures to prevent individuals from transitioning to longterm care needs, we performed an analysis based on
cognitive function for ADL items that affect certification
change. The reason for assessing cognitive condition
was that ADL capacity depends on the degree of cognitive condition, and as mentioned above, dementia is themost frequent reason for individuals being categorized
as requiring long-term care [6]. Thus, it was hypothesized that given the difficulty to identify early cognitive
dysfunction in older persons with support needs, it may
be possible to determine it based on IADL.

2. Materials and Subjects
Participants in this study were individuals living
in a Japanese city (which we refer to as City A) who
completed the 2014 and 2016 LTCI certification surveys. The certification questionnaire was developed by
the Japanese Ministry of Health, Labour and Welfare; itsurveyed respondents on 74 items: 62 items related tophysical, life, cognitive function, psychological and behavioral disorders, and social life, and 12 items related
to special medical care.
The LTCI certification process consisted of twostages. First, individuals were placed into one of sevenneeds categories based on their responses to the certification survey. The first two levels were referred to assupport-needs levels 1–2, which consisted of preventive
services for individuals with less intensive needs. The
remaining five levels were referred to as care-needs
levels 1–5, which consisted of services for individuals
categorized by disability severity. Second, a committeeof physicians and other professionals determined theeligibility of each applicant. The survey data for thisstudy were collected by a medical worker (certified
researcher) from City A and met LTCI eligibility. The
survey data were collected by trained professionals at
the users’ homes and were stored in City A’s database inaccordance with an agreement established between City
A and the co-researcher’s institution.
A total of 23,818 individuals living in City A completed the certification surveys at two time points: 2014
and 2016. Of the 7,621 older adults who were categorized in the support needs group in 2014, 6,219 (2,555
and 3,664 with support-needs levels 1 and 2, respectively) also completed the certification survey in 2016 andmade up the sample for this study. The remaining 1,402
respondents were not included because they did not needlong-term care certification, had relocated, or died. The
individuals certified for long-term care needs in 2016
comprised the changed group and those who remained

Sagari A et al.

Asian J Occup Ther 17: 69−77, 2021

certified for support needs made up the unchanged group(Table 1).

3. Method
We categorized and organized the basic attributesof the 2014 participants into two groups: those who
required care needs in 2016 and those who remainedin need of support (Table 1). Next, we classified andorganized the basic attributes of all participants according to the degree of independence in the daily living ofolder adults with dementia (Table 2). We then sorted andorganized the 2014 participants’ activities of daily living
scores by the degree of independence in daily living ofolder adults with dementia (Table 3). After organizing
the data, we moved on to the statistical analysis. A
series of stepwise logistic regression analyses were
performed to identify the factors associated with certification change, and the variables were selected using the
backward method. The dependent variable was whether
an individual experienced a change in certificationfrom support needs to long-term care needs. In our first
analysis using data from the 2014 certification survey,
the independent variables were gender, age, degree of
independence in daily living among older adults withdisabilities, and degree of independence in daily living
among those with dementia.
In the second analysis, we identified ADL affecting
the likelihood of certification change. Based on previous
studies [8–9, 17], items were selected from the certification survey in 2014 to serve as independent variables.
The analysis was adjusted for age, gender, and degreeof independence in daily living. Multicollinearity wasassessed using the variance inflation factor coefficientand correlation analyses. We examined the ADL factors
affecting certification change by performing a separate
logistic regression for each level of cognitive functioning. Based on the parameters of the Japanese Ministry of
Health, Labour and Welfare, the degree of independence
in the daily living of older adults with dementia in 2014
was classified into three levels—Independence, I, and II—ranging from more to less independent. Due to thesmall number of individuals assigned to category III, we
excluded it from the analysis. While taking cognitive
function into account, independence was further classified into eight levels: Independence, I, IIa, IIb, IIIa,
IIIb, IV, and M. Level I is defined as “the patient has
some dementia, but can live independently at home andin society”; level II as “although the patient has some
symptoms or behaviors disturbing daily living, they
can live independently with the attention and support ofothers (IIa: symptoms or behaviors are present outside
the home, IIb: symptoms or behaviors are present at

71

Table 1 Participants’ Baseline Characteristics in 2014 by Group (N =6,219)
Items
N
GenderMale
FemaleAge, years (mean ± SD)
Support needs
Level 1
Level 2Care needs
Level 1
Level 2
Level 3
Level 4
Level 5

Unchanged group

Changed group

4,062

2,157

908
3,154
80.61 ± 6.32

627
1,530
82.57 ± 6.48

1,821
2,241

734
1,423

0
0
0
0
0

0
0
0
0
0

Degree of independence in daily living of older adults withdisabilitiesa
22
Independence
27
74
J1
802
1,945
J2
601
1,128
A1
677
861
A2
44
49
B1
4
3
B2
0
0
C1
0
0
C2
Degree of independence in daily living of older adults withdementiab
734
2,502
Independence
1,019
1,369
I
213
124
IIa
184
63
IIb
6
4
IIIa
1
0
IIIb
0
0
IV
0
0
M
Note. a J1 = [the patient can go out by using public transportation], J2= [the patient can go out in the neighborhood], A1 = [the patient goesout with assistance and is mostly out of bed during the day], A2 =[the patient goes out infrequently and alternates between sleeping andbeing out of bed during the day], B1 = [the patient can transfer to thewheelchair, as well as eat and excrete away from the bed], B2 = [thepatient transfers to the wheelchair with assistance], C1 = [the patient
can roll over], C2 = [the patient cannot roll over], b I = [the patient has
some dementia but can live independently at home and in society], IIa= [although the patient has some symptoms or behaviors disturbing
daily living, they can live independently with the attention and supportof others; symptoms or behaviors are present outside the home], IIb =[although the patient has some symptoms or behaviors disturbing dailyliving, they can live independently with the attention and support ofothers; symptoms or behaviors are present at home], IIIa = [the patient
has symptoms or behaviors that disturb daily living and they requirecare; symptoms or behaviors mainly occur in the daytime], IIIb = [thepatient has symptoms or behaviors that disturb daily living and theyrequire care; symptoms or behaviors mainly occur at night], IV = [thepatient frequently has symptoms or behaviors that disturb daily living
and they always require care], M = [the patient has severe mental,
behavioral, and psychological symptoms of dementia or severe
physical disease, therefore, they require specialized care].

72

EFFECT OF DAILY LIVING ACTIVITIES ON CERTIFICATION

Table 2 Summary of Attributes of Older Adults with Dementia by Degree of Independence(Degree of independence in daily living of older adults with dementia)

Items

Independence

I

II

III

3,236
2,388
584
N
Gender (N)
766
577
187
Male
2,470
1,811
397
Female80.53 (6.46)
82.23 (6.14)
81.68 (7.00)
Age, years M (SD)
Degree of care (N)Support 1
1,440
883
228
Support 2
1,796
1,505
356
Degree of independence in daily living of older adults with disabilities (N)013Independence
12
35
54
J1
201
1,029
1,513
J2
173
634
922
A1
189
654
689
A2
8
32
52
B1
1
3
3
B2
0
0
0
C1
0
0
0
C2

11
5
6
79.27 (7.23)
4
7
0
0
4
0
6
1
0
0
0

Note. N = [number of people], M (SD) = [mean ± standard deviation]

Table 3 Number of Older Adults with Dementia by Degree of Independence and Scores on Activities of Daily Living in 2014
Degree of Independence
Item

Bathing
Nail trimming
Functional mobility
Mobility
Ability to swallow foodSelf-feeding
Toilet hygiene (urinary)
Toilet hygiene (fecal)
Brushing teeth/rinsing mouth
Face cleaning
Combing/styling hair
Getting dressed (upper body)
Getting dressed (lower body)Frequency of going outdoors
Taking prescribed medications
Managing money
Decision-making ability
Inability to mingle with others
Shopping for daily necessities
Preparing meals

Score
Range
4
3
4
4
3
4
4
4
3
3
3
4
4
3
3
3
4
3
4
4

Independence

I

1

2

3

4

2,467
1,973
3,195
3,039
2,938
3,206
3,184
3,211
3,192
3,171
3,191
3,042
3,064
2,488
2,866
2,658
3,003
3,231
1,288
1,978

703
914
36
188
298
26
1
0
44
64
18
11
11
559
370
436
233
2
9
2

37
29
349
0
5
0
9
0
0
4
2
49
2
23
0
1
27
0
183
1
160
189
0
142
0
0
3
748 1,191
23 1,233

1

2

II
3

4

45
579 191,745
738 288
1,362
0
6
19
2,363
0
6
227
2,155
0
383
2,005
0
3
14
2,371
2
8 58
2,320
1
4 31
2,352
1
34
2,353
1
46
2,341
16 13
2,359
0
9 140
2,239
2
9 107
2,270
441 129
1,818
1
833
1,554
607 1401,641
0
1
1,346 1,041
2 16
2,370
17 475 1,083
813
9 1,070
6
1,303

III

1

2

3

4

1

2

3

4

414
355
579
527
477
580
546
563
556
565
573
546
547
417
144
218
109
581
123
237

4 14
152
146 83
0
0
5
1
2
54
0
107
0
0
4
1
7 30
3
3 15
0
28
0
19
4
7
0
12 26
0
14 23
105 62
3437
260 10608467
3018 75 368
5 334
8

7
6
11
10
8
10
8
11
9
11
9
9
9
6
5
3
2
10
1
3

4
4
0
1
3
1
1
0
2
0
1
2
2
4
6
5
7
0
0
0

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

0
0
0
0
0
0

0
0

0
9
8

Note. Daily life function consists of the following 20 items: “Bathing,” “Functional mobility,” “Mobility,” “Self-feeding,” “Toilet hygiene (urinary),” “Toilet hygiene (fecal),” “Getting dressed (upper body),” “Getting dressed (lower body),” “Decision-making ability,” “Shopping for daily
necessities,” and “Preparing meals” are scored from 1 to 4. “Nail trimming,” “Ability to swallow food,” “Brushing teeth/rinsing mouth,” “Facecleaning,” “Combing/styling hair,” “Frequency of going outdoors,” “Taking prescribed medications,” “Managing money,” and “Inability to mingle
with others” are scored from 1 to 3. Higher scores indicate lower daily life functioning and an increased need for assistance.

Sagari A et al.

Asian J Occup Ther 17: 69−77, 2021

73

Table 4 Results of the Multivariate Stepwise Logistic Regression Analysis for Each Activity of Daily Living
Items

IndependenceOR

95% CIp

Bathing

1.271< 0.01Nail trimming

1.229

Mobility

2.342

1.082–
1.493
1.080–
1.399
1.746–
3.141

I
R

2

II

OR

95% CIP

1.321

1.140–
1.530< 0.001

1.457

1.107–
1.917< 0.010.054< 0.0011.400< 0.001

1.347
1.088

1.024–
1.156

1.320

Decision-making ability

1.817

p

0.052
1.099–
1.586
1.196–
1.640
1.133–
1.602

Taking prescribed medications
1.192–
1.982
1.354–
2.437

95% CI

R2< 0.001

Toilet hygiene (fecal)

1.537

OR

< 0.01

Toilet hygiene (urinary)Managing money

R

2

0.013

< 0.01< 0.001

1.481

1.153–
1.902< 0.01< 0.001

Shopping for daily necessities
Preparing meals< 0.01

Note. OR = odds ratio, CI = confidence interval.
Stepwise logistic regression analysis.

home)”; level III as “the patient has symptoms or behaviors that disturb daily living, and they require care (IIIa:
symptoms or behaviors mainly occur during daytime,
IIIb: symptoms or behaviors mainly occur at night)”;
level IV as “the patient frequently has symptoms or behaviors that disturb daily living, and they always requirecare”; and level M as “the patient has severe mental,
behavioral, and psychological symptoms of dementia, orsevere physical disease, and requires specialized care.”
For older adults with disabilities, the Japanese Ministry of Health, Labour and Welfare classifies individuals’
degree of independence in daily living as follows:
independence, J1, J2, A1, A2, B1, B2, C1, and C2.
Therefore, for our study, patients without disabilities
were classified in the Independence category. Level J
comprises patients with some disability but are nearly
independent (J1: “the patient can go out by using public
transportation” and J2: “the patient can go out in theneighborhood”). Level A comprises patients who canlive mostly independently at home but need a caregiverto go out (A1: “the patient goes out with assistanceand is mostly out of bed during the day” and A2: “thepatient goes out infrequently and alternates between
sleeping and being out of bed during the day”). Level
B patients require some care in their home and spend
most of the day in bed (B1: “the patient can transfer tothe wheelchair and eat and excrete away from the bed”
and B2: “the patient transfers to the wheelchair withassistance”). Level C patients are bedridden and requirecare for excretion, eating, and dressing (C1: “the patient
can roll over,” and C2: “the patient cannot roll over”).

SPSS software version 24 for Windows (IBM Corp,
Armonk, NY, USA) was used for the analyses, with asignificance level of p < 0.01. The National Instituteof Population and Social Security Research signed amemorandum of understanding with City A concerning
the use of its data, which was approved by the appropriate ethics committee (IPSS-TRN#15001-2). Due toa change in affiliation for one of the authors, Saitama
Prefectural University signed a new memorandum of
understanding with City A. The procedures used tocollect the data followed all ethical standards of the
Declaration of Helsinki.

4. Results
Table 1 shows individual baseline characteristics
and ADL scores for the unchanged and changed groups.
Tables 2 and 3 show the attributes and ADL scores foreach group of older adults with dementia, respectively,
classified according to their degree of independence indaily living. For the entire sample, the attributes affecting change in certification after two years were gender(OR = 0.674, 95% CI = [0.593, 0.766], p < 0.001), age(OR = 1.047, 95% CI = [1.038, 1.057], p < 0.001), anddegree of independence in daily living of older adults
with disabilities (OR = 1.312, 95% CI = [1.233, 1.397]
p < 0.001) or dementia (OR = 2.203, 95% CI = [2.043,
2.374], p < 0.001). Table 4 shows the results of the analysis of ADL affecting change in certification after two
years within different levels of cognitive function. For
the entire sample, certification change was associated

74

EFFECT OF DAILY LIVING ACTIVITIES ON CERTIFICATION

with bathing, mobility, toilet hygiene (fecal), taking prescribed medications, managing money, decision-making
ability, and shopping for daily necessities. For the
independent group, a certification change was associatedwith bathing, nail trimming, mobility, managing money,
and decision-making ability. In group I, significant
factors affecting certification change were bathing,
toilet hygiene (urinary), taking prescribed medications,managing money, decision-making ability, and preparing meals. In group II, a certification change was only
associated with managing money.

5. Discussion
Our findings indicated that change in certification
after two years was associated with gender, age, anddegree of independence in daily living of older adults
with disabilities and dementia. Certification change tolong-term care needs after two years occurred more frequently among men, compared to women. Conversely,
previous studies have reported a higher incidence of
BADL disorders in women, compared to men [18, 19].
However, research on gender differences in ADL is rarein Japan [20]. In addition, the disparity between our
results and those of previous studies may be explainedby the fact that the participants of this study required
assistance and care, while Japanese men have a higher
mortality rate than Japanese women [21]. This study
confirmed that men are more likely to experience a certification change from support needs to long-term careneeds.
We also found that the degree of independence indaily living of older adults with disabilities or dementia
was a significant factor in certification changes. Previous
studies have reported that a decline in physical function
affects the severity level of long-term care needs certification and frailty progression [22, 23]. Similarly, adecline in cognitive function has been shown to affectchanges in long-term care needs [7]. This study confirms that certification change to long-term care needs isaffected by the degree of independence in daily living ofolder adults with disabilities or dementia.
Our findings also suggest that increased support
for ADL may reduce LTCI usage. Among older adults
with the highest level of independence, impairments
in mobility, bathing, nail trimming, managing money,
and decision-making were significantly associated withcertification change, suggesting that supporting ADL
associated with physical function decline may reduce
the level of long-term care needs. Managing money is
not a fragmentary living behavior, and long-term management is needed. Decision-making involves serious
decisions, such as choosing a treatment or care plan. On

the other hand, non-serious decisions include where togo out and what to wear. Therefore, decision-making isfundamental for everyday life, which is why a decline
in the individual’s decision-making ability implies thatthey require assistance. Based on our results, we believethat even for independent individuals without dementia
symptoms, increased support for IADL is key to reducing LTCI usage.
Furthermore, in group I (individuals with the secondhighest level of independence), items that reflected
declining capabilities were significantly associated withcertification change to long-term care needs. Like theindependent group, decision-making, managing money,
and bathing, which are important items from the viewpoint of care prevention, were significantly associatedwith certification change. Additionally, taking prescribed
medications, preparing meals, and toilet hygiene (urinary) were associated with the need for nursing care [24,25]. Taking prescribed medications and preparing meals
are IADL prone to decline along with cognitive function and require complex cognitive processing. Toilet
hygiene (urinary) may be related to urinary control
difficulty as cognitive function declines. An association
between cognitive decline and urinary incontinence has
been reported in studies of older adults living in thecommunity [26, 27]. Further, biometric studies havereported that the frontal cerebral cortex might be associated with bladder control problems in older people [29,30].
In group II (individuals with the third highest levelof independence), only managing money was linked tocertification change. As shown in Table 3, unlike “bathing” and “decision-making ability,” about 20% of participants in the “managing money” category received apartial assistance grade. In other words, we can assume
that money management is very difficult for people
with declining cognitive function, which may have led
to this result. Moreover, managing money was the only
significant ADL factor identified across all levels of
independence, suggesting that, from a preventive longterm care standpoint, assistance in managing money isimportant for individuals with support needs. Previous
studies have shown that, when declines in BADL occur,
IADL deteriorate due to the progression of cognitive
impairment [8–9, 30, 31]. These findings are similar to
those of ADL associated with certification changes identified in this study.
Cognitive decline affects both IADL and BADL
[8–9, 30]. In this study, we identified ADL items thatwere significantly associated with a change from support
needs to long-term care needs and analyzed the results
based on the level of cognitive function. Recently, effective approaches to improve older adults’ decision-making

Sagari A et al.

Asian J Occup Ther 17: 69−77, 2021

abilities [32], prescribed medication-taking behaviors[33, 34], and money management abilities [35, 36] havebeen developed. For individuals with long-term careneeds certification, it might be useful to provide support
for ADL involving complex cognitive processing in
addition to those for improving physical functioning.
Moreover, developing and implementing effective caremanagement plans may support the independence ofolder adults with support needs by identifying ADL interventions from occupational therapists using data fromcertification surveys.
Occupational therapists can use the findings ofthis study to deter individuals’ transition from support
needs to care needs. First, an occupational therapist
needs to evaluate the degree of independence in dailyliving among older adults with dementia and the ADL
of individuals with support needs. Next, the presenceor absence of high-risk items should be confirmed bycomparing the individual’s evaluation results with theresults of this study (Table 4). If a risk item is identified,
the subject should be given appropriate occupational
therapy focusing on improvement of said factor as soon
as possible. In the future, we need to clarify the effectiveness of this intervention strategy.
A limitation of this study was its reliance on certification survey data, as it did not provide backgroundinformation of individuals, which may include factors,
such as disease type, educational background, economic
status, and family structure, that could affect the severity
level of their long-term care needs. Further, we did
not obtain data from clinical tools used by physicians
to diagnose patients. Therefore, we could not infer
causality based on our study design. The number ofsamples differed greatly between the cognitive functiongroups independent, I, and II. Given the results of thelogistic regression analysis, the power of each test may
have differed and affected the results. Although there
were several levels of care needs (ranging from 1 to 5),
the dependent variable in this study was “care needs”;
therefore, some important ADL items might have been
overlooked during analysis.

6. Summary and Conclusions
This study examined the effects of ADL on older
adults’ certification change from support needs to longterm care needs after two years. The findings showedthat ADL affecting certification change varies dependingon the level of cognitive functioning. Within levels ofcognitive functioning, the ADL associated with certification change among the most independent individuals(level Independence) were bathing, nail trimming,
mobility, managing money, and decision-making ability.

75

At the next level of independence (level I) the activities
included bathing, toilet hygiene (urinary), taking prescribed medications, managing money, decision-making
ability, and preparing meals. At the lowest level of independence (group II), only managing money was associated with certification change. In particular, managing
money was considered to be the most important item, as
it influences the change in certification in all cognitive
categories. When occupational therapists intervene older
persons with support needs, they should grasp IADL
abilities such as managing money, which requires complex cognitive functions, from an early stage, and thismay lead to the reduction of the need for care in older
persons with support

Conflict of Interest
The authors report no conflicts of interest.

Funding
This research received no external funding.

Author Contributions
Study concept and design: A.S., T.T., M.K.; dataacquisition: M.K.; data analysis and interpretation: A.S.,
M.M., H.M.; manuscript writing: A.S., T.T., T.H., M.K.

Acknowledgments
The authors thank the City A residents and government employees who provided the information forthis research, as well as Editage (www.editage.jp) for
English language editing.

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■CASE REPORTAn Intervention to Overcome Locomotion Difficulties
in a Patient with Oculomotor Nerve Palsy:
A Case Study
Masato Sato1, Atsuko Shiosaki1, Yoshiki Samoto1, Ryo Yoshimura2
1
2

Department of Rehabilitation, Hashimoto Municipal Hospital
Department of Neurosurgery, Hashimoto Municipal Hospital

Abstract: Introduction: Diplopia due to restricted eye movements makes it difficult to locomote. There are no reported therapies that overcome the locomotion difficulties of patients with oculomotor nerve palsy after a stroke. We
outline a therapy process conducted by an occupational therapist (OT) that combines ptosis therapy and the treatment of
impaired eye movements with exploratory activities for locomotion that enabled the patient, a Japanese woman in her
70s, to improve her engagement in daily activities.
Methods: The OT therapy consisted of two phases. Phase I: Ptosis and eye movement interventions were performed.
Phase II: Interventions supported locomotion that linked visual exploration and the somatosensory system, and the experienced locomotion was adapted to the environmental structure. The outcomes for the intervention effects were thedegree of ptosis, eye movement and diplopia, gait functions, and a functional independence measure for activities ofdaily living.
Results: The patient's ptosis and eye movement disorder improved, and the difficulty of locomotion due to diplopia wasovercome. She was thus able to become independent in all daily activities.
Conclusion: Therapy that combines interventions for ptosis and eye movement with exploratory activities supporting
locomotion have overcome locomotion difficulties and improved the outcomes of patients with oculomotor nerve palsy.
Current interventions may improve locomotion in post-stroke patients with oculomotor nerve palsy. Our findings led us
to hypothesize that locomotion difficulties in patients with diplopia due to oculomotor nerve palsy can be overcome bycombined therapy for ptosis and eye movements with support for exploratory action in locomotion.
Keywords: oculomotor nerve palsy, eye movement disorder, diplopia, locomotion, exploratory activities(Asian J Occup Ther 17: 79−82, 2021)

Introduction
About 60% of stroke patients experience visual
impairment [1]. An unpleasant symptom of such impairment is diplopia [2], which is a cause of oculomotor
nerve palsy. Its symptoms are associated with saccadic
eye movement and gaze problems [2], and having
diplopia makes locomotion in activities of daily living(ADLs) difficult. Eye-movement rehabilitation has been
attempted [3, 4], but no optimal therapy is established.
Received: 9 November 2020, Accepted: 4 August 2021
Corresponding to: Masato Sato, Department of Rehabilitation, Hashi­
moto Municipal Hospital, 22-8-14, Ominedai, Hashimoto, Wakayama
648-0005, Japane-mail: sato.my1005@gmail.com©2021 Japanese Association of Occupational Therapists

Adaptive locomotion to the environment requires
moving the gaze to explore the surrounding environment and associating self-movements [5]. Exploratory
activities that link the surrounding environment with
self-movement may thus facilitate locomotion, but thispossibility is not verified. We describe an effective therapy comprised of combined therapies for ptosis and eye
movements with exploratory activities for locomotion.

Subject
A Japanese woman in her 70s had experienced abrainstem infarction in the oculomotor nucleus area
due to vertebral artery occlusion (Fig. 1). Cranial nerve
findings showed ptosis of the left eye and movement
disorders of the left eye’s upward adduction, adduction,
upward abduction, and downward abduction, indicating

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AN INTERVENTION TO OVERCOME LOCOMOTION DIFFICULTIES IN A PATIENT WITH OCULOMOTOR NERVE PALSY: A CASE STUDY

Fig. 1. Brain magnetic resonance imaging (MRI) on admission.
a) Coronal diffusion-weighted imaging (DWI) on admission shows a slightly hyperintense lesion on the midbrain’s left side.
b) Axial DWI.

left oculomotor nerve palsy. Eye-opening and eye-movement patterns required enhanced effort by excessivecompensatory activity of the head/neck and facialmuscles. The patient’s diplopia was severe based onher results on the Diplopia Questionnaire (www.pedig.
net), which evaluates diplopia in ADLs on a 5-point
scale. She had no physical paralysis, but her diplopia
worsened with the changes in her binocular-vision gaze,and her mental and physical tension was constantly
increasing. Her self-care ADLs could be performed withmonocular vision (right eye), but the movements needed
for toileting, bathing, and gait including locomotion
were stagnant due to the diplopia’s worsening, and sheneeded a caregiver’s constant guiding.

MethodTherapy process
The interventions based on ptosis, eye movement,
and exploratory activities for locomotion were divided
into two phases and performed by an occupational therapist (OT): a 40-min therapy session each morning and a
60-min therapy session each afternoon, 5 days/week for
2 weeks. The two phases were performed consecutively
in one therapy session. Phase I lasted 30 min, and Phase
II lasted 10–30 min. The patient’s informed consent forthis report was obtained.
Phase I: Ptosis and eye movements therapy
The OT adjusted the patient’s head/neck and facialmuscle tone and facilitated selective movements withthe aim of achieving independent eye-opening and eye
movements. Using the vestibulo-ocular reflex is effective for facilitating eye movements for brainstem-derived
eye movement disorders [3]. Therefore, the patient’s
atlanto-occipital joint was quickly rotated to facilitate

the saccadic eye movement in binocular vision (Fig. 2a).
Next, the OT administered an activity for approaching a visual object with the aim of enabling the patient
to intentionally control her gaze from saccadic eye
movement to the visual object (Fig. 2b). This intervention prepared the environment so that the patient’s gazeand body movements could be easily oriented by using
the environmental structure, and the patient thus experienced locomotion linked with her gaze and her body
movements.
Phase II: Locomotion therapy
The occluding edge was used to help achieve thepatient’s locomotion adapted to the environmental
structure; the ‘occluding edge’ refers to the edge of thesurface structure of the environment, and it is a stimulusthat changes the environment’s appearance with locomotion [6]. We speculated that the patient was unable toaccept changes in visual stimuli during sensory reception because her diplopia increased her mental/physicaltension. The OT thus oriented the patient’s locomotion
by having her look to the occluding edge to enable her
to pass through a gap while keeping her body in contact
with the gap in the environmental structure (Fig. 2c).

Results
Table 1 summarizes the changes following the interventions. The patient’s ptosis and her levator muscle
function improved, and there was almost no difference
between the left and right eyes. The eye-movement
disorder also improved, and the diplopia in ADLs wasnearly eliminated. For this patient, even if diplopia
occurs when she performs ADLs, the direction in which
the diplopia occurs is now limited, and it has become
possible to resolve the diplopia by self-adjustment.

Asian J Occup Ther 17: 79−82, 2021

Sato M et al.

81

2. Reproduction of the therapy setting.
AnFig.intervention
to overcome locomotion difficulties in a patient with oculomotor nervea) Manipulating the rotation of the atlanto-occipital joint induced the vestibulo-ocular reflex in binocular vision and facilitatedsaccadic eye movement. b) By adjusting the body to the environmental structure, we guided the approach activity to the visual
palsy: Acase study
1
object beyond it. c) The door is the smallest gap through which the patient’s body passes. The patient is looking into the gap in
the door. Locomotion was induced to link with the movement of the gaze while maintaining the patient’s body contact with theenvironmental structures.

Table 1. Effect of the interventions
on the main outcome measures
Table 1 Effect of the interventions on the main outcome measures

The evaluation of ptosis and diplopia used the method that is used in clinical diagnoses in Japan. Degree of ptosis: Ptosis is judged when the
distance from the corneal reflex image to the levator palpebra is ≤ 2 mm. Levator muscle function: If the width of movement when the gaze is
directed from downward to upward is ≤ 10 mm, the levator muscle function is classified as impaired. Δ: The pre-data subtracted from the postdata. ADL: activities of daily living, FIM: functional independence measure, TUG: Timed up and go test.

The evaluation of ptosis and diplopia used the method that is used in clinical diagnoses
in Japan. Degree of ptosis: Ptosis is judged when the distance from the corneal reflex
image to the levator palpebra is ≤2 mm. Levator muscle function: If the width ofRegarding her gait function, her tension about locomoDiscussion
tion
decreased
andshebecameable
toperform
ADLs
movement when the gaze is directed from downward to upward is ≤10 mm, the levator
independently. Since she became able to conduct selfThe patient had a midbrain infarction, and thecareactivities
withbinocular
vision,sheovercameallsymptoms
of inferiorsubtracted
rectus muscle fromand unilateralptosismuscle function is classified as impaired. Δ: The pre-data
the post-data.
difficulties involving locomotion.
suggested oculomotor fascicle damage. In that lesion,
the nerve
fibers distal to ischemia
are vulnerable,caus- up
ADL: activities of daily living, FIM: functional
independence
measure,
TUG: Timedand go test.

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AN INTERVENTION TO OVERCOME LOCOMOTION DIFFICULTIES IN A PATIENT WITH OCULOMOTOR NERVE PALSY: A CASE STUDY

ing predominant damage to the extraocular muscles [7].
Since our patient had severe diplopia symptoms, shepracticed ptosis and eye-movement therapy in Phase I.
Although there is no therapy for ptosis to date, our patient’s results indicate that the adjustment of muscle tone
and the facilitation of selective movements may havecontributed to her recovery of levator muscle function.
The eye-movement therapy used herein is based on thestimulation of the superior colliculus, which is involvedin the execution of saccadic eye movement [1, 3]. This
therapy assisted the movement of the gaze [8] and appears to have been appropriate.
To our knowledge, the Phase II exploratory activity
described herein is the first therapy to provide a stimulus
composed of vision and somatosensory information.
Processes based on audiovisual stimuli are known to improve the accuracy of visual exploration [9]. The Phase
II intervention’s effectiveness was suggested to involve
learning transitions in exploratory activity [10], andsomatosensory stimuli may have oriented our patient’s
locomotion and facilitated visual exploration accuracy.
However, spontaneous recovery from brain lesions canoccur several months post-onset [1], and further research
and a large patient series are required to validate thepresent interventions’ effectiveness. Moreover, the intervention conditions are limited to ptosis and eye-movement disorder without motor paralysis of limbs.

Conclusion
The combined interventions for ptosis, eye movements, and exploratory activities for locomotion helped
a post-stroke patient with oculomotor nerve palsy overcome locomotion difficulty.

Acknowledgements
We thank the patient for her participation.

References[1] Bulboaca A, Bulboaca A, Stanescu I, Blidaru M, Bulboaca AI, Nicula C, et al. Post-stroke visual rehabilitation the impact on life quality of the stroke survival patients a brief review. Balneo Res J. 2019; 10(1): 17–23.
[2] Nicula C, Nicula D, Bulboaca AE. Non-surgical correction of diplopia after stroke- a strong impact factor on
quality of life-mini review. Balneo Res J. 2019; 10(4):489–94.
[3] Kawahira K, Shimodozono M, Etoh S, Tanaka N. New
facilitation exercise using the vestibulo-ocular reflex for
ophthalmoplegia: preliminary report. Clin Rehabil. 2005;
19(6): 627–34.
[4] Watabe T, Abe M, Ozasa Y, Nagashima J. Improvementof disturbance through oculomotor training in the daily
life of a patient with brainstem infarction (in Japanese).
The Japanese Occupational Therapy Research (sagyouryouhou). 2017; 36(5): 524–9.
[5] Graci V, Elliott DB, Buckley JG. Utility of peripheralvisual cues in planning and controlling adaptive gait.
Optom Vis Sci. 2010; 87(1): 21–7.
[6] Gibson JJ. The ecological approach to visual perception.
Boston: Houghton Mifflin; 1979.
[7] Nakamura Y, Kurauchi Y, Takahashi A, Yamauchi R,
Shimo­hama S. Unilateral ptosis induced by pure midbrain infarction: a case report (in Japanese). Clin Neurol(Rinsho Shinkeigaku). 2020; 60(8): 527–32.
[8] Yamaguchi M, Kaneko H. Integration system of head,eye, and retinal position signals for perceptual direction.
Optical Review. 2007; 14: 411–5.
[9] Passamonti C, Bertini C, Làdavas E. Audio-visual stimulation improves oculomotor patterns in patients withhemianopia. Neuropsychologia. 2009; 47(2): 546–55.
[10] Hacques G, Komar J, Dicks M, Seifert L. Exploring tolearn and learning to explore. Psychol Res. 2021; 85(4):1367–79.

■ORIGINAL ARTICLE

Social Participation of People
with Intellectual Disabilities
in Rural Areas of the Philippines
Akira Teramura1, 2, Kosuke Hamada2, 3, Seiji Yamamoto1, 4
1Osaka Health Science University
Graduate School of Human Sciences, Osaka University
3
Aichi Medical College for Physical and Occupational Therapy
4
Graduate School of Health Sciences Department of Public Health, Kobe University
2

Abstract: The purpose of this study was to analyze the current status and challenges related to social participation facedby people with intellectual disabilities living in rural areas in the Philippines. Semi-structured interviews were conducted with 10 professionals, including nurses of public health center, social workers of nonprofit facility for persons withdisabilities, and teachers of public and private special needs schools. The study was approved by the Graduate Schoolof Human Sciences, Osaka University. The results indicated five categories and 21 subcategories. The five categories
are: Current status of social participation of people with intellectual disabilities in rural areas; Interventions performed
by rural professionals for people with intellectual disabilities; Improved activities of people with intellectual disabilities
owing to study participants’ interventions; Recognition of hindrances to promote social participation; Recognition of
the ideal social participation for people with intellectual disabilities. Based on the current conditions, there were challenges in leisure activities and employment, especially for adults with intellectual disabilities. Our findings suggest it isimportant for Philippine occupational therapists and those working in international organizations to conduct occupation
analysis for understanding the backgrounds, strengths, limitations, concerns, and goals for their leisure activities andemployment. In addition, occupational therapists can contribute not only to providing individual support but also to thedevelopment of community supporters.
Keywords: Philippines, Rural, Intellectual Disability, Social Participation(Asian J Occup Ther 17: 83−89, 2021)

Introduction
In September 2015, the Sustainable Development
Goals (SDGs) were adopted by the United Nations
General Assembly. They were based on the concept of“no one will be left behind,” meaning no one will be left
vulnerable to society, including persons with disabilities.
Previous research has already clearly delineated theissues faced by persons with disabilities, such as accessto medical care, education, employment, and community
development, as well as the importance of their social
participation [1]. According to the World Report on DisReceived: 31 May 2020, Accepted: 30 May 2021
Corresponding to: Akira Teramura, Osaka Health Science University,
1-9-27 Tenman, Kita-ku, Osaka-shi, Osaka 530-0043 Japane-mail: u402964b@ecs.osaka-u.ac.jp©2021 Japanese Association of Occupational Therapists

ability published in 2011 by the World Health Organization and the World Bank, the number of persons withdisabilities accounts for 15% of the world population,of which about 80% live in developing countries [2].
Many persons with disabilities face poverty because of
the barriers imposed upon their access to social participation in a wide variety of fields (e.g., education, health,and employment) [3]. Particularly, persons with disabilities living in rural areas of developing countries tend
to be excluded from society [4], and experience great
differences in various aspects of their lives comparedto those living in urban areas. For example, people withdisabilities living in rural areas have fewer opportunities
for medical services including rehabilitation, education,and employment than people with disabilities living inurban areas. Moreover, it is not easy to use public transportation in rural areas [2–4].
Furthermore, only 0.1–0.4% of people with intellec-

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SOCIAL PARTICIPATION OF PEOPLE WITH INTELLECTUAL IN THE PHILIPPINES

tual disabilities (PID) living in developing countries canreceive appropriate public services [5]. PID living in developing countries do not receive appropriate support forsocial participation compared to those in developed countries [2, 6]. Due to these current conditions, many PID
are not able to work, which often leads to poverty [2–4].
The Japanese government created a support projectcalled the Japan International Cooperation Agency(JICA). For over 60 years, JICA has assisted people
with disabilities living in developing countries by managing the work of medical welfare workers who attend
to these populations. JICA has achieved this by dispatching volunteers to support occupational therapists
and conducting financial cooperation projects. In thepast, many of JICA’s projects aimed at supporting PID
in targeted urban areas [5, 6]. Recently, there has been
an increase in the number of projects targeting rural
areas [6]. For example, JICA has implemented barrierfree development in many countries such as Bolivia,
India, Vietnam, and Senegal. However, persons withphysical disabilities are the main targets of most of theserural projects, and there are few rural programs targetedat improving the social participation of PID [7].
In 2018, the first author investigated a welfare facility in rural areas of Bohol, the Philippines, to examine
the progress—and current status—of the activities for
Filipino adults with intellectual disabilities. However,the content was limited to activities within only one
facility, and the relationship between professional
interventions and social participation was not clarified.
Further, the details of the interventions of specialists in
multiple facilities in rural areas, especially in the medical, welfare, and education fields, were unclear [8].
To the best of our knowledge, there is no comprehensive study on the current status of support for PID
living in rural areas of the Philippines. Therefore, thisstudy aimed to interview workers engaged in providing
medical, welfare, and educational support for PID living
in rural areas of Bohol, the Philippines. Particularly,
we aimed to examine the support that this vulnerable
population is currently receiving, as well as their current
levels of social participation. Moreover, we aimed toclarify the benefits of occupational therapists in rural
areas of developing countries working with other specialists in the same settings. This type of cooperation
could make occupational therapy intervention more
useful by better understanding the interventions of otherexperts and the social participation of PID.
This study is significant because it seeks to contribute to the promotion of social participation of PID
living in rural areas of developing countries; hence, we
propose methods on this subject based on occupational
therapists’ expertise.

Methods
1. Research ParticipantsParticipants were 10 professionals—nurses of publichealth center, social workers of nonprofit facility for
persons with disabilities, teachers of public and private
special needs schools, and teachers of private special
needs schools in rural areas of Bohol. We utilized
snowball sampling method by procuring an introduction
from a director of a welfare facility having previous
experience with our work. Given the purpose of thisstudy, participants were required to know both disability
characteristics and regional characteristics.
2. Data Collection
We visited each facility and conducted semi-structured interviews in English between August 1 and 9,
2019. We asked participants about their basic information—gender, age, facility, specialty, years of experiencein supporting persons with disabilities, and years ofexperience in supporting PID. Then, we conducted
the interviews based on four guiding topics: (1) Social
participation of PID: “How do PID spend their time athome or in the community?” (2) Interventions aimed
at PID: “What kind of interventions do you apply for
PID?” (3) Difficulties in social participation: “Whatare the difficulties that PID experience when trying toparticipate in society?” (4) Specific methods aimed atenhancing the social participation of PID: “What kind ofintervention are you considering to further their social
participation?”
The interviews were conducted based on theoutlined interview guide, but we also listened to participants’ narratives outside of the interview questions andtook all measures to respect their answers and descriptions regarding each of the four major topics. After eachparticipant provided written consent, we recorded eachinterview through an IC chip recorder.
3. Data Analysis
We conducted qualitative analyses based on M-GTA(Modified Grounded Theory Approach) [9, 10], which
was considered suitable, because its theoretical groundings relate to the social participation construct, are relevant for analyses in the intellectual disability context,
and are excellent in explaining and predicting humanbehavior.
First, a verbatim transcript was created from raw
interview data. Participants’ narrative contents were
simplified into single sentences that denoted the generalidea of the content of a phrase, and were subsequently
coded, while maintaining the meaning of the expressedphrase/word. We generated analytical concepts that

Teramura A et al.

Asian J Occup Ther 17: 83−89, 2021

85

Table 1 Profile Characteristics of Participants№

GenderAge(years)Affiliation

Professional

Period for PWDs
(years)Period for PIDs
(years)Interview Time
(min)

1
2
3
4
5
6
7
8
9
10

FemaleFemaleFemaleFemaleFemaleFemaleFemaleFemale
Male
Male

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

Public Health Center
Public Health Center
Public Health Center
Welfare Facility
Welfare Facility
Public Special School
Public Special School
Public Special School
Private Special School
Private Special School

Nurse
Nurse
Nurse
Social Worker
Social Worker
Teacher
Teacher
Teacher
Teacher
Teacher

8
9
17
20
25
25
23
5
15
6

3
5
11
12
20
10
15
3
10
6

47
52
37
88
45
85
55
49
39
44

15.3 ± 7.4

9.5 ± 5.3

54.1 ± 17.7

PWD: People with Disability
PID: People with Intellectual Disability

explained the proposed codes and conducted continuouscomparative analysis by focusing on the context of thenarratives, which were strongly related to the social participation of PID. Next, we formed categories based on
the relationships between the generated codes. During
these procedures relevant to generating analytical concepts, we discussed the proposed classifications until wefound no possible theoretical objections regarding the
proposed classifications.
Based on the categories and subcategories createdby the aforementioned procedures, we structurally organized the current situation of the social participationof PID living in rural areas of Bohol and examined the
problems regarding the topic. We highlight that one of
the researchers had already engaged in international
medical and health research (SY) and was well versedwith the subject matter. Moreover, multiple researchers
engaged in international medical and health researchwith different theoretical and methodological backgrounds (KH and MK) participated in this study. To
ensure the study’s credibility, all researchers jointly
conducted triangulation procedures.
4. Ethical Considerations
This study followed the ethical standards of the
Declaration of Helsinki exactly, and was performed
with the approval of the ethics review committee of the
Graduate School of Human Sciences, Osaka University.
Prior to participation, we explained—both verbally andon paper—the study aims and procedures to the participants and obtained their written consent.

Results
1. Participants’ Characteristics
Our sample comprised 2 male and 8 female participants (average age = 37.2 ± 10.2 years). Their average

number of years of experience in supporting persons
with disabilities was 15.3 ± 7.4 years, and average
number of years of experience in supporting PID was 9.5± 5.3 years. There were 3 nurses, 2 social workers and 5
teachers. The average interview time for each research
participant was 54.1 ± 17.7 minutes (Table 1).
2. Social Participation and Issues of PID Living in Rural
Areas
In total, we extracted 464 codes related to the current state of social participation, support contents, andthe issues of PID living in rural areas of Bohol, the Philippines. We categorized codes based on those that had
similar meanings and expressions and made efforts toconstantly return to the context of the specific codes in
the participants’ narratives, to ensure that each code was
accurately categorized. In total, we obtained 5 categories
and 21 subcategories (Table 2).
The subcategories that make up each category
are described in Table 2. To facilitate differentiation
between the categories, subcategories, and raw data inthe text, we utilized the following symbols:【 】= a category, [ ] = a sub-category, and “ ” = raw data.
In the category【Current status of social participation of PID in rural areas】, the following example
narratives from participants provide context to theresults. One participant provided a statement related tothe subcategory [People with mild intellectual disabilities have roles in the home and in the community]:“Adults with intellectual disabilities can help cook athome and play basketball with local residents.” Anotherstudy participant provided a statement related to thesubcategory [PID have few opportunities to interact withlocal residents]: “PID have little interaction with others
because they cannot speak at the same language levelas do their families and community residents, and they
are not good at communicating.” One study participant

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SOCIAL PARTICIPATION OF PEOPLE WITH INTELLECTUAL IN THE PHILIPPINES

Table 2 Social participation of people with intellectual disabilities through the recognition of rural professionals
Category (Code quantity)

Sub category (Code quantity)

Current status of social participationof people with intellectual disabilities
in rural areas (141)

People with mild intellectual disabilities have roles in the home and in the community (21)People with intellectual disabilities have few opportunities to interact with local residents (33)People with intellectual disabilities have restrictions on home activities (35)People with intellectual disabilities have restrictions on community activities (39)
People with intellectual disabilities tend to be treated unfairly by local residents (13)Interventions performed by ruralprofessionals for people withintellectual disabilities (81)Professionals provide medical examinations and family guidance on how to treat infants (10)Professionals provide learning guidance and emotional education programs (34)Professionals provide few vocational training programs (14)Professionals provide opportunities for people with intellectual disability to interact with local
residents (23)

Improved activities of people withintellectual disabilities owing to study
participants’ interventions (56)People with intellectual disabilities have more activities to do at home (10)People with intellectual disabilities have become more actively engaged in institutional programs (14)People with intellectual disabilities have mutual peer assistance, and relationships have been built (22)People with intellectual disabilities have more opportunities to interact with local residents (10)Recognition of hindrances to promotesocial participation (115)

People with intellectual disabilities cannot receive continuous medical services (9)People with intellectual disabilities cannot receive education and welfare services owing toaccessibility issues (20)People with intellectual disabilities cannot work (58)
Local residents sometimes do not comply with the legal system for intellectual disabilities (9)Local residents have prejudice and discrimination against people with intellectual disabilities (19)

Recognition of the ideal social
participation for people withintellectual disabilities (71)

People with intellectual disabilities need to increase their leisure activities (20)People with intellectual disabilities can earn money (37)People with intellectual disabilities can make their own decisions (14)provided a comment related to the subcategory [PID
have restrictions on home activities]: “PID are unable
to help with housework, and they do nothing at home.”
One study participant provided a comment related to thesubcategory [PID have restrictions on community activities]: “PID cannot perform leisure activities outside theirhome.” Lastly, a study participant provided a statementthat related to the subcategory [PID tend to be treatedunfairly by local residents]: “Children with disabilities
may be bullied and women with intellectual disabilities
may be raped.”
Regarding the category【Interventions performed
by rural professionals for PID】, one study participant
provided a statement related to the subcategory [professionals provide medical examinations and family
guidance on how to treat infants]: “We carry out simple
medical examinations and family instructions several
times.” Another participant provided a statement related
to the subcategory [professionals provide learning
guidance and emotional education programs]: “I teachlanguage, calculation, music, etc. at a special needs
school.” Moreover, one research participant provided acomment related to the subcategory [professionals provide vocational training programs]: “We provide PID theopportunity to experience cooking, crafting, agriculture,and selling goods at welfare facilities.” Finally, a par-ticipant provided a statement regarding the subcategory[professionals provide opportunities for PID to interact
with local residents]: “We encourage participants toparticipate in events such as local sports competitions
through the organization.”
The category【Improved activities of PID owing tostudy participants’ interventions】also included many
narratives. One research participant provided a comment
related to the subcategory [PID have more activities to
do at home]: “PID have started to care for their homes
by cleaning their desks and cooking rice.” Another participant said about the subcategory [PID have become
more actively engaged in institutional programs]: “PIDbegan to calculate the values of their products while selling goods and worked with agriculture.” Furthermore, aparticipant provided a statement related to the subcategory [PID have mutual peer assistance, and relationships
have been built]: “PID started to help each other withtasks they are not good at.” Another participant provided
a comment related to the subcategory [PID have more
opportunities to interact with local residents]: “PID havebeen invited by residents to participate in religious festivals and volleyball competitions held in the district.”
In the category 【Recognition of hindrances topromote social participation】a participant provided acomment related to the subcategory [PID cannot receiveAsian J Occup Ther 17: 83−89, 2021

continuous medical services]: “In private clinics, medical costs are high, so PID cannot access these services.”
Another provided a statement related to the subcategory[PID cannot receive education and welfare services
owing to accessibility issues]: “Children with severe
intellectual disabilities and adults with intellectual disabilities cannot frequently attend schools and facilities
because they are located far away.” Additionally, a participant provided a statement regarding the subcategory[PID cannot work]: “There are few places in the areathat provide vocational training, such as workshops.
Further, there are few professionals who provide employment support.” Another participant said about the
subcategory [Local residents sometimes do not comply
with the legal system for intellectual disabilities]: “Thelaw that regulates discounts for persons with disabilities
to access entertainment facilities is not fully enforcedin the area.” Concluding this category, a participant
commented about the subcategory [Local residents haveprejudice and discrimination against PID]: “The prejudice and discrimination of local residents is strong, andthe behaviors of PID are not understood.”Coming to the category【Recognition of the idealsocial participation for PID】, a participant provided
a statement related to the subcategory [PID need toincrease their leisure activities]: “PID should continue
to have opportunities to interact with local residents at
local events.” Another participant remarked about the
subcategory [PID can earn money]: “PID can do manyrural jobs, such as agriculture and fishing, in a shortperiod of time.” Finally, a participant said about the
subcategory [PID can make their own decisions]: “Evenif family members and professional supporters provide
assistance, PID can still make their own decisions.”

Discussion
In this study, participants reported that some people
with mild intellectual disabilities who lived in rural areasof Bohol, the Philippines were involved in local sports
and employment. However, most had few opportunities
to interact with other local residents, experienced limited activities, and were mistreated by some residents
within the local community. Participants reported that
community health centers, welfare facilities, and special
needs schools provided PID simple medical services,educational and employment support, and encouragement to participate in community activities. Owing tosuch institutions, PID in this setting seem to be currently
experiencing improvements regarding the number ofopportunities available to perform different types ofactivities and to experience interpersonal exchanges.
However, some barriers to the promotion of social par-Teramura A et al.

87

ticipation among this population remain; for example,
difficulty in providing continuous medical services,travelling/access problems (owing to the distance fromtheir homes to the institutions and facilities in which theactivities are performed), difficulty finding work opportunities, and local residents’ lack of understanding about
the behaviors and characteristics of PID.
The category【Current situation of social participation of PID in rural areas】comprised topics regarding
the lack of opportunities for PID to experience interpersonal exchanges, the unfair treatment they receivefrom local residents, and restrictions on the activities
available to them both inside and outside their homes.
Owing to their disability characteristics, PID experience a deficit in abstract thinking and judgment, as
well as in planning and problem-solving skills [11].
Additionally, people without disabilities tend to have aharder time understanding PID than those with physicaldisabilities, and the former are more likely to experience
discrimination and prejudice than the latter [12, 13].
Furthermore, the provision and accessibility of social
resources are weaker in rural areas than in urban areas[2]. Convention on the Rights of Persons with Disabilities that the United Nations General Assembly wasdrafted in 2006, and the Philippines ratified in 2008 [14].
Our study participants recognized that there is a tendency for equal opportunities and participation to be impeded, especially among those with moderate to severe
intellectual disabilities.
Additionally, the categories【Interventions perform­
ed by rural professionals supporters for PID】 and【Improved activities of PID owing to study participants’interventions】comprised topics related to specialized
professional interventions in the fields of medical care,welfare, and education by the study sample. The maininterventions provided by the professionals related tosimple examinations regarding patients’ intellectual
functions, and family guidance for infants who werein medical institutions—mostly public health facilities, where costs are low. Private medical institutions
also provide services but are not preferred as they are
expensive. Another concern is the inability to accessthese services regularly after school age. Moreover,educational institutions provided support for children
with disabilities throughout school years; the contents
comprised math, language (learning the alphabet), andmusic activities. Additionally, welfare facilities provided
opportunities for this populational group to have accessto different daily and community activities. After using
the services provided by these facilities, our participants
reported that the PID they interacted with started being
able to assist in the cooking and cleaning chores at theirhomes and being able to actively carry out activities

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SOCIAL PARTICIPATION OF PEOPLE WITH INTELLECTUAL IN THE PHILIPPINES

such as making crafts (wood and paper craft) andcaring for pets (such as dogs and cats or livestock suchas chickens and ducks) in the facility. Furthermore,those frequenting the facility also started to engage inactivities to help each other with their intellectual disabilities, and to participate in sports competitions withlocal residents, all of which increased their opportunities
to engage in interpersonal interactions. Nonetheless,although the Convention on the Rights of Persons with
Disabilities requires participating countries to ensurethat rehabilitation services are provided for this public[14], our results showed that the welfare institutions had
only few rehabilitation specialists. Hence, PID living
in rural areas of Bohol still need individual and groupinterventions that evaluate their intellectual functioning
and social adaptation and consider their culture andenvironment.
Regarding the category【Recognition of hindrances
to promote social participation】, our participants recognized that PID were not able to receive continuous medical services or access education and welfare services
owing to transport accessibility issues, such as theirinability to board the local buses and pay the fare, andthe lack of available buses to reach the far-off facilities.
Moreover, they faced difficulties in finding work. Theinterviewed supporters also felt that local residents had
prejudice against PID, so the residents often did notcomply with the legal system for PID.
Although there is an employment support programthat is promoted by a public rehabilitation center in thePhilippines, it is implemented mainly in urban areas [15].
Therefore, employment support initiatives for PID in
the region are limited to some disability support groups
and special support schools. In order to enhance theemployment opportunities of PID living in rural areas of
the Philippines, a project that specializes in employment
support for this public should be implemented. Particularly, stakeholders should engage with not only one
institution but also promote a strategic cooperation withprofessionals and a wider array of institutions and companies, both public and private.
Regarding the category【Recognition of the idealsocial participation for PID】
, participants recognizedthat persons with disabilities should ideally participate
in leisure activities, be able to work, and earn theirincomes. However, participants were not able to provide
specific methods regarding the promotion of such idealsocial participation and were not able to outline how todevelop interventions that are tailored to the disability
and environment characteristics that surround this populational group.
To promote the social participation of people withdisabilities living in developing countries, World HealthOrganization recommends the concept of Community-Based Rehabilitation (CBR), which is used worldwide [16]. CBR comprises five components: Health,
Education, Livelihood, Social, and Empowerment. It
is aimed at developing the entire community and is notjust an intervention for the recovery of functional disabilities. Additionally, in CBR, occupational therapists
are also expected to participate for the purpose of social
participation in supporting people with disabilities indeveloping countries [17]. The results of this research
indicate that the development of employment and leisureactivities in adulthood is essential for the ideal social
participation of PID. Occupational Therapy Associationof the Philippines has also stated the need for OT intervention for adults with intellectual disabilities in rural
areas [18]. These findings suggest the need for OT in the
study area. To promote their leisure activities, occupational therapists use occupational analysis to match anindividual’s abilities with the demands of the task [19].
In addition, occupational therapists use the concepts of
COPM and ICF to assess their activities for providing
effective support. Occupational therapist understands
the experience background, strengths, weaknesses, worries, and goals of the person with disability and provides
highly specialized interventions [17].
In CBR, occupational therapists are also expected
to teach and train CBR workers and volunteers inbasic assessment and interventions to help people withintellectual disabilities lead better daily lives [20]. The
supporters and occupational therapists then check on
the progress of the program and support the parents
in their guidance and activities to diminish stigma inthe community [19]. In other words, in a study area inwhich the number of occupational therapists is limited,
it is important not only to provide individual support but
to also train supporters to support the entire community.
We hope that this study’s findings provide guidance tooccupational therapists from support groups in the Philippines and elsewhere, such as JICA and international
NGOs.

Limitations
Although our study included novel qualitative results in the field of disability research, it still had methodological limitations. First, our sample size was small.
Second, we performed our interviews in a very limitedarea of the Philippines. In the rural areas of the Philippines, the number of facilities and professionals that
supported PID was very limited at the time of this study.
Therefore, our study comprised only the Bohol province, making it difficult to generalize our results. Futurestudies should conduct interviews among PID and theirAsian J Occup Ther 17: 83−89, 2021

families, other types of specialists, and other types ofcompanies in order to plan more detail OT interventions.
Moreover, we suggest future research endeavors collectdata in other regions of the Philippines on the current
situation and issues regarding the social participation of
PID, which will contribute to a clearer understanding of
the problems throughout the country on the topic andallow specific solutions and programs to be devised foreach region.

Conclusion
Based on our qualitative results, many PID living
in rural areas of the Philippines experience difficulties
regarding social participation owing to their activity
restrictions. Our study participants reported that thestudied populational group lacked continuous medical
services, lacked adequate access to education (owing
to living in remote areas and having severe intellectual
disabilities, because of which they needed to be accompanied to the distant locations to access the services),
experienced difficulties in receiving employment
assistance, and were not understood by local residents.
We propose that international stakeholders try to collaborate with specialists in the fields of medicine, welfare,education, and occupational therapy to improve on thestudied populational group’s access to leisure activities
and employment opportunities; such collaborations may
ensure the promotion of an ideal social participation of
PID living in the rural areas of the Philippines.

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