■RAPID COMMUNICATIONSPreliminary Survey of Factors Associatedwith Promoting Evidence-Based PracticeAmong Occupational Therapists Working
in Convalescent Rehabilitation Wards
Yusuke Masuda1, Jun Yaeda2, Tamami Aida3
1

Department of Rehabilitation, Shonan University of Medical Sciences
Graduate School of Comprehensive Human Sciences, University of Tsukuba
3
Graduate School of Rehabilitation, Mejiro University
2

Abstract: In recent years, the concepts of value-based practice (VBP) and shared decision-making (SDM) have become
popular as methods of clinical decision-making and consensus-building. Moreover, the underlying decision-making iscommonly known as evidence-based practice (EBP). EBP is the necessary knowledge and skills for clinical practice ofoccupational therapy, but at the same time, the difficulties of EBP have been reported.
Purpose: The purpose of this study was to explore the structure of EBP-promoting factors, including clinical, educational, and research experiences, among occupational therapists.
Methods: A questionnaire survey using a postal method was conducted among 30 occupational therapists working inJapanese convalescent rehabilitation wards.
Results: Factors associated with the implementation of EBP and self-efficacy regarding EBP included the following: (1)experience of learning in graduate school, (2) experience of receiving education on research methods, (3) positive experience with research, (4) experience of working in professional teams, (5) experience as a clinical practice supervisor
for students, (6) frequency of database use, (7) outcome expectancy, (8) work environment, (9) intrinsic motivation, and(10) barriers. The number of years of clinical experience of occupational therapists was not associated with the implementation of EBP and self-efficacy regarding EBP.
Conclusions: Research experience, working in professional teams, and being clinical practice supervisors for students
and others were more important factors than years of clinical experience to promote the implementation of EBP and
self-efficacy regarding EBP among occupational therapists. The structures of these factors interacted with each other.
Keywords: evidence-based practice, evidence, occupational therapist, convalescent rehabilitation wards, survey(Asian J Occup Ther 19: 1−7, 2023)

Introduction
Until the early 1990s, medical care was often
provided, relying solely on opinion and experience [1].
Medical care that relied solely on opinion and experience often resulted in poor decision-making [2]. In thiscontext, in the mid-1990s, when evidence-based medicine (EBM) became widespread, the rate of treatment
Received: 5 November 2021, Accepted: 19 July 2022
Corresponding to: Yusuke Masuda, Department of Rehabilitation,
Faculty of Medical Sciences, Shonan University of Medical Sciences,
16-48, Kamishinano, Totsuka-ku, Yokohama-shi, Kanagawa, 2440806, Japane-mail: yusuke.masuda@sums.ac.jp©2023 Japanese Association of Occupational Therapists

without evidence clearly decreased due to the implementation of EBM [3]. In addition, it was reported thatphysicians’ practice and patients’ outcomes significantly
improved by using various medical guidelines developed by applying EBM methods [4].
“The practice of EBM means integrating individual
clinical expertise with the best available external clinicalevidence from systematic research.” It also means “theconscientious, explicit, and judicious use of current
best evidence in making decisions about the care ofindividual patients” [5]. EBM is the process of STEP
1, asking an answerable clinical question based on thehealth needs of a specific client; STEP 2, finding the best
available evidence by searching the literature; STEP 3,
critically appraising the literature (check for validity,

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PRELIMINARY SURVEY OF EBP-PROMOTING FACTORS

clinical relevance, and applicability); STEP 4, applying
the evidence in clinical practice; STEP 5, evaluating
STEPS 1−4 [6]. Subsequently, EBM has been widely
disseminated throughout health care as evidence-based
practice (EBP) since 2000.
However, it has been pointed out that EBP does notprovide a specific methodology for STEP 4. Therefore,
value-based practice (VBP) was proposed as a concept
to develop EBP, focusing on the “value” of clients, theirfamilies, and medical professionals [7]. In addition,
shared decision-making (SDM) has gained worldwide
attention as a method for clinical decision-making andconsensus-building against the backdrop of the growing
social demand to respect the values of clients in medicine and the trend toward EBP [8].
Thus, in recent years, the concepts of VBP and
SDM have become increasingly popular, and the underlying decision-making is commonly known as EBP. EBP
is said to help develop the knowledge and skills necessary for the clinical practice of occupational therapy[9]. In addition, the number of occupational therapists
who have a positive attitude toward EBP is increasing
because advances in information technology have madeit easier to access high-quality evidence, and various
medical guidelines have become more widely used.
However, the implementation of EBP is challenging
because it requires a variety of knowledge and skills,
such as effective search skills, critical appraisal, understanding of individualization, and skills in understanding
the context of clients [10]. If occupational therapists canimplement EBP, which is the foundation of decisionmaking in medicine, it can lead to VBP and SDM,
and it can avoid poor decision-making and providing
treatments without evidence, which can efficiently andeffectively realize meaningful outcomes for clients.
Therefore, to promote EBP among occupational
therapists, in recent years, there have been increasing
reports that training sessions and workshops have been
held mainly in Europe and the United States to improve
the knowledge of and skills required for EBP. In addition, scales have been developed to measure the knowledge and skills of occupational therapists regarding EBP
as an indicator of the effectiveness of EBP education[11]. This scale is the self-efficacy regarding EBP basedon the self-efficacy theory [12]. In our previous study,
it was clear that the most important factor in the implementation of EBP was self-efficacy regarding EBP [13].
Therefore, what kinds of clinical, educational, andresearch experiences are necessary to promote the implementation of EBP and self-efficacy regarding EBP?
In addition, how are the factors that promote EBP structured? There are no previous studies that have clarified
these research questions. To clarify these research ques-

tions, we conducted an empirical survey of occupational
therapists working in convalescent rehabilitation wards
in Japan. The main survey is a large-scale study using
a questionnaire-based postal method. The main survey
aims to solve these research questions through multivariate analysis, such as factor analysis and structural
equation modeling.
This preliminary study was conducted to exploratively examine the structure of factors that promote
EBP, including clinical, educational, and research experiences, to promote EBP among occupational therapists.

Methods
Structure of the questionnaire
The questionnaire consisted of two parts: basic
information and questions about EBP.
The basic information included the number of yearsof clinical experience, sex, and clinical, educational, andresearch experiences related to EBP facilitators, such as
final educational background (graduation from vocational school, university, or graduate school), post-graduate
education on EBP methodology, education on researchmethods, positive experience with research, work
experience in professional teams, such as by disease orintervention methods, experience as clinical practicesupervisors for students, and frequency of use of academic databases (0: never to 10: often) [14].
First, to develop the EBP questions, we referred
to EBP scales whose reliability and validity had been
confirmed in previous studies [15]. In addition, factors
related to EBP were extracted from previous studies.
Next, based on behavioral theories, three researchers
examined the structure of the questionnaire, and a totalof 42 items consisting of six major categories were created: “Implementation of EBP (Implementation),” “Selfefficacy regarding EBP (Self-efficacy),” “Outcome
expectancies for EBP (Outcome expectancies),” “Workplace environment that encourages EBP (Workplaceenvironment),” “Intrinsic motivation for EBP (Motivation),” and “Barriers to EBP (Barriers).” For eachquestion, responses were requested on 10-point scales(0: Strongly Disagree to 9: Strongly Agree).
Survey procedure
In this preliminary survey, we first selected one
occupational therapist from each of the three convalescent rehabilitation wards in the Tokyo metropolitan area
using the snowball sampling technique, and we asked
them to work together as the preliminary survey leader.
These three preliminary study leaders were selected on
the condition that they belonged to a hospital with anaverage of ≥ 18 occupational therapists working there.

Asian J Occup Ther 19: 1−7, 2023

This selection criterion took into account the staffing ofoccupational therapists in convalescent rehabilitation
wards throughout Japan. Next, the three preliminary
survey leaders selected ten occupational therapists
each at their hospitals and distributed the explanatory
documents and questionnaires. In this way, a total of
30 occupational therapists participated in the present
preliminary study.
To determine the sample size, G*Power 3.1.9.2 forWindows was used. We set the effect size at 0.5, the risk
ratio at 0.05, and the power at 0.8, resulting in a required
sample size of 26 participants. Considering the interruption or withdrawal of the survey, we decided to ask 30
occupational therapists to cooperate in this survey.
The questionnaires were collected by the preliminary survey leaders, and we requested them to be returned in a self-addressed envelope. The implementation
period was set at 1 month, from January 22 to February
21, 2020.
Ethical considerations
Consent for this study was obtained from theresearch participants by answering and returning thequestionnaire. This study was conducted in compliancewith the ethical guidelines of the World Medical Association (Declaration of Helsinki, 1964 and Declaration ofTokyo 1975, revised 2013). In addition, this study wasapproved by the Research Ethics Committee for Human
Sciences, University of Tsukuba (No. East 2019-76).
Data analysis
First, the median and quartiles were calculated
for the response scores to the EBP questions. The item
means within each scale were calculated for participants,
and the median was calculated as a subscale score.
Next, to provide insight into the research questionof “what kinds of clinical, educational, and research experiences are necessary to promote the implementationof EBP and self-efficacy regarding EBP?” the effectof basic information on “Implementation” and “Selfefficacy” score was compared using the Mann−
Whitney’s U test, and effect size (r) was calculated. In
addition, to provide insight into the research questionof “how are the factors that promote EBP structured?”
Spearman’s rank correlation analysis was conducted forcorrelations between each scale, years of clinical experience, and frequency of use of academic databases.
IBM SPSS for Windows, ver. 26.0 J was used forstatistical analysis, and the significance level was set at< 5%.

Masuda Y et al.

3

Table 1 Basic information about participants (n = 29)
Basic informationn (%)

Years of clinical experience

1–5 years
6–10 years
11–15 years
More than 16 years

8 (27.6)
9 (31.0)
9 (31.0)
3 (10.3)

Sex

Male
Female12 (41.4)
17 (58.6)

Final educational background

Vocational Schoolor University
Graduate School

Experience with post-graduate
education on EBP methodology

NoYes

14 (48.3)
15 (51.7)

Experience with education on
research methods

NoYes

10 (34.5)
19 (65.5)

Positive experiences with researchNoYes

9 (31.0)
20 (69.0)

Work experience in a professionalteam, such as by disease or intervention methodNoYes

14 (48.3)
15 (51.7)

Experience as clinical practicesupervisor for students

NoYes

8 (27.6)
21 (72.4)

Frequency of use of academic
databases (0: never to 10: often)

0–2 points
3–5 points
6–8 points
9–10 points

3 (10.3)
6 (20.7)
15 (51.7)
5 (17.3)

21 (72.4)
8 (27.6)

Results
Responses were obtained from all 30 participants.
Of these, 29 (12 males and 17 females, years of clinicalexperience: median 7.0 years) who answered all thequestions were considered valid responses. Basic information about the participants is shown in Table 1.
The response scores for the EBP questions areshown in Table 2. Questions 01−05 included in “Implementation” were all 6.0. Question 06 included in “selfefficacy” had a high score of 7.0, while questions 07 and10−14 had relatively low scores of 4.5−5.0. Questions
15−21 included in “Outcome expectancy” were allabove 6.0. Questions 23−28 and 31 included in “Workenvironment” had high scores of 7.0, while questions 22
and 30 had relatively low scores of 5.0. Questions 32−36
included in “Motivation” were all above 7.0. Question
38 included in “Barriers” had a high score of 7.0, whilequestion 40 had a low score of 2.0. The highest score foreach subscale was 7.4 for “Motivation,” followed by 6.6
for “Outcome expectancy,” 6.4 for “Implementation,”
6.3 for “Workplace environment,” 5.3 for “Self-efficacy,”and 4.5 for “Barriers.”
Table 3 shows the effects of basic information of

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PRELIMINARY SURVEY OF EBP-PROMOTING FACTORS

Table 2 Response Scores to EBP Questions (n = 29)
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42

EBP Questions

Median (IQR)

I actively make use of the evidence described in clinical practice guidelines (e.g., the guideline for the management ofstroke) in clinical practice of occupational therapy.
I actively make use of the best evidence in clinical practice of occupational therapy.
I incorporate intervention methods with established evidence in clinical practice of occupational therapy.
I use academic databases (such as PubMed and the ICHUSHI database) when selecting effective interventional methods
for clients.
I help clients make their own choices and decisions, while taking the evidence into consideration.
Implementation of EBP (Implementation)
I can assess clients’ needs, values, and preferences for intervention methods.
I can integrate the best research findings, my clinical judgment, as well as the client’s values and preferences to determine
appropriate intervention plans.
I can pose appropriate questions relating to queries and issues when performing occupational therapy.
To resolve queries and issues, I can use academic databases (such as PubMed and the ICHUSHI database) to effectively
conduct literature searches to obtain research findings on the best intervention methods.
I can critically appraise the strengths and weaknesses of study methods (e.g., the adequacy of study design, criteria for the
study, data collection, and analytical methods etc.).
I can critically appraise the characteristics (i.e., reliability and validity, sensitivity, specificity, etc.) of standardized assessment scales that are being considered for use in clinical practice.
I can critically appraise the validity and generalization of study results.
I can determine whether research findings are applicable to clients.
Based on the results, I can carry out an ongoing assessment of the impact of intervention plans.
Self-efficacy regarding EBP (Self-efficacy)
I believe the implementation of EBP will improve the effectiveness of occupational therapy.
I believe that by the implementation of EBP, I can avoid selecting ineffective methods of intervention.
I believe that the implementation of EBP can support the decisions made by clients.
I believe that the implementation of EBP will make it easier to develop the trust of clients.
I believe that the implementation of EBP will improve client satisfaction.
I believe that the implementation of EBP will allow me to keep up-to-date on occupational therapy assessments and interventions.
I believe that the implementation of EBP will improve cost-effectiveness.
Outcome expectancy for EBP (Outcome expectancy)
My workplace works and liaises with university teaching staff and researchers to implement and carry out occupational
therapy research.
Senior staff in my workplace have a positive attitude toward EBP.
In my workplace, there are senior staff and colleagues who ask about research.
In my workplace, I am expected to implement EBP as part of my role as an occupational therapist.
My workplace environment is such that I can view academic databases and journals.
In my workplace, there is a system that supports presentations at scientific meetings and the writing of academic papers
related to occupational therapy.
In my workplace, there is a system for conducting research related to clinical practice of occupational therapy.
In my workplace, there is a research department and development department, both of which occupational therapists
actively participate.
In my workplace, there is a culture of having opportunities to learn about research and holding study sessions to read anddiscuss research papers.
In my workplace, there is a database of clients and a system for accumulating data.
Workplace environment that encourages EBP (Workplace environment)
I wish to implement EBP.
I wish to learn about EBP.
I enjoy reading research papers closely related to occupational therapy to investigate whether they could be applied to myclients.
I think it is very important to implement EBP.
I think that EBP must be incorporated into occupational therapy.
Intrinsic motivation for EBP (Motivation)
I have no time to incorporate EBP into occupational therapy.
Ongoing educational costs will be required to implement EBP.
Experience-based practice is more effective than EBP.
I do not believe that EBP is worthwhile in occupational therapy.
I do not have sufficient education and training to implement EBP.
I believe that EBP puts too much pressure on my role as an occupational therapist.
Barriers to EBP (Barriers)

6.0 (5.0–7.8)

IQR: interquartile range
0: SD (Strongly Disagree) – 9: SA (Strongly Agree)

6.0 (4.3–7.0)
6.0 (5.0–7.0)
6.0 (4.0–7.0)
6.0 (5.0–7.0)
6.4 (4.8–7.0)
7.0 (5.0–8.0)
5.0 (5.0–7.0)
6.0 (5.0–7.0)
6.0 (4.0–7.0)
5.0 (3.0–6.0)
4.5 (3.0–6.0)
5.0 (3.0–6.0)
5.0 (4.0–7.0)
5.0 (4.3–7.0)
5.3 (4.3–6.4)
7.0 (6.0–9.0)
6.0 (4.0–7.0)
7.0 (5.0–7.8)
6.5 (5.0–7.0)
7.0 (6.0–7.0)
7.0 (5.3–8.0)
6.0 (5.0–7.0)
6.6 (5.3–7.7)
5.0 (2.3–7.0)
7.0 (6.0–8.0)
7.0 (5.0–8.0)
7.0 (5.0–7.0)
7.5 (6.0–9.0)
7.5 (7.0–8.8)
7.0 (4.0–7.0)
6.0 (2.3–7.0)
5.0 (4.0–7.0)
7.0 (4.0–8.0)
6.3 (4.8–7.1)
7.0 (7.0–8.8)
8.0 (7.0–9.0)
7.0 (5.0–8.0)
7.0 (6.0–9.0)
7.0 (6.0–8.8)
7.4 (6.0–8.2)
4.5 (2.0–6.0)
7.0 (4.3–8.0)
4.0 (3.0–5.0)
2.0 (0.0–3.0)
5.0 (4.3–7.0)
4.0 (2.0–5.8)
4.5 (3.7–5.0)

Asian J Occup Ther 19: 1−7, 2023

Masuda Y et al.

5

Table 3 Influence of basic information about participants on the implementation of EBP and self-efficacy for EBP (n = 29)
Basic information

n
12
17

Implementation of EBP

Self-efficacy for EBPMedian (IQR)

P-value

ES (r)Median (IQR)

P-value

ES (r)

7.0 (6.4–7.8)
5.2 (4.4–6.4)

.006

.49

6.3 (5.4–6.8)
4.8 (4.1–5.6)

.007

.48

.003

.52

.003

.53

Sex

Male
FemaleFinal educational background

Vocational School21
or University
Graduate School
8

Experience with post-graduate education
on EBP methodology

No
Yes

14
15

5.2 (3.4–6.8)
6.8 (6.2–7.0)

.041

.38

5.1 (4.3–5.6)
6.2 (4.8–6.7)

.07

.34

Experience with education on researchmethods

No
Yes

10
19

4.8 (2.8–6.0)
6.8 (6.4–7.6)

.003

.52

4.4 (2.9–5.4)
6.1 (5.1–6.7)

.004

.51

Positive experiences with research

No
Yes

9
20

5.2 (2.8–6.6)
6.8 (5.5–7.6)

.022

.42

5.1 (2.9–5.3)
5.9 (4.6–6.7)

.026

.40

Work experience in a professional team,such as by disease or intervention method

No
Yes

14
15

4.8 (3.4–6.6)
7.0 (6.4–7.8)

.001

.59

4.6 (3.4–5.6)
6.5 (5.3–6.9)

.003

.52

Experience as clinical practice supervisor
for students

No
Yes

8
21

4.6 (2.8–6.5)
6.8 (5.5–7.6)

.024

.41

3.8 (2.6–4.8)
5.9 (5.2–6.7)

.001

.56

5.4 (4.4–6.8)
7.3 (6.7–7.7)

4.8 (4.1–5.6)
6.7 (6.2–6.9)

IQR: interquartile range
ES: Effect Size, .10 ≤ r < .30 (Small), .30 ≤ r < .50 (Medium), .50 ≤ r (Large)

the participants on “Implementation” and “Self-efficacy”(r : effect size). As clinical, educational, and researchexperiences affect both “Implementation” and “Selfefficacy,” (1) experience of learning in graduate school,(2) experience of receiving education on research methods, (3) positive experience for research, (4) experienceof working in professional teams, such as by diseaseor intervention methods, and (5) experience as clinicalpractice supervisor for students all showed significant
effects ( p < .05). In particular, the effect sizes of (1), (2),and (4) were larger depending on the experience (0.5≤ r).
The results of the correlation analysis between
years of clinical experience, frequency of database use,and each scale are as follows. There were no significant
correlations between the number of years of clinical experience and “Implementation” and “Self-efficacy”, but(6) frequency of database use had a significantly highcorrelation with “Implementation” (r = .88, p < .001)
and “Self-efficacy” (r = .72, p < .001). Inter-scales
correlations showed significant correlations between“Implementation” and “Self-efficacy” and (7) Outcome
expectancy, (8) Workplace environment, (9) Motivation,and (10) Barriers (r = .39–.75, p < .05) (r : correlation
coefficient).

Discussion
Factors to promote “Implementation of EBP” and “Selfefficacy regarding EBP”
First, responses to the EBP questions were requested on 10-point scales (0−9). A score of 0−2 can be interpreted as “low score,” 3−6 as “middle score,” and 7−9
as “high score.” In each subscale score, “Motivation”
was 7.4, while “Self-efficacy” was 5.3, showing a difference of more than two points. This can be interpreted
as a state of low confidence in the specific knowledge
and skills for EBP, while feeling a desire to implement
EBP. The results suggest that there is a gap between
the perceptions of “I want to” and “I can.” Self-efficacy
theory states that “Self-efficacy becomes a primary,
explicit explanation for motivation” when “large discrepancies between self-efficacy and ability can create
motivational problems for the individual” [12]. In otherwords, if self-efficacy is low, there is a possibility that
“Implementation” and “Motivation” will be reduced. To
solve this issue, it is considered necessary to improve
confidence in knowledge and skills related to STEPS
3−5 of EBP, such as questions 07 and 10−14 included in“Self-efficacy.”
Further, the results of the intergroup comparisonand correlation analysis suggest that clinical, educational, and research experiences related to EBP, such as
items (1) to (6), and the implementation of EBP-related
scales, such as items (7) to (10), are more important fac-

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PRELIMINARY SURVEY OF EBP-PROMOTING FACTORS

tors in promoting “Implementation” and “Self-efficacy”
than years of clinical experience of occupational therapists. These are possible structures that interact witheach other. In particular, if we rely on the self-efficacy
theory [12], it can be expected that successful experiences in situations that require knowledge about the
research, such as (1), (2), and (4), where the effect size
was higher depending on the experience, will improve“Self-efficacy” and promote “Implementation.”In the previous study [13], self-efficacy was foundto be the factor most associated with the implementationof EBP. The novelty of this study was that it provided
specific suggestions on clinical, educational, and research experiences to promote “implementation of EBP”
and “self-efficacy regarding EBP” and the structure of
EBP-promoting factors.
Limitations and future prospects
Since this preliminary survey was an exploratory
study conducted prior to the main survey, we considered
the following as limitations of this study: (1) the small
number of research participants, (2) the existence of
selection bias due to research cooperation by snowball
sampling technique and the target area is limited to theTokyo metropolitan area, (3) insufficient examinationof reliability and validity of EBP questions. To solvethese limitations, we believe two things are necessary:to conduct a large-sample survey study of occupational
therapists who work in convalescent rehabilitation wards
throughout Japan and conduct statistical analysis after
examining reliability and validity.
In the future, we will consider adding or deletingquestions and making additions or revisions based on the
results of this preliminary survey. In addition, we plan toorganize the content regarding specific clinical, educational, and research experiences to promote EBP amongoccupational therapists from multiple perspectives
and then move on to the main survey. After examining
the reliability and validity of the questionnaire items
through factor analysis, the main survey will structure
the factors that promote EBP and build a practice model
to promote EBP among occupational therapists.

Summary and Conclusion
This study was the preliminary survey conductedprior to the main survey with the aim of providing answers to the research questions, “what kinds of clinical,
educational, and research experiences are necessary to
promote the implementation of EBP and self-efficacy
regarding EBP?” and “how are the factors that promote
EBP structured?” The participants were 30 occupational
therapists working in three convalescent rehabilitation

wards in the Tokyo metropolitan area.
As a result of the analysis based on the researchquestions, the following clinical, educational, and research experiences were identified as factors related tothe implementation of EBP and self-efficacy regarding
EBP: (1) experience of learning in graduate school, (2)experience of receiving education on research methods,(3) positive experience for research, (4) experience ofworking in professional teams, such as by disease orintervention methods, (5) experience as clinical practicesupervisor for students, and (6) frequency of databaseuse. In addition, the following factors were identified: (7)Outcome expectancy, (8) Workplace environment, (9)Motivation, and (10) Barriers. Experience in research,working in professional teams, and being clinicalpractice supervisors for students and others were more
important factors than years of clinical experience topromote the implementation of EBP and self-efficacy
regarding EBP among occupational therapists. The
structures of these factors interacted with each other.

Conflict of interest
The first author and co-authors have no conflicts ofinterest related to this study that should be disclosed.

Acknowledgments
We would like to express our sincere gratitude to
all the occupational therapists working in convalescentrehabilitation wards who cooperated in this study.

References[1] Dubinsky M, Ferguson JH. Analysis of the National
Institutes of Health Medicare coverage assessment, Comparative Study. Int J Technol Assess Health Care. 1990;
6(3): 480–8.
[2] The Cardiac Arrhythmia Suppression Trial Ⅱ Investigators: Effect of the antiarrhythmic agent moricizine on
survival after myocardial infarction. N Engl J Med. 1992;
327(4): 227–33.
[3] Michaud G, McGowan JL, van der Jagt R, Wells G,
Tugwell P. Are therapeutic decisions supported by evidence from health care research? Arch lntern Med. 1998;
158(15): 1665–8.
[4] Grimshaw JM, Hutchinson A. Clinical practice guidelines–do they enhance value for money in health care? Br
Med Bull. 1995; 51(4): 927–40.
[5] Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what
it isn’t. BMJ. 1996; 312(7023): 71–2.
[6] Sackett DL. Evidence-based medicine. Semin Perinatol.
1997; 21(1): 3–5.

Asian J Occup Ther 19: 1−7, 2023

[7] Brown GC. Value-based medicine: the new paradigm.
Curr Opin Ophthalmol. 2005; 16(3): 139–40.
[8] Barry MJ, Edgman-Levitan S. Shared decision making–pinnacle of patient-centered care. N Engl J Med. 2012;
366(9): 780–1.
[9] Tickle-Degnen L, Bedell G. Heterarchy and hierarchy: acritical appraisal of the “levels of evidence” as a tool forclinical decision making. Am J Occup Ther. 2003; 57(2):234–7.
[10] Lindstrom A, Bernhardsso S. Evidence-Based Practice inPrimary Care Occupational Therapy: A Cross-Sectional
Survey in Sweden. Occup Ther Int. 2018; 5376764.
[11] Clyde JH, Brooks D, Cameron JI, Salbach NM. Validation of the Evidence-Based Practice Confidence (EPIC)
Scale With Occupational Therapists. Am J Occup Ther.
2016; 70(2): 7002280010p1-9.

Masuda Y et al.

7[12] Bandura, A. Self-efficacy: toward a unifying theory of
behavioral change. Psychol Rev. 1997; 84(2): 191–215.
[13] Masuda Y, Yaeda J, Sakata S, Kondo K. Factors related
to Evidence-Based Practice (EBP): Stages of readinessfor occupational therapists at convalescent rehabilitation
wards (in Japanese). The Japanese Occupational Therapy
research (sagyouryouhou). 2018; 37(5): 499–507.
[14] Thomas A, Law M. Research utilization and evidencebased practice in occupational therapy: a scoping study.
Am J Occup Ther. 2013; 67(4): e55–65.
[15] Masuda Y, Yaeda J. Development, reliability and validityof stages of the readiness scale on Evidence-Based Practice for occupational therapists at convalescent rehabilitation wards (in Japanese). The Japanese Occupational
Therapy research (sagyouryouhou). 2017; 36(5): 483–90.

■ORIGINAL ARTICLE

Predictors of Occupational Dysfunctionin Community-Dwelling Female Older Adults
Shan Yun1, Risa Takashima2, Mari Sakaue3, Daisuke Sawamura2,
Takao Inoue4, Shinya Sakai2
1

Faculty of Health and Sciences, Hokkaido University
Department of Rehabilitation Science, Faculty of Health Sciences, Hokkaido University
3
School of health sciences, Sapporo Medical University
4
Department of Rehabilitation, Osaka Kawasaki Rehabilitation University
2

Abstract: Background: Occupational dysfunction (OD) can become a major health problem for community-dwellingolder adults. OD can be experienced by older adults despite the absence of an apparent medical diagnosis or disability.
Therefore, OD may be a new health indicator in the field of preventive medicine.
Objectives: This study investigated possible predictors of OD in community-dwelling older adults.
Methods: Fifty-four participants (aged 63–94) in Japan completed a demographic questionnaire, the Classification andAssessment of Occupational Dysfunction Scale (CAOD), assessments of functional health (Five Times Sit-to-Stand
Test, Timed Up & Go, Automatic Thoughts Questionnaire-Revised, and Japan Science and Technology Agency Index
of Competence), and responded about their subjective health (self-rated health). Only seven participants were men;
therefore, male data were excluded from the analysis. Independent t-test and analysis of multiple regression model was
performed to identify the predictors of OD.
Results: The results of the independent samples t-test shows that the OD group correlated to a significant younger age,more negative automatic thoughts, and better social engagement in older women. The results of the multiple regression
analysis showed that negative automatic thoughts was a significant predictor of OD among older women.
Conclusion: Negatively evaluating stressful events related to occupational engagement may be associated with OD. It
may be useful to assess, maintain, and improve negative automatic thoughts to prevent OD. The results of this study canprovide an assessment perspective and intervention strategy focusing on occupations to occupational therapists active inthe field of preventive occupational therapy.
Keywords: occupational dysfunction, older adults, community-dwelling, preventive occupational therapy(Asian J Occup Ther 19: 8−15, 2023)

Introduction
Several preventive occupational therapy interventions have been reported as beneficial for communitydwelling older adults [1–4]; these are worth noting
as the world’s population ages rapidly. Occupational
dysfunction (OD), which can be experienced despite theabsence of an apparent medical diagnosis or disability[5], may be a new health indicator for communityReceived: 25 May 2021, Accepted: 28 September 2022
Corresponding to: Risa Takashima, Hokkaido University, N12-W5,
Kitaku, Sapporo, Hokkaido, 060-0812, Japane-mail: risa-t@hs.hokudai.ac.jp©2023 Japanese Association of Occupational Therapists

dwelling older adults, who are the primary clients of
preventive occupational therapy.
OD was a concept proposed by Kielhofner [6, 7]
in the Model of Human Occupation and is defined as anegative experience arising from the inability to engage
in daily activities properly. OD may be the result of
disturbing dynamic interaction among multiple factorsthat generate occupational engagement. Teraoka et al.
[8] identified the four most common experiences in OD:
occupational marginalization, imbalance, alienation, anddeprivation. Occupational marginalization is defined as
not having the opportunity to engage in desired daily
activities, occupational imbalance describes a loss ofbalance in engagement in daily activities, occupational
alienation occurs when individual needs relating to daily

Asian J Occup Ther 19: 8−15, 2023

activities are not satisfied, and occupational deprivationrefers to a lack of options in daily activities due to factors outside the individual’s control [9].
Teraoka and Kyougoku [10] reported that for
healthcare workers with psychological issues such as
stress, burnout syndrome, and depression, the reductionof OD might be a target for more effective preventive
occupational therapies. In older adults, however, only
an association between OD and metabolic syndrome has
been reported [11]. To enhance their health through theoccupational therapy approach, it is necessary to explore
how therapists could help prevent OD or improve theoccupational health of older adults.
Since the aging process is one of the importantfactors affecting occupational engagement [12], we
focused on the relationship between OD and the declineof functional health that older adults frequently experience during the aging process [13]. Functional health isoperationally defined by the International Classificationof Functioning, Disability and Health, known morecommonly as ICF, from different functions that constitute health, including body function and body structure,to activities of daily living and participation in society[14]. In addition, although objective health is generally
positively associated with subjective health, the association is known to diminish with age [15]. Subjective
health refers to how individuals evaluate their own
health status [16]. Araújo et al. [16] reported that mental
health aspects rather than physical health variables could
predict subjective health status in older adults. As noted
above, though the subjects were not older adults, it has
been shown that OD is associated with psychologicalproblems [10].
Therefore, we predicted that functional and subjective health would affect the development of OD in community-dwelling older adults. In this proposed study,
we aimed to examine the hypothesis that functional andsubjective health could be predictors of OD in community-dwelling older adults. The results of this study
may provide occupational therapists with assessment
perspectives and intervention strategies to prevent andimprove older adults’ OD as a new health outcome.

Materials and Methods
Participants and Recruitment
This cross-sectional study examined the predictorsof OD in community-dwelling older adults in Japan.
Participants were recruited from two community-based
preventive care centers for older adults in Hokkaido,
Japan from September to November 2018. Researchers both verbally and on paper invited members of
the center to participate in the study, and almost all

Yun S et al.

9members agreed to participate. Fifty-four communitydwelling older adults participated in our study; however,
only seven participants were men. Therefore, maledata were excluded from the analysis. All participants
met the following criteria: aged 60 years or older,living independently in the community, and equippedwith the requisite cognitive and Japanese language
skills to respond to questionnaires without assistance.
While participants were completing the questionnaire,
two researchers made the rounds to see if they could
continue to complete it on their own. A man, who tooka significantly longer time compared to the other participants, had difficulty answering on his own and gave
up participating in this study. All participants provided
oral and written informed consent. The study protocol
was approved by the Research Ethics Committee at theauthors’ affiliated institution.
Measures
The participants completed a demographics questionnaire that recorded data concerning their gender,
age, height, and weight. Body mass index (BMI) was
calculated based on self-reported weight and height. To
identify the predictors of OD in the functional health ofcommunity-dwelling older adults, occupational dysfunction, functional assessments, and subjective health were
measured. It took about 15 min in total to complete thequestionnaires, and about 10 min to perform the functional assessments.
Occupational Dysfunction
The Classification and Assessment of Occupational
Dysfunction Scale (CAOD), a self-reported questionnaire, was used to assess OD status. This assessment
comprises four items for each of the following fourdomains of OD: occupational imbalance, deprivation,
alienation, and marginalization [17, 18]. All 16 items arescored on a 7–point Likert scale, with 1 representing not
at all and 7 representing all the time. The CAOD has
been tested for reliability and validity in terms of item
characteristics, structural validity and internal consistency with university students, healthcare professionals,
community-dwelling older adults, people with mental
disabilities, and people with physical disabilities [19].
The scale’s Cronbach’s alpha was .902 in the previous
study, indicating acceptable internal consistency [18].
The cutoff score was set at 52, where a score of morethan 52 reflects a greater risk of OD and a more likely
occurrence of physical and mental disorder [19]. The
higher the CAOD score is, the greater the risk of OD
appearance. However, classification into healthy andclinical groups on the basis of a single value, has the
disadvantage of the possibility of false positives and10

PREDICTORS OF OCCUPATIONAL DYSFUNCTION

false negatives [20, 21]. The cutoff value could not
estimate the various conditions of the clients and to takedetailed approaches according to the severity of OD [22].
A statistical model that overcomes these problems is the
Latent Rank Theory [23], which is theory for step-bystep and sequential evaluation of abilities [24]. CAOD
used the latent rank theory to estimate the severity ofOD [22]: rank 1, healthy group; rank 2, preliminarygroup that appears to have difficulties in daily life; rank
3, mild group; rank 4, moderate group; rank 5, severegroup.
Functional Assessments
Physical functions were assessed with the Five
Times Sit-to-Stand Test (FTSST) and Timed Up & Go
(TUG). The FTSST was used to assess functional lower
extremity strength, transitional movements, balance, andthe risk of falling. In this assessment, participants are
asked to stand up straight and sit back down as quickly
as possible, five times in a row, without resting in
between. TUG is a measure for evaluating balance andfall risk. In this timed activity, participants are asked tostand up from a chair and move as quickly as possible
through a 3-meter path, walk back, and return to a sitting
position with their back resting on the back of the chair.
FTSST and TUG were measured visually by inspectors
using a digital stopwatch. The time (seconds) needed toaccomplish these tests was recorded. Participants withpoor performance on these tests have a significantly
higher risk of developing disability than participants
who had better lower extremity functioning. The FTSST
and TUG are reliable and valid clinical tools [25]. For
falling risk, cutoff points of 12 to 15 seconds for the
FTSST and 14 to 15 seconds for the TUG have beensuggested [25].
Psychological function was assessed using the Automatic Thoughts Questionnaire-Revised (ATQ-R). This
questionnaire assesses the frequency of automatic positive (10 items) and negative (30 items) statements about
oneself [26]. According to Beck [27]’s cognitive theory
for depression, negative automatic thoughts could result
in depression. ATQ has been clarified to differentiate
dysphoric and nondysphoric in both clinical and nonclinical clients [28, 29]. Therefore, we adopted ATQ-R,
which could also assess the psychological status before
depression, instead of Center for Epidemiologic Studies
Depression Scale, which was used in a previous study[10]. The 40 items are scored on a 4–point Likert scale
simplified for older adults, where 1 represents not at all
and 4 represents all the time. The total scores of positive
and negative automatic thoughts are 120 and 40, respectively. Higher scores reflect a greater number of positive
and negative automatic thoughts. The Japanese version’s

reliability and validity have been verified [30, 31]. The
Cronbach’s alpha was 0.969 [31].
The Japan Science and Technology Agency Index
of Competence (JST-IC) [32, 33] was used to assess
the functional capacity of participants in their activities
and participation. The JST-IC is an instrument that canmeasure the competence of older adults living alone, notonly to live independently in the community, but also tolive more actively in accordance with modern lifestyles.
The instrument includes four domains: technology
usage, information practice, life management, and social
engagement, with each domain consisting of four items.
The 16 items are scored on a binary scale with 1 representing Yes and 0 representing No. The total score is 16
points. The higher the score, the higher the activity competence of each area and the more active the community
life. Using data from community-dwelling older adults,
the reliability coefficients (alpha coefficient) for all 16
items was α = .86, and the reproducibility of the 4-factor
structure (cross validity) and its association with otherimportant endpoints (criterion-related validity) werehigh.
Subjective Health
Subjective health was measured through self-rated
health score constructed from a single item asking “Howdo you feel about your health condition?” Response
options included very good (1), good (2), fair (3), poor(4), and very poor (5). A higher score represents lower
self-rated health status. This index is a simple five-point
scale that can be easily answered by older adults [34]. It
is also used in the “Basic Survey of Living Conditionsof the People” by the Ministry of Health, Labour andWelfare of Japan [35].
Data Analysis
We used descriptive statistics, including means andstandard deviations, for each demographic and outcome
variable. Participants were divided into healthy group(rank 1) and OD group (ranks 2–5) according to theestimating latent rank of OD conducted by software
Exametrika Ver 5.5 [36]. The independent samples t-test
was used to identify if variables differed according to
the ranks of CAOD. A multiple regression model was
also created with the CAOD total value as dependent
variables, and the variables that were significantly different by group comparison as independent variables,using a forced entry method. All statistical analyses
were performed using SPSS Statistics 26.0 (IBM SPSS
Inc., Chicago, IL, USA).

Asian J Occup Ther 19: 8−15, 2023

Yun S et al.

11

Table 1 The comparison of each variable between rank groups.
Variable
Demographic variables
Age (years)
BMI (kg/m2)
Functional assessments
FTSST (sec)
TUG (sec)
Automatic thoughts
Positive automatic thoughts
Negative automatic thoughts
JST-ICTechnology usage
Information practiceLife management
Social engagement
Total score
Subjective healthSelf-rated health

Healthy group (N = 35)

OD group (N = 12)

Statistics

Mean (SD)

Mean (SD)t value

P value

78.200 ( 6.135)
22.720 ( 2.726)

73.250 ( 7.187)
23.153 ( 3.140)

2.309−0.4570.026*
0.650

7.568 ( 1.532)
6.007 ( 1.241)

7.108 ( 1.601)
5.623 ( 0.924)

0.887
0.980

0.380
0.332

22.657 ( 7.207)
41.200 (10.726)

21.667 ( 6.228)
49.583 (14.438)

0.424−2.1340.673
0.038*

3.057 ( 1.235)
3.343 ( 1.027)
3.057 ( 1.211)
1.857 ( 1.556)
11.314 ( 3.169)

3.500 ( 0.905)
3.250 ( 0.866)
3.250 ( 1.422)
3.000 ( 1.348)
13.000 ( 3.516)−1.1380.280−0.455−2.266−1.547

0.261
0.781
0.651
0.028*
0.129

2.486 ( 0.818)

2.917 ( 0.900)−1.536

0.132

BMI: Body Mass Index; FTSST: Five Times Sit-to-Stand Test; TUG: Timed Up & Go; JST-IC: Japan Science andTechnology Agency Index of Competence.
*P < 0.05.

Table 2 Factors affecting OD for community-dwelling women (N = 47).

Intercept
Age
Negative automatic thoughts
Social engagement

95% confidence interval

Partial regression
coefficientStandardized partial
regression coefficient (β)

Significance(P)

Lower endpoint

Upper endpoint

37.675−0.4960.755
1.289−0.199
0.550
0.121

0.177
0.114
< 0.001
0.308−17.687−1.1160.425−1.23093.037
0.124
1.085
3.807

Adjusted R2 = 0.407.
Standardized error of the estimate = 12.875.
OD: Occupational dysfunction.

Results
The participants were 47 community-dwelling
women whose ages ranged from 63 to 94 years. The average ages were 78.20 ± 6.14 years in the healthy groupand 73.25 ± 7.19 years in the OD group. CAOD scores
ranged from 16 to 92, and twelve participants (25.5%)
were estimated into OD group (Four people were included in Rank 2 and 3 each, one in Rank 4, and three in
Rank 5), which showed higher risk of OD. Participantsin both groups had the functional capacity to perform
more than 70% of the 16 performance indicators set by
the JST-IC for living actively in the community. The
results of the independent samples t-test shows that
the OD group showed a significant younger age (t =2.309, P = 0.026), more negative automatic thoughts(t = −2.134, P = 0.038), and better social engagement of
JST-IC (t = −2.266, P = 0.028). No significant difference

was observed for any other variable. Table 1 summarizes
the results of the comparison of each variable between
groups.
Table 2 presents the results of the multiple regression analysis of OD. Negative automatic thoughts was
identified as a significant variable (t = 4.614, P < 0.001,
95% confidence interval (CI) [0.425, 1.085]). Age andsocial engagement were not significant variables (t =−1.615, P = 0.114, 95% CI [−1.116, 0.124], t = 1.032, P =0.308, 95% CI [−1.230, 3.807], respectively). Overall,this model accounted for 40.7% of the variance.

Discussion
This study investigated factors associated with OD
in community-dwelling older women using the analysis of multiple regression model. Negative automatic
thoughts was identified as a significant predictors of OD.

12

PREDICTORS OF OCCUPATIONAL DYSFUNCTION

Although the age and social engagement were significantly younger and better in OD group, they were notsignificant predictors of OD. The analysis suggested that
OD among community-dwelling older women might beprevented by decreasing negative automatic thoughts.
Negative automatic thoughts were identified as apredictor of OD. Automatic thoughts were first studied
as a type of cognitive bias that bolsters cognitive distortions [27], and the concept has positive and negative
aspects. While no previous study has directly demonstrated the relationship between automatic thoughts
and OD to support our results, there is evidence that
automatic thoughts and OD are both associated withdepression. For example, Kwon and Oei [37] reported
that changes in automatic thoughts led to changes in
depressive symptoms. Likewise, OD factors have been
demonstrated to significantly contribute to depression[10]. In our results, we first demonstrated that negative
thoughts predicted OD. Beck [27] also noted that negatively evaluating stressful events (a pattern of thought)
resulted in depression, as opposed to it being an inherent
negative side effect of the event itself. Combining these
two results, we expected to find a relationship in which
negative thoughts influenced an individual’s daily occupations, causing OD in older adults, and further leading
to depressive symptoms. However, whether there areother factors influencing this result or other paths leading to the observed results should be verified in futurestudies. Furthermore, the participants included in thisanalysis were women. Previous studies have found thata decrease in depression and anxiety could be linked toa decrease in negative thoughts, rather than an increasein positive thoughts [38]. Concerning the gender difference, it has been reported that there is a higher prevalence of anxiety disorders and depression in womenthan men [39, 40]. This well-known gender difference
continues into old age. A review analyzed 85 studies
found substantial support for the same gender differences in depression in individuals under 60 years of age [41].
Thus, negative thoughts might be more frequent among
women than among men, and compared with men, community-dwelling older women might have higher risk
experiencing OD. Therefore, to prevent or improve OD
status, and further prevent depression for communitydwelling older women, approaches on negative automatic thoughts might be effective.
According to the t-test, the OD group showedyounger age compared to healthy group. This result is
consistent with the following previous study. Miyake
et al. [11] reported that in community-dwelling Japanese
adults (mean age 70.6 ± 9.4 years), the group with thehighest CAOD scores (≥ 31) had significantly lower age
than the other groups (CAOD scores of 16–19 or 20–30). However, the results of multiple regression analysis
in this study showed that age was not a significant predictor of OD. Among older people, age may affect OD
differently for younger- and older-older adults.
The participants’ ages in this study ranged from63 to 94 years (Mean 76.94 ± 6.70). Despite reduced
functional capacity and increased psychological distress,
people older than 80 years have been found to exhibit
less pessimistic self-rated health, especially whencompared with younger-older people [42]. In addition,
Araújo et al. [16] reported the impact of downward
social comparisons on self-rated health. According
to the study, by comparing themselves to their peers
who are in poor health, older adults seem to be able tomaintain positive self-rated health. The older they get,the more likely they are to interact with people theirown age who are in poorer health, which is considered
an important and common mechanism for older adults
to evaluate their own health [43]. Similarly, OD may beless likely to occur as people age because they are more
likely to meet peers with poorer OD conditions. Moreover, for younger-older adults who are just beginning toexperience functional decline, they may expect higher
occupational performance. As a result, younger-older
adults might assess the aging process more pessimistically and experience OD. We believe that future studies
would need to investigate the impact of age on OD,
distinguishing between younger- and older-older adults.
Another variable “social engagement” among thesubcategories of JST-IC showed significant difference
between healthy group and OD group, and the OD group
showed higher score, which means better social engagement. However, social engagement was not identified asa significant predictor of OD.
“Social engagement” of the JST-IC asked about
participation in four types of social activities, such as
local festivals, events, and volunteer activities. The OD
group had better social engagement. In other words,
women of the OD group are engaging in more social activities than the healthy group. However, the OD group
had higher risk of experiencing OD, which presented
a possibility that those social activities might be too
many or compelling for them. Having social activities
to engage in is expected to improve participants’ OD
in terms of occupational deprivation and alienation. In
contrast, if the number of social engagements measured
by JST-IC increases and it is felt to be too much for theindividual, it may cause occupational imbalance of OD.
It is important to have an optimal occupational balance
for the individuals, not simply to have more activities toengage in [44, 45]. In addition, the individuals may experience occupational marginalization of OD if they feelcompelled to participate in the activity, unrecognizedAsian J Occup Ther 19: 8−15, 2023

during the activity, or neglected by others [46]. For thisreason, there is a need for a more careful assessmentof the individual’s perception regarding social engagements. The following four most common experiences in
OD often occur simultaneously and they interact to constitute the problem of OD: occupational marginalization,
imbalance, alienation, and deprivation [47]. In future
research, it may be useful to explore which of the four
are the most likely occupational dysfunctions amongcommunity dwellers.
Finally, the results showed that our female participants had higher daily competence, based on instrumental activities of daily living measured by the JST-IC [33].
Compared with the participants in the national-level
survey using the JST-IC [32], our participants were agroup of community-dwelling high-functioning older
adults who had few difficulties in daily occupational
performance. Nevertheless, it is worth noting that someparticipants did experience OD. The results of this study
suggest that OD among community-dwelling older
women might be prevented by decreasing negative automatic thoughts. In order for occupational therapists tofocus on occupational dysfunction in older women in thearea of care prevention and to provide occupation-based
support, assessment of their negative automatic thoughts
and approaches to them may be useful.

Limitations
Our study has several limitations. First, the numberof male participants in the sample was small, and we
had to exclude their data from the analysis. We recruitedparticipants from two community-based aging centersin a district of Japan, but only seven male participants
attended. Milligan et al. [48] reported that older men
generally have poorer health-seeking behaviors than
women and are often more reluctant to engage in genericsocial activities. Our results might highlight a challenge
in developing acceptable health-promoting interventions
for older men in the community, based on their distinct
characteristics. Different recruitment strategies may alsoneed to be implemented.
Second, participants in the study had comparatively
higher functioning in daily life than expected. This
study’s results might be referenced for other older adults
who have similar higher daily functioning as our participants. However, there are a large number of older adults
who experience inactivity and might be more vulnerable
to OD. Future studies should target older adults withlower daily physical activity and/or lower daily competence to clarify the predictors of OD.
Third, this study explored potential predictors of
OD by focusing on functional health and subjective

Yun S et al.

13

health as measured by subjective questionnaires, withthe exception of FTSST and TUG, which partiallymeasure physical functions. Factors such as medical
conditions that are objectively assessed in determining
the status of older adults’ health might be also associated with OD. In addition, factors that commonly cause
health disparities, such as financial burdens, environmental hardship, and access to health care, may also be
associated with OD in older adults.
Fourth, the results of this study showed that negative automatic thoughts was a significant predictor in
older women. Strong negative automatic thoughts may
suggest an association not only with pre-depressive
states but also with depressive symptoms themselves[27]. In future studies, it may be beneficial to consider
using an assessment tool that can assess depressive
symptoms themselves. In the field of preventive occupational therapy, OD as a new health indicator is justbeginning to be explored. Further investigations are necessary into the relationship between diversified healthand OD among community-dwelling older adults.
Last, CAOD total score was used in this study for
analysis. However, the four most common experiences of OD (occupational marginalization, imbalance,
alienation, and deprivation) might be characteristic for
specific groups. Future studies would be necessary to
explore which experience is the most likely to occur incommunity-dwelling older adults, to better prevent or
improve their OD.

Conclusions
To explore the predictors of OD in communitydwelling older adults, an investigation focusing onfunctional and subjective health was conducted. Negative automatic thoughts was a significant predictor
in older women. This was the first study to determine
predictors of OD in community-dwelling female older
adults. In addition, this is a noteworthy result, even for
older adults who appear to maintain a high degree ofactivity. Age, physical functions, as measured by FTSST
and TUG, and activity and participation, as measured
by JST-IC, were not significant factors. In contrast, thepsychological factor of negative automatic thoughts was
identified as significant. Negatively evaluating stressful
events related to an occupation may cause OD. In orderto prevent OD in community-dwelling older women,
it may be useful to evaluate, maintain, and improvenegative automatic thoughts to prevent OD. The resultsof this study can provide an assessment perspective
and intervention strategy focusing on occupations to
occupational therapists active in the field of preventive
occupational therapy.

14

PREDICTORS OF OCCUPATIONAL DYSFUNCTION

Conflict of Interests
est.

The authors declare that there is no conflict of inter-

Acknowledgements
We would also like to thank Mr. Joao Carlos Koch
Junior from Sapporo Gakuin University, Hokkaido,
Japan, for the proofreading of this manuscript.

References[1] Jackson J, Carlson M, Mandel D, Zemke R, Clark F.
Occupation in lifestyle redesign: The well elderly study
occupational therapy program. Am J Occup Ther. 1998;
52(5): 326–36.
[2] Clark F, Jackson J, Carlson M, Chou CP, Cherry BJ, Jordan-Marsh M, et al. Effectiveness of a lifestyle intervention in promoting the well-being of independently living
older people: results of the Well Elderly 2 Randomised
Controlled Trial. J Epidemiol Community Health. 2012;
66(9): 782–90.
[3] Levasseur M, Filiatrault J, Larivière N, Trépanier J,
Lévesque MH, Beaudry M, et al. Influence of Lifestyle
Redesign® on health, social participation, leisure, andmobility of older French-Canadians. Am J Occup Ther.
2019; 73(5): 7305205030p1-8.
[4] Chippendale T, Boltz M. Living legends: Effectivenessof a program to enhance sense of purpose and meaningin life among community-dwelling older adults. Am J
Occup Ther. 2015; 69(4): 6904270010p1-1.
[5] Kyougoku M. Unstructured assessment for occupational
therapy, 4 condition method (in Japanese). Tokyo: Seishin
Shobo; 2010.
[6] Kielhofner G. Model of human occupation: Theory andapplication, 2nd ed. Baltimore, MD: Williams & Wilkins;
1995.
[7] Kielhofner G. Conceptual foundation of occupational
therapy 2nd ed. Philadelphia: F. A. Davis; 1997.
[8] Teraoka M, Kyougoku M, Nakayama T, Nishimoto Y,
Yamasaki S, Nakamura H. Basic study on Classification
and Assessment of Occupational Dysfunction (CAOD).
Sogo Rehabilitation. 2013; 41: 475–9.
[9] Teraoka M, Kyougoku M. Analysis of structural relation­
ship among the occupational dysfunction on the psycho­
logical problem in healthcare workers: a study using
structural equation modeling. PeerJ. 2015a; 3: e1389.
[10] Teraoka M, Kyougoku M. Causal relationship between
occupational dysfunction and depression in healthcare
workers: A study using structural equation model. PeerJ
PrePrints; 2015b; 3: e787v1.
[11] Miyake Y, Eguchi E, Ito H, Nakamura K, Ito T, Nagaoka
K, et al. Association between occupational dysfunction
and metabolic syndrome in community-dwelling Japanese adults in a cross-sectional study: Ibara study. Int J

Environ Res Public Health. 2018; 15(11): 2575.
[12] Stav WB, Hallenen T, Lane J, Arbesman M. Systematic
review of occupational engagement and health outcomesamong community-dwelling older adults. Am J Occup
Ther. 2012; 66(3): 301–10.
[13] Marzetti E, Calvani R, Tosato M, Cesari M, Di Bari M,
Cherubini A, et al. Sarcopenia: an overview. Aging Clin
Exp Res. 2017; 29(1): 11–7.
[14] Svestková O, Sládková P, Kotková K. Application ofinternational classification of functioning, disability andhealth (ICF), functional health and disability. Cent Eur J
Public Health. 2016; 24(1): 83.
[15] Montoliu T, Hidalgo V, Salvador A. Importance of Personality for Objective and Subjective-Physical Health inOlder Men and Women. Int J Environ Res Public Health.
2020; 17(23): 8809.
[16] Araújo L, Teixeira L, Ribeiro O, Paúl C. Objective vs.
subjective health in very advanced ages: Looking for
discordance in centenarians. Front Med. 2018; 5: 189.
[17] Teraoka M, Kyougoku M. Development of occupationbased practice 2.0 that integrates occupation basedpractice and dissolution approach for belief conflict. Jpn
Occup Ther Res. 2014; 33(3): 249–58.
[18] Teraoka M, Kyougoku M. Development of the final version of the classification and assessment of occupational
dysfunction scale. PloS one. 2015c; 10(8): e0134695.
[19] Teraoka M, Kyougoku M. Psychometric properties ofClassification and Assessment of Occupational Dysfunction for healthcare professionals. Jpn Occup Ther Res.
2015d; 34: 403–13.
[20] Nakai Y. The validity of Eating Attitudes Test (EAT) (inJapanese). Seishin Igaku. 2003; 45(2): 161–5.
[21] Fukushi M. Re-examination of cut-off values for galactosemia screening and discussion of standard cut-off values(in Japanese). J Jpn Soc Mass-screening. 2010; 20(3):199–210.
[22] Teraoka M, Kyougoku M. Estimating latent rank of occupational dysfunction for healthcare workers (in Japanese).
Jpn Occup Ther Res. 2017; 36(3): 309–19.
[23] Shojima K [online]. The batch-type neural test model:
A latent rank model with the mechanism of generative
topographic mapping [cited 2022 February 10]. Available
from: http://shojima.starfree.jp/ntt/index.htm.
[24] Shiraga K, Kawano K. Interpreting health-related qualityof life using latent rank theory (in Japanese). Jpn J Psychol. 2018; 89(3): 251–61.
[25] Makizako H, Shimada H, Doi T, Tsutsumimoto K, Naka­
kubo S, Hotta R, et al. Predictive cutoff values of the
five-times sit-to-stand test and the timed “up & go” testfor disability incidence in older people dwelling in thecommunity. Phys Ther. 2017; 97(4): 417–24.
[26] Kendall PC, Howard BL, Hays RC. Self-referent speech
and psychopathology: The balance of positive and negative thinking. Cognit Ther Res. 1989; 13(6): 583–98.
[27] Beck AT. Cognitive therapy and the emotional disorders.
UK: Penguin; 1976.
[28] Harrell TH, Ryon NB. Cognitive-behavioral assessment

Asian J Occup Ther 19: 8−15, 2023

of depression: Clinical validation of the AutomaticThoughts Questionnaire. J Consult Clin Psychol. 1983;
51: 721–5.
[29] Hollon SD, Kendall PC, Lumry A. Speciﬁcity of depressotypic cognitions in clinical depression. J Abnorm
Psychol. 1986; 95: 52–9.
[30] Kodama M, Katayanagi H, Shimada H, Sakano Y. The relationships among stress coping with automatic thoughts,
state of anxiety, and depressive symptoms in college
students (in Japanese). The Human Sciences (Human
Research Center, Waseda University). 1994; 7: 14–26.
[31] Eguchi M, Kunikata H. Construct validity and reliabilityof Automatic Thoughts Questionnaire-Revised (ATQ-R)(in Japanese). Nihon Hokenkagaku Gakkaishi. 2015;17(4): 187–94.
[32] Iwasa H, Masui Y, Inagaki H, Yoshida Y, Shimada H,
Otsuka R, et al. Development of the Japan science andtechnology agency index of competence to assess functional capacity in older adults: Conceptual definitions
and preliminary items. J Gerontol Geriatr. 2015; 1:2333721415609490.
[33] Iwasa H, Masui Y, Inagaki H, Yoshida Y, Shimada H,
Otsuka R, et al. Assessing competence at a higher level
among older adults: development of the Japan Scienceand Technology Agency Index of Competence (JST-IC).
Aging Clin Exp Res. 2018 ;30(4): 383–93.
[34] Kodama S, Kurimori S, Hoshi T. Association between
feelings of happiness among community-dwelling, independent, elderly individuals in an Okinawan farm village
and survival three years later (in Japanese). Nihon Koshu
Eisei Zasshi. 2018; 65(5): 199–209.
[35] Ministry of Health, Labour and Welfare of Japan [online].
Comprehensive survey of living conditions [cited 2021
April 10]. Available from: https://www.mhlw.go.jp/toukei/
list/20-21.html.
[36] Shojima K. Exametrika (Version 5.5) [online]. [cited 2022
February 10]. Available from: http://antlers.rd.dnc.ac.jp/~shojima/exmk/jindex.htm[37] Kwon SM, Oei TP. Cognitive change processes in agroup cognitive behavior therapy of depression. J Behav
Ther Exp Psychiatry. 2003; 34(1): 73–85.
[38] Alsaleh M, Lebreuilly R, Lebreuilly J, Tostain M. The
relationship between negative and positive cognition and

Yun S et al.

15

psychopathological states in adults aged 18 to 20. J Ther
Comport Cogn. 2016; 26(2): 79–90.
[39] McLean CP, Asnaani A, Litz BT, Hofmann SG. Genderdifferences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res.
2011; 45(8): 1027–35.
[40] Carayanni V, Stylianopoulou C, Koulierakis G, Babatsikou F, Koutis C. Sex differences in depression amongolder adults: are older women more vulnerable thanmen in social risk factors? The case of open care centersfor older people in Greece. Eur J Ageing. 2012; 9(2):177–86.
[41] Girgus JS, Yang K, Ferri CV. The gender difference in depression: are elderly women at greater risk for depression
than elderly men? Geriatrics. 2017; 2(4): 35.
[42] Araújo L, Ribeiro Ó. Incapacity paradox of very-old
people (in Portuguese). Acta Med Port. 2011; 24: 189–96.
[43] Henchoz K, Cavalli S, Girardin M. Health perception andhealth status in advanced old age: A paradox of association. J Aging Stud. 2008; 22(3): 282–90.
[44] Wagman P, Björklund A, Håkansson C, Jacobsson C,
Falkmer T. Perceptions of Life Balance Among a Working Population in Sweden. Qual Health Res. 2011; 21(3):
410–8.
[45] Wagman P, Håkansson C. Exploring Occupational Balance in Adults in Sweden. Scand J Occup Ther. 2014;21(6): 415–20.
[46] Durocher E, Gibson BE, Rappolt S. Occupational Justice:
A Conceptual Review. J Occup Sci. 2014; 21(4): 418–30.
[47] Hasebe S, Kohiyama K. Clinical usefulness of occupational therapy focused on the severity of occupational
dysfunction among three hospitalized patients in a convalescent rehabilitation ward: A case study. Jpn Occup Ther
Res. 2021; 40(3): 351–8.
[48] Milligan C, Dowrick C, Payne S, Hanratty B, Neary D,
Irwin P, et al. [online]. Men’s sheds and other genderedinterventions for older men: Improving health and well­being through social activity: A systematic review andscoping of the evidence base. Lancaster: Lancaster University Centre for Ageing Research [cited 2021 April 10].
Available from: http://envejecimiento.csic.es/documentos/
documentos/lancaster-ac-uk-men-in-sheds2013-02-2015.
pdf.

■RAPID COMMUNICATIONS

Trail Making Test-Japanese Edition (TMT-J) Scoresin Early Stages of Mild Ischemic Stroke
Miho Yoshioka1, Zen Kobayashi2, 3, Kaori Kato1, Keisuke Inoue1,
Masaki Hakomori1, Kazunori Toyoda1, Yoshiyuki Numasawa4,
Hiroyuki Tomimitsu2, Shuzo Shintani2
1

Department of Rehabilitation, JA Toride Medical Center
Department of Neurology, JA Toride Medical Center
3
Tsubasa Home Care Clinic Nishifunabashi (present affiliation)
4
Aozora Clinic
2

Abstract: Background: The Trail Making Test (TMT) is widely used as a measure of attention and executive functions. The time needed to complete TMT (TMT score) is prolonged in the presence of attention and executive dysfunction in patients with brain diseases. Thus far, there have been few reports examining the TMT score in the early stagesof mild ischemic stroke.
Methods: We evaluated the TMT-Japanese edition (TMT-J) score 8–14 days after onset in patients with mild ischemic
stroke. When the TMT-J Part A or Part B score was high, re-evaluation was performed 29–35 days after onset.
Results: In a total of 54 patients, 1 and 4 patients could not complete TMT-J Part A and Part B, respectively. The average Part A and Part B scores were 65 and 119 seconds, respectively. Part A and Part B scores were higher than one
standard deviation above the age-specific average scores in 51 and 47% of patients, respectively. In these patients, Part
A and Part B scores improved in 81 and 69% of the patients on re-evaluation, respectively.
Conclusions: This study demonstrated that a significant proportion of mild ischemic stroke patients exhibited a high
TMT-J score 8–14 days after onset, and scores improved over time in the majority of patients.
Keywords: attention, executive function, mild ischemic stroke, Trail Making Test-Japanese edition (TMT-J)(Asian J Occup Ther 19: 16−21, 2023)

1. Introduction
The Trail Making Test (TMT) is widely used as anevaluation scale for attention and executive functions[1–9]. Attention and executive dysfunction are typicallyassociated with frontal lobe impairment [2]. However,
the time needed to complete TMT (TMT score) is prolonged in association with involvement of not only thefrontal lobe, but also various brain regions including the
temporal lobe, insular cortex, caudate, globus pallidus,
posterior parietal lobe, occipital cortex, cerebellum [3],and brainstem [4]. In a clinical setting, TMT for brain
disease patients has been used to identify unsafe drivers.
Received: 12 November 2021, Accepted: 28 September 2022
Corresponding to: Zen Kobayashi, Department of Neurology, JA Toride
Medical Center, 2-1-1 Hongo, Toride, Ibaraki 302-0022, Japane-mail: kobayashiz112@yahoo.co.jp©2023 Japanese Association of Occupational Therapists

Previous studies reported that brain disease patients
showing a TMT-B score > 147 seconds [5] or 180 seconds [6] were considered unsafe drivers.
In previous studies of stroke patients, Barker-Colloet al. examined the TMT score within 4 weeks after the
onset of ischemic stroke, 6 weeks after the onset, and6 months after the onset, and reported that the TMT-B,
but not TMT-A score improved over time [2]. Wolf et
al. reported that in patients with mild stroke, there wasno significant change in the TMT score within 3 weeks
after discharge and 6 months after onset [7].
There have been few reports examining TMT scoresin the early stages of ischemic stroke [8, 9]. In patientswith mild ischemic stroke, however, an early evaluationof TMT is required because they are often discharged
early and hope to return to a life similar to the previous
one. A previous study demonstrated that 40% of patientswith acute lacunar stroke showed abnormal TMT Part
A scores (> 60 seconds) between days 2 and 7 of theirAsian J Occup Ther 19: 16−21, 2023

Yoshioka M et al.

Table 1 The average score and standard deviation (SD) by age groupin TMT-Japanese edition (TMT-J) [1].
Age
group
40s
50s
60s
70s
80s

Part APart B

Average score(seconds)

Standard
deviation

Average score(seconds)

Standard
deviation

30.3
33.7
34.9
46.5
51.1

7.5
6.2
7.2
10.5
9.2

49.0
60.4
62.6
88.8
103.8

11.9
14.0
12.7
24.7
24.3

stay in the stroke unit [8]. Nevertheless, whether theseabnormal scores improve later remains unclear, and thisstudy did not investigate the Part B score.
Prior to 2019, Japan had neither standardized inspection sheets nor evaluation methods for TMT. However,
the TMT-Japanese edition (TMT-J) [1] was publishedin 2019, after the publication of our previous study [9].
TMT-J adopts vertical inspection sheets and includes theaverage score and standard deviation (SD) by age group(Table 1). The present study was aimed to investigate
the TMT-J score and its serial changes in the early stagesof mild ischemic stroke.

2. Methods
Between January 2019 and August 2020, 319
patients were admitted to the Department of Neurology
within 14 days after the onset of ischemic stroke andwere evaluated in the Department of Rehabilitation.
We evaluated TMT-J and Hasegawa Dementia ScaleRevised (HDS-R) scores 8–14 days after onset in patients
who met all 3 of the following criteria: (1) Aged 20–89,(2) National Institutes of Health Stroke Scale (NIHSS)
score of 7 points or less, (3) Diffusion-weighted brain
MRI showing acute ischemic stroke.
Re-evaluation of both Part A and Part B was performed 29–35 days after onset when the initial TMT-J
Part A or Part B score was high (higher than 1 SD above
the age-specific average scores). Because we investigated the patients in this study as a regular medical
examination, re-evaluation was not done when the initial
TMT-J Part A or Part B score was not high.
Patients with any of the following 3 criteria were
excluded: (1) A history of brain disease, (2) Showing
progression, recurrence, or complications of ischemic
stroke after admission, (3) Receiving carotid endarterectomy, carotid stent placement, or percutaneous carotid
artery vasodilation before evaluation of TMT-J, (4)Showing aphasia or hemispatial neglect.
The classification of ischemic stroke was based on
the clinical categories of ischemic stroke described in17

the report from the National Institute of Neurological
Disorders and Stroke [10]. In patients whose NIHSS
score was not described in the medical records, NIHSS
was evaluated retrospectively based on the description
in the medical records [11]. With this evaluation method[11], it is possible to calculate a score close to what
would have been the original NIHSS score.
TMT-J is usually performed by the dominant hand.
However, when the dominant hand is affected by paralysis or ataxia associated with stroke, any associatedwriting disturbance may incidentally increase the TMT-J
score. Therefore, when an evaluator judged that there
was paralysis or ataxia of the dominant hand that would
affect the TMT-J score, patients were asked to use their
non-dominant hand. In a previous study [12], there wasno clear difference in the Part A score between dominant
and non-dominant hands, but the Part B score increased
by about 5 seconds when using the non-dominant hand.
In the present study, we judged the result of Part A
or Part B as “not completed” when the patients could
not complete Part A within 180 seconds or Part B within
300 seconds. If a patient could not complete Part A, themore difficult Part B was not evaluated in this patient.
Comparisons of median values of initial and second
Part A scores were made using the Wilcoxon signed-rank
test, as the second Part A scores did not show a normal
distribution. The average values of initial and second
Part B scores were compared using the paired-samples
t-test. A value of P < 0.05 was regarded as significant.
Statistical analyses were conducted using Dr. SPSS II
for Windows 11.0.1J. This study was approved by an
ethics committee of a hospital.

3. Results
The patient selection and exclusion criteria areshown in Fig. 1, and the clinical information of the 54
patients is shown in Table 2. The average age of the 54
patients was 70.4 years. Clinical classifications of ischemic stroke were: 23 cases of lacunar infarction, 14 ofatherothrombotic infarction, 6 of cardiogenic embolism,
and 11 of other infarctions. Out of the 54 patients, 39
were discharged from the acute ward to their homes,
13 were transferred from the acute ward to our rehabilitation ward, and 2 were transferred to another hospitalfrom the acute ward. The average length of hospitalization of patients who were discharged home from theacute ward was 13.8 days.
In 20 out of the 54 patients, the NIHSS score at admission was not described in the medical records, and so
it was determined retrospectively based on descriptionsin the records [11]. In 7 out of the 54 patients, TMT-J
was performed with their non-dominant hand. The

18

TMT-J SCORES IN MILD ISCHEMIC STROKE

319 patients were diagnosed with acute ischemic stroke, admitted to the Department of
Neurology of our hospital, and evaluated at the Department of Rehabilitation between
January 2019 and August 2020.

81 patients met 3 criteria: (1) Aged 20-89, (2) National Institutes of Health Stroke Scale(NIHSS) score of 7 points or less, (3) Diffusion-weighted brain MRI showing acuteischemic stroke.
15 patients with past histories of brain diseases were excluded.

8 patients presenting with progression, re-attack, or complication of stroke
were excluded.

2 patients receiving carotid endarterectomy or percutaneous transluminal
angioplasty were excluded.

2 patients presenting with aphasia or hemispatial neglect were excluded.

54 patients

Fig. 1. Tree diagram showing inclusion and exclusion of patients.

HDS-R scores were 21 or higher (not abnormally low)
except for in 1 patient (patient 47).
In 32 out of the 54 patients, the Part A or Part B
score was higher than 1 SD above the age-specificaverage, and re-evaluation was performed 29–35 days
after onset. In 19 out of these 32 patients, the second
evaluation was performed after discharge, and it was
conducted in the remaining 13 during hospitalization.
Analysis of the 54 patients
In one out of the 54 patients, Part A could not becompleted (patient 47). This patient was also unable
to complete Part A on re-examination. In 4 out of the
54 patients, Part B could not be completed (patients 6,
14, 38, and 42). Among these 4 patients, 2 were able tocomplete Part B on re-evaluation (patients 6 and 38).
Excluding 1 patient who could not complete PartA, the average score for Part A of 53 patients was 65
seconds, and Part A scores were high (higher than 1 SD
above the age-specific average scores) in 27 of the 53
patients (51%).
Excluding 1 patient who was not examined withPart B (patient 47) and 4 patients who could not complete Part B, the average score for Part B of 49 patientswas 119 seconds, and Part B scores were high in 23 of
the 49 patients (47%).
In 31 patients with both initial and second Part A
scores, the median Part A scores on initial and second

evaluations were 74 and 56 seconds (Table 2), respectively. This change was significant (Fig. 2). In these 31
patients, 25 (81%) showed improvement in the Part A
score.
In 26 patients with both initial and second Part B
scores, the average Part B scores on initial and second
evaluations were 155 and 130 seconds, respectively(Table 2). This change was significant (Fig. 3). In these26 patients, 18 (69%) showed improvement in the Part
B score.

4. Discussion
Thus far, there have been few reports examining the
TMT score in the early stages of mild ischemic stroke[8, 9]. One may consider that in patients with ischemic
stroke, TMT should be performed in the chronic stage
when symptoms are completely fixed. However, patientswith mild ischemic stroke are often discharged earlyand hope to return to a life similar to the previous one.
Therefore, we believe that an early evaluation of TMT
for mild stroke patients has a certain value.
The present study showed that TMT-J scores werehigh in a significant proportion of patients in early stagesof mild ischemic stroke. Although the lesion locationof ischemic stroke varied among the patients, the stroke
might have impaired the attention and executive functions that are required for the performance of TMT-J. In-

Asian J Occup Ther 19: 16−21, 2023

Yoshioka M et al.

19

Table 2 Clinical information on the 54 patients.
Case, Sex, Age (years)
1*, M, 79
2, M, 83
3, M, 73
4*, F, 69
5, F, 84
6*, M, 80
7, F, 49
8, M, 70
9, M, 53
10*, F, 70
11, M, 72
12*, M, 78
13, M, 78
14, M, 81
15, M, 69
16*, F, 83
17, F, 74
18, M, 51
19*, M, 67
20*, M, 74
21*, F, 71
22, M, 74
23, M, 56
24, M, 80
25, M, 60
26, F, 87
27, M, 72
28, M, 73
29, F, 66
30, M, 73
31, M, 81
32*, M, 58
33*, F, 54
34, F, 82
35*, M, 72
36, F, 80
37*, F, 51
38, M, 83
39, M, 57
40*, M, 70
41, F, 4942*, M, 76
43, M, 74
44*, F, 81
45*, F, 77
46, F, 68
47, M, 81
48*, M, 82
49, M, 84
50, M, 61
51, F, 51
52, F, 53
53, M, 67
54*, M, 62
Average score
Standard deviation
Median score
Maximum score
Minimum score

TMT-J

Clinical
category

Lesion location

NIHSS

HDS-R

1st

2nd

1st

2nd

OI
ATI
LI
LI
OI
LI
LI
LI
LI
ATI
ATI
OI
OI
CEI
ATI
ATI
ATI
ATI
OI
CEI
ATI
CEI
LI
ATI
OI
LI
LI
LI
LI
ATI
LI
LI
LI
LI
CEI
ATI
OI
CEI
LI
ATI
OI
OI
LI
LI
ATI
LI
OI
CEI
LI
OI
LI
LI
LI
ATI

Lt FL
Lt FL, Lt TL, Lt OL, Lt CR
Lt Pu
Lt Pu, Lt CR
Lt Pu, Lt CR
Lt Pu, Lt IC
Lt Th
Lt IC
Lt IC, Lt Th
Rt FL
Rt FL
Rt FL
Rt FL
Rt FL
Rt FL, Rt TL
Rt FL, Rt PL
Rt FL, Rt TL, Rt OL
Rt FL, Rt TL, Rt OL
Rt FL, Rt PL, Rt OL
Rt FL, Rt PL, Rt OL
Rt TL, Rt PL, Rt OL
Rt OL
Rt Pu, Rt CR
Rt Pu, Rt GP
Rt Pu, Rt CR, Rt GP
Rt Pu, Rt CR, Rt IC
Rt Pu, Rt CR
Rt GP, Rt IC
Rt CR
Rt CR
Rt CR
Rt IC
Rt Th
Rt Th
Bi FL
Rt FL, Rt TL, Rt PL, Lt CN
Bi FL, Bi OL, Bi Ce
Lt Mi, Lt Ce
Rt Mi
Rt Mi, Rt Po
Lt Ce
Bi Ce
Lt Po
Lt Po
Lt Po
Rt Po
Rt Po
Rt Po
Rt Po
Rt Po, Rt Me
Lt Me
Lt Me
Lt Me
Rt Me

1
3 (R)
3
3
3
3
1 (R)
3 (R)
2
1 (R)
3
1
0 (R)
0
1 (R)
0 (R)
0 (R)
1 (R)
2
3
4
1
3
3
0
2 (R)
3
3 (R)
4
1 (R)
1 (R)
3
2 (R)
2
1
6
3
0
1
1 (R)
0 (R)
5
2
4
0 (R)
4
5
2 (R)
5
5 (R)
1 (R)
0
4
2

26
21
24
27
26
27
30
29
24
24
29
27
27
23
29
26
29
29
30
28
24
28
29
25
29
28
24
30
29
30
30
28
30
27
23
21
30
27
30
28
30
21
24
21
27
30
19
29
26
27
30
30
27
23

76
57
34
64
67
159
33
24
23
89
53
68
47
98
33
64
44
32
33
93
74
49
37
47
36
50
108
41
49
37
58
44
46
135
91
150
74
104
27
57
26
125
81
98
72
56
NC
77
66
172
25
34
42
41

63
NE
NE
61
71
117
NE
NE
38
48
NE
50
NE
132
NE
53
NE
NE
23
58
59
NE
44
NE
NE
NE
36
NE
56
NE
NE
27
27
102
58
134
35
95
NE
NE
NE
68
62
54
40
42
NC
53
114
82
NE
NE
NE
33

215
93
104
237
244
NC
54
67
120
179
74
82
88
NC
50
190
73
53
87
164
139
79
80
112
67
114
156
59
85
43
67
51
59
227
175
246
110
NC
34
73
57
NC
138
300
251
98
NE
96
222
267
48
45
74
103

176
NE
NE
109
178
164
NE
NE
135
98
NE
64
NE
NC
NE
162
NE
NE
62
168
182
NE
71
NE
NE
NE
155
NE
69
NE
NE
117
44
167
175
257
41
190
NE
NE
NE
NC
153
NC
209
97
NE
94
164
114
NE
NE
NE
105

27
3
27
30
19

82
36
74
172
23

62
30
56
134
23

155
66
148
267
51

130
53
126
257
41

Part A (seconds)

Part B (seconds)

ATI: atherothrombotic infarction, Bi: bilateral, CC: corpus callosum, Ce: cerebellum, CEI: cardioembolic infarction, CN: caudate nucleus, CS:
central semiovale, CR: corona radiata, F: female, FL: frontal lobe, GP: globus pallidus, IC: internal capsule, LI: lacunar infarction, Lt: left, M:
male, Me: medulla oblongata, Mi: midbrain, NC: not completed, NE: not evaluated, OI: other infarction, OL: occipital lobe, Po: pons, PL: parietal lobe, Pu: putamen, R: retrospective NIHSS score, Rt: right, Th: thalamus. TL: temporal lobe, Patients who were reevaluated after discharge
are indicated with an asterisk. Patients evaluated with the non-dominant hand are underlined. TMT-J scores higher than 1 SD above age-specificaverage scores are underlined. Average, median, maximum, and minimum Part A scores in this table were calculated from data of 31 patients forwhom an initial and second evaluations could be performed. Similarly, average, median, maximum, and minimum Part B scores in this table were
calculated from data of 26 patients for whom an initial and second evaluations could be performed.

20

TMT-J SCORES IN MILD ISCHEMIC STROKE

Fig. 2.

Serial changes in TMT-J Part A scores.

between the patients and healthy elderly. A previous
study demonstrated that the mean values of Part A
scores in healthy adults decreased from 29.3 to 24.9
seconds in 2–3 weeks, and those of Part B scores from70.1 to 61.4 seconds [13]. Secondly, 20 patients did nothave an NIHSS score at admission and were retrospectively evaluated based on the medical records. Thirdly,
patients with very mild ischemic stroke who were nothospitalized could not be included. Fourthly, TMT-J
scores in the chronic stage could not be evaluated. Fifthly, we could not show effect size or minimal clinicallyimportant differences in serial changes in TMT-J score.
Further studies are needed to clarify the factors affecting
the TMT score as well as appropriate time of conducting
TMT after mild ischemic stroke.

Funding
This research was supported by a research grantfrom the Japanese Association of Rural Medicine.

Conflict of Interest
The authors declare no conflict of interest.

Fig. 3.

Serial changes in TMT-J Part B scores.

terestingly, all 7 patients with isolated pontine infarction(patients 43–49) showed high Part A or Part B scores on
initial evaluation. Patients with pontine infarction may
be likely to show high TMT-J scores in the early stages
even if the stroke itself was mild.
In patients showing high TMT-J scores in thisstudy, the score improved over time in more than 60%
of patients. This improvement may be associated withthe restructuring of neural networks related to the performance of TMT-J as well as a learning effect due torepeated evaluation [13].
There are some reports that TMT can identify patients who should not drive a car [5, 6] Considering theresults of these and our studies, if the TMT score is very
high in patients with mild ischemic stroke 8–14 days
after onset, it may be reasonable to refrain from driving
and re-conduct TMT 29 days or later after onset. If the
TMT score is not so high, medical staff should judge
the pros and cons of driving a car by combining otherevaluations including other inspection batteries, driving
simulator evaluations, and actual in-vehicle evaluations.
This study has several limitations. Firstly, because
healthy control elderly were not evaluated, the extent of
improvement on repeated TMT-J could not be compared

Statement of Authorship
MY: analysis of the data, ZK: conceptualization,
design, writing the original draft, review, and editing.
KK: analysis of the data, KI: analysis of the data, MH:analysis of the data, KT: analysis of the data, YN: review
and editing. HT: review, SS: review

References[1] Brain Function Test Committee, Japan Society for Higher
Brain Dysfunction. Trail Making Test, Japanese edition(TMT-J). Tokyo: Shinkoh-Igaku Shuppan Co., Ltd. 2019.
[2] Barker-Collo S, Feigin V, Lawes C, Senior H, Parag V.
Natural history of attention deficits and their influence onfunctional recovery from acute stages to 6 months after
stroke. Neuroepidemiology. 2010; 35: 255–62.
[3] MacPherson SE, Cox SR, Dickie DA, Karama S, Starr
JM, Evans AC, et al. Processing speed and the relationship between Trail Making Test-B performance, corticalthinning and white matter microstructure in older adults.
Cortex. 2017; 95: 92–103.
[4] Fu X, Lu Z, Wang Y, Huang L, Wang X, Zhang H, et al.
A Clinical Research Study of Cognitive Dysfunction and
Affective Impairment after Isolated Brainstem Stroke.
Front Aging Neurosci. 2017; 9: 400.
[5] Ball KK, Roenker DL, Wadley VG, Edwards JD, RothDL, McGwin G Jr, et al. Can high-risk older drivers
be identified through performance-based measures in a

Asian J Occup Ther 19: 16−21, 2023

Department of Motor Vehicles setting? Am Geriatr Soc.
2006; 54: 77–84.
[6] Roy M, Molnar F. Systematic review of the evidence forTrails B cut-off scores in assessing fitness-to-drive. Can
Geriatr J. 2013; 16: 120–42.
[7] Wolf TJ, Rognstad MC. Changes in cognition following
mild stroke. Neuropsychol Rehabil. 2013; 23: 256–66.
[8] Fure B, Bruun Wyller T, Engedal K, Thommessen B.
Cognitive impairments in acute lacunar stroke. Acta
Neurol Scand. 2006; 114: 17–22.
[9] Yoshioka M, Kobayashi Z, Inoue K, Watanabe M, Kato
K, Toyoda K, et al. Serial changes in Trail Making Test
score after minor ischemic stroke. J Rehabil Neurosci.
2019; 19: 33–6.
[10] A committee established by the National Institute of

Yoshioka M et al.

21

Neurological Disorders and Stroke, National Instituteof Health. Special report from the National Institute of
Neurological Disorders and Stroke. Classification of
cerebrovascular diseases III. Stroke. 1990; 21: 637–76.
[11] Williams LS, Yilmaz EY, Lopez-Yunez AM. Retrospective assessment of initial stroke severity with the NIH
Stroke Scale. Stroke. 2000; 31: 858–6.
[12] Klaming L, Vlaskamp NS. Non-dominant hand use
increases completion time on part B of the Trail Making
Test but not on part A. Behav Res Methods. 2018; 50:
1074–87.
[13] Bartels C, Wegrzyn M, Wiedl A, Ackermann V, Ehrenreich H. Practice effects in healthy adults: a longitudinal
study on frequent repetitive cognitive testing. BMC
Neurosci. 2010; 11: 118.

■ORIGINAL ARTICLE

Factors Relating with Excessive Daytime Sleep
in Elderly Stroke Patients Undergoing
Inpatient Rehabilitation
Yuki Nakagawa1, 2, Kazue Noda1, Hiroaki Naritomi3, Hiroshi Nakata4,
Tomoki Nishi5, Keishi Yoshida3, Hideyuki Shiotani6
1

Department of Rehabilitation Science, Graduate School of Health Sciences, Kobe University
Faculty of Health Sciences, Osaka University of Human Sciences3
Department of Rehabilitation, Kyowakai Medical Corporation Senri-chuo Hospital
4
Department of Rehabilitation, Kyowakai Medical Corporation Kyowakai Hospital
5
Department of Rehabilitation, Kyowakai Medical Corporation Kyoritsu-Onsen Hospital
6
School of Health Sciences, Kobe Tokiwa University
2

Abstract: Background: Patients in rehabilitation facility have enormously long free time and often fall asleep during
daytime. Excessive daytime sleep (DS) was reported to decrease rehabilitation efficiency resulting in poor functional
recovery. In general population, insomnia, obesity, depression, dementia and the use of sleeping pills are known to beimportant risk factors of excessive DS. However, the causes of excessive daytime sleep in patients undergoing inpatient
rehabilitation have not been clearly identified. Therefore, the current preliminary study aimed to explore factors underlying excessive DS in elderly patients undergoing inpatient rehabilitation following acute stroke.
Methods: Subjects were 17 patients without dementia with more than 65 years of age who were admitted to our rehabilitation wards following acute stroke. In all the patients, daytime and nighttime sleep states were monitored with wrist
actigraphy consecutively for five days. Relationships of DS duration with insomnia, obesity, depression, apathy, hypnotic administration, motor functional ability, recreational activities and self-exercise were investigated.
Results: All the patients had more or less DS, the duration of which widely ranged from 43 to 550 min/day with meanvalue 210 ± 122 min/day. This DS duration was 3 - 4 times longer than that in general elderly population. The majorityof patients had sufficiently long nighttime sleep (NS). There was no correlation between DS duration and NS duration.
DS duration had no relationship with obesity, depression, apathy, hypnotic administrations, or motor functional ability. DS duration was, however, significantly shorter in patients performing self-exercise (n = 10, 157 ± 82 min) than inthose without self-exercise (n = 7, 285 ± 135 min) ( p = 0.03). Recreational activities did not shorten DS duration.
Conclusion: Patients in rehabilitation facility tend to have long DS because of enormously long free time and consequent idleness. Taking up the free time with self-exercise appears to be useful for preventing excessive DS.
Keywords: nap, stroke, elderly, self-exercise, activity, occupational therapy(Asian J Occup Ther 19: 22−29, 2023)

1. Introduction
In Japan, the time for inpatient rehabilitation including occupational, physical and speech therapy is limited
to 180 min per day because of medical insurance reguReceived: 26 September 2021, Accepted: 28 September 2022
Corresponding to: Kazue Noda, Department of Rehabilitation Science,
Graduate School of Health Sciences, Kobe University, 7-10-2 Tomo­ga­
oka Suma-ku, Kobe-shi, Hyogo-ken 654-0142 Japane-mail: noda@kobe-u.ac.jp©2023 Japanese Association of Occupational Therapists

lation connected with the three-hour rule [1]. In our rehabilitation facility, patients get up at 6:00 am and go to
bed at 10:00 pm. Thus, our rehabilitation inpatients havethe total of 16 daytime hours every day and spend only
three hours or less for rehabilitation therapy. According
to a fact-finding survey performed in our rehabilitation
facility prior to the current study, many patients complain of idleness and tend to fall asleep during daytime.
Several studies also reported that patients in rehabilitation facility had long daytime sleep [2, 3]. In general,adequate DS is thought to be beneficial. Short naps
less than 30 min were reported to reduce drowsinessAsian J Occup Ther 19: 22−29, 2023

and raise activity [4, 5]. On the other hand, excessive
DS increases fatigue [6] and decreases physical andmental functions. Previously, Alessi et al. studied sleep
condition of elderly stroke patients undergoing inpatient
rehabilitation using wrist actigraphy and found that they
had enormously long DS which was connected withpoor functional recovery [2, 7]. Excessive DS is, thus, aseriously disturbing problem for patients in rehabilitation facilities. Unfortunately, however, Allessi et al. did
not investigate why those patients had excessive DS andwhat kind of factors were contributing to the excessive
DS. Various factors may be involved with mechanismsof excessive DS. Insomnia, obesity, depression, apathy,
dementia and administration of hypnotics are known to
be important risk factors of excessive daytime sleepiness in general population [8]. Several workers using
wrist actigraphy reported that nursing home residents
had long DS [9, 10]. Nursing home is the environment
similar to rehabilitation facility, since the residents are
generally old and have enormously long free time withlimited enjoyment. Idleness may be one of importantrisk factors for long DS in nursing home residents.
Unfortunately the causes of excessive DS in patients
undergoing inpatient rehabilitation have not yet been
precisely investigated. In order to clarify this point clear,
the current preliminary study was designed to explore
factors relating with excessive DS in elderly patients
undergoing inpatient rehabilitation. Stroke is the mostcommon condition in rehabilitation facilities. Therefore,
we restricted participant materials to those with rehabilitation following acute stroke.

2. Participant Materials and Research
Methods
Participants and Recruitment
Participants were selected from 48 stroke patients
admitted to our rehabilitation facility during the period
from June 1, 2018 to September 30, 2018. Inclusion
criteria were 65 years of age or more, a score of 24 or
higher on the mini-mental state examination (MMSE),
and the admission within 60 days following acute stroke.
Exclusion criteria included severe immobilization, consciousness disturbance and no doctor`s permission due
to the association of serious complications. Nineteen patients met the inclusion criteria and agreed to participate
with the study. Informed consent was obtained from all
the patients. Two of them were, however, excluded fromthe study because of the following reasons: one wastransferred to other hospital during the study period andthe other could not retain a wrist actigraphy throughout
the study period. The study protocol was approved by
local ethical committee of A Hospital in Japan.

Nakagawa Y et al.

23

Data collection and Measures
Basic characteristics
The information concerning the gender, age, administration of hypnotics, body mass index (BMI) and
MMSE scores of the patients were obtained from theparticipants’ medical records.
Sleep duration
The study was initiated more than a week after theadmission in order to obtain such a circumstance that thepatients became acclimatized to the hospitalized life. All
the patients were requested to wear a wrist actigraphy(Life Microscope, Hitachi, Tokyo) for five-day study
period. Actigraphy was developed to monitor the sleep
condition of children and adults, and its validity wasconfirmed repetitively by numerous studies [2, 3, 9–12].
When comparing actigraphy’s ability to assess sleep parameters to the gold standard of polysomnography, theexcellent concordance was shown in the measurementof total sleep duration among healthy subjects with asensitivity more than 90% [9–12]. The actigraphy wasthen chosen to be a tool for measuring sleep durationin the current study. In many previous studies using
actigraphy, the measurements were carried out for one
week. However, in rehabilitation institutes, there arecommonly family visits on Saturday and Sunday which
likely prevent daytime sleepiness of patients. Therefore,
in the current study, the actigraphy measurements were
initiated and ensued for five weekdays excluding theweekends. The actigraphy was attached to the non-paralyzed side wrist and kept unremoved all day long except
for a bath time. That was because it not water proof.
The actigraphy automatically detected sleep and arousal
using an automated discrimination algorithm and identifies the time falling asleep and waking up. Using thisdevice, sleeping data were collected over three consecutive days from the second to the fourth day of five-day
study period. The data obtained at the first day and lastday were excluded from the analysis for the following
reasons. At the first day, the patients are likely to betense for actigraphy measurements and may tend tokeep awake during daytime. At the last day, the patients
may make effort to keep awake in order to improve theactigraphy records.
The patients were also asked to hand-record thetime going to bed at night, waking up in the following
morning and taking DS every day throughout the study
period. The recorded data were used as reference ofsleep conditions.
The NS was assumed to be the main sleep period
over a 24-hour cycle. The total time spent for every
sleep during the daytime was defined to be DS duration. DS was further divided to three periods such as,

24

FACTORS RELATING WITH EXCESSIVE DAYTIME SLEEP IN ELDERLY STROKE INPATIENTS

morning sleep (from wake-up time to 13:00), afternoon
sleep (from 13:00 to 15:00) and evening sleep (from15:00 to bedtime at night). The Meterological Agency
in Japan defines the time from 15:00 to bedtime at night
to be evening. NS efficiency (%) and nocturnal waking
frequency were determined from the measurements ofactigraphy data. Average NS duration and average DS
duration per day in each patient obtained from three-day
measurements were calculated.
Motor functional ability and locomotive independency
At the beginning of the study, motor functional
ability of patients was assessed with the motor subtotal
rating score of functional independence measure (FIM)[13]. FIM is a reliable and valid assessment of motor
function widely used in the field of rehabilitation [14–16]. The FIM consists of 13 motor items with a 7-point
scale for independence, which provides a detailed numerical assessment on the patient’s motor function. FIM
was assessed by physical therapists and occupational
therapists at the first day of the study. Apart from FIM
evaluation, the patients were divided into two groups
according to the locomotive faculty, either independent
or dependent. The former can freely move around thewards by themselves, and the latter needs someone’s
help to move around.
Mental function
Mental function was evaluated using Zung’s selfrating depression scale (SDS) [17] and apathy scale(AS) [18, 19]. SDS consisting of 20 questions with wide
range scores from 20 to 80 points allows to assess thegrade of depressive moods in detail within a short time.
It is commonly used to assess the mental function of
stroke patients and the elderlies [20, 21]. Scores 40 or
more were judged to be depressive. Apathy scale (AS)is also used commonly to evaluate apathetic moods ofstroke patients [19, 20, 22]. Patients can answer simple
questions of AS within a short time and feel little physical or mental burden. Scores 16 or more were judged tobe apathetic.
Time of recreational activities and self-exercise
Patients undergoing inpatient rehabilitation commonly spend the free time either enjoying recreational
activities, such as watching television, reading books,
playing with artistic paper folding (Origami), or performing self-exercise, such as walking around the wards
by oneself or stretching the legs. Through the study
period, all the patients were requested to record the timespent for such recreational activities and/or self-exercise
before going to bed. At the end of the study, averagetime spent for the recreational activities or self-exercise

per day was calculated.
Data analysis
The relationship of DS duration with gender, hypno­
tic medication, obesity, depression, apathy, locomotive
independency, recreational activities or self-exercise,
was compared using unpaired t-test. The relationship between DS duration and NS duration was analyzed with
Pearson’s correlation coefficients. P values < 0.05 wereconsidered statistically significant.

3. Results
Basic characteristics of 17 patients are listed inTable 1. There were 12 men and five women with ages
ranging from 66 to 89 years. Three patients were taking
hypnotics, whereas the other 14 had neither hypnotics
nor drugs inducing sleepiness. BMI ranged from 18.1
to 29.3; only three patients were overweight. All thesethree patients showing BMI values 25–30 were regarded
mildly obese. MMSE scores ranged from 25 to 30; noneof them was demented. Motor FIM scores ranged from
14 to 89. As for locomotive faculty, seven patients wereable to move independently (independent group), andthe other 10 needed the aid of someone else to movearound (dependent group). All the independent grouppatients showed motor FIM scores 76 or above, whereas
all the dependent group patients exhibited motor FIM
scores below 76. Thus, the locomotive independency
was closely connected with motor FIM levels.
Table 2 demonstrates DS duration, NS duration,
SDS scores, AS scores, the time spent for recreational
activities or self-exercise of the 17 patients. All the patients had more or less DS which ranged from 43 min to
550 min. Mean DS duration was 210 ± 122 min. Mean
durations of morning sleep, afternoon sleep and evening
sleep were 70 ± 47 min, 24 ± 21 min and 116 ± 67 min,respectively. When these were adjusted to the time perhour, the durations of morning sleep, afternoon sleepand evening sleep were 10.4 ± 6.8 min/h, 12 ± 11 min/h,and 16 ± 9 min/h, respectively. Thus, evening sleep was
the longest of all DS durations.
DS duration was compared between males andfemales. There was no gender difference in DS duration(Table 3). DS duration in three patients with hypnotics
was not longer than that in 14 patients without hypnotics(Table 3). DS duration in three patients with mild obesity was almost the same as that in 14 non-obese patients(Table 3). When compared from the aspect of locomotive independency, DS duration in the dependent group
did not differ significantly from that in the independentgroup (Table 3).
The majority of patients had a sufficiently long NS,

Asian J Occup Ther 19: 22−29, 2023

Nakagawa Y et al.

25

Table 1 Basic characteristics of 17 patients.
Case No

GenderAge
years

Hypnotics
Administration

BMI

MMSE
score

Motor FIM
score

Locomotive
independence

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

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

66
68
88
66
83
83
83
75
78
67
77
85
76
80
66
81
89

no
no
yes
no
yes
no
no
no
no
no
no
no
no
no
yes
no
no

22.8
18.9
18.8
19.2
29.3
18.2
20.9
18.1
22.2
23.9
20.9
26.0
21.0
24.6
22.2
26.9
21.1

30
29
29
28
30
26
28
28
29
28
28
28
26
28
30
26
25

89
77
64
73
76
79
67
37
59
56
82
54
14
80
75
88
65

yes
yes
no
no
yes
yes
no
no
no
no
yes
no
no
yes
no
yes
no

M: male F: female
BMI: body mass index
MMSE: mini-mental state examinations
Motor FIM: motor subtotal rating of functional independence measure
Table 2 Results of measurements in 17 patients.
Case NoDS durationmin

NS duration
min

SDS
score

Apathy Scale
score

Recreational Activities
minSelf-exercise
min

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

43
81
87
120
144
145
161
163
171
218
225
240
270
291
312
342
550

354
411
527
515
363
452
338
535
460
572
364
338
469
525
501
489
444

27
42
34
47
45
36
30
67
39
37
38
43
36
44
40
35
48

5
6
14
17
6
6
11
18
26
13
8
16
18
6
8
17
9

150
210
120
180
70
0
360
231
120
0
180
180
508
210
60
30
120

150
120
5
35
20
120
0
3
0
0
30
0
30
15
0
0
0

DS: daytime sleep
NS: nighttime sleep
SDS: self-rating depressive scale

the duration of which ranged from 338 min to 572 minwith mean value 451 ± 76 min. Mean NS efficiency was
87.7 ± 7.6%, and mean nocturnal waking frequency was
5.6 ± 3.2 times, although the values were not listed inTable 2. There was no significant correlation between
DS duration and NS duration (r = 0.157, p = 0.547)(Table 4). DS duration also did not correlate with NS
efficiency (r = 0.169, p = 0.515) or nocturnal waking

frequency (r = −0.221, p = 0.395) (Table 4).
The results of SDS showed eight patients to be
depressive and the other nine not depressive (Table 2).
DS duration in the depressive patients (237 ± 151 min)was somewhat longer as compared with that in the
non-depressive patients (185 ± 91 min). However, thedifference was not significant at all ( p = 0.39) (Table 3).
According to AS, six patients were apathetic, and the

26

FACTORS RELATING WITH EXCESSIVE DAYTIME SLEEP IN ELDERLY STROKE INPATIENTSTable 3 Comparison of daytime sleep duration with various influential factors.
Factors
Gendermales (n = 12)
females (n = 5)
Hypnotics
yes (n = 3)
no (n = 14)
Obesityobese (n = 3)
not obese (n = 14)
Locomotive independence
independent (n = 7)
dependent (n = 10)
Depressive state
depressive (n = 8)
non-depressive (n = 9)
Apathy stateinactive (n = 6)
active (n = 11)
Self-exercise
Yes (n = 10)
No (n = 7)
Recreational activities
long (n = 8)
short (n = 9)

DS duration (min)Mean ± SDp

194 ± 91247 ± 1850.43

181 ± 117213 ± 1260.67

242 ± 99203 ± 1280.63

182 ± 109229 ± 1320.45

237 ± 151
185 ± 910.39

217 ± 82
205 ± 1430.85

157 ± 82285 ± 1350.03*

194 ± 74
223 ± 156

0.63*: p < 0.05

Table 4 Correlations between daytime sleep duration and various
factors.
Factorsrp

Age
Motor Subtotal Rating of FIM
Nighttime sleep duration
Nighttime sleep-efficiency
Nocturnal waking frequency

0.35−0.1400.157
0.169−0.221

0.17
0.592
0.547
0.515
0.395

other 11 were not apathetic (Table 2). DS durations in
the apathetic patients (217 ± 82 min) and the non-apathetic patients (205 ± 143 min) were almost the same
(Table 3).
During the study period, all the patients except for
two enjoyed recreational activities, although the timespent for the activities widely varied from 30 min to
508 min. The recreational activities included watching
television, reading books, listening to music and playing
with artistic paper folding (Origami). The 17 patientswere then divided into two groups according to theduration of recreational activities, i.e. a group with longactivities for three hours or more (long recreational
activity group) and the other with short activities for lessthan three hours (short recreational activity group). Twopatients without recreational activities were included
into the short activity group. There was no significant
difference in DS duration between the two groups.
During the study period, 10 patients performed selfexercise, whereas the other seven had no self-exercise(Table 2). DS duration in the patients with self-exercise(157 ± 82 min) was significantly shorter than that in thepatients without self-exercise (285 ± 135 min, p = 0.03).
Of the 10 patients with self-exercise, six patients (60%)
had locomotive independency. Of the seven patients
without self-exercise, only one (14%) had locomotive
independency. Thus, more than a half of the patientswith self-exercise had locomotive independency, while
the majority patients without self-exercise had no locomotive independency.

4. Discussion
All the patients in the current study had more orless DS, the average of which was 210 min. DS durationin healthy elderly subjects was reported to be approximately 60 min [23]. DS duration in our patients is 3 4 times longer as compared with that in healthy elderly
subjects. Stroke patients are known to have longer DS as
compared with subjects without stroke [24, 25]. While
the prevalence rate of excessive daytime sleepiness instroke patients widely ranges between 18% and 72%,
daytime sleepiness may persist for more than 6 months
after stroke [24, 25]. This may be one reason for theenormously long DS of our patients. Previously, Alessi
et al. also studied sleep conditions in elderly stroke
patients undergoing inpatient rehabilitation [2]. In theirpatients, DS duration was also very long reaching 126
min in average. It, thus, seems that elderly stroke patients undergoing inpatient rehabilitation tend to haveexcessive DS irrespective of nationality.
Sleep physiology studies suggest that DS for lessthan 30 min may be beneficial because of minimizing
the negative influence of sleep inertia which can leadto the prolongation of NS [4, 5]. On the other hand,
the longer DS likely brings about the onset of slowwave sleep which may cause the feeling of fatigue, thedecrease of work efficiency and the lower quality of NS[6]. As reported by Allessi et al., excessive DS decreases
rehabilitation efficiency leading to poor functional recovery in patients undergoing inpatient rehabilitation [2].
Therefore, DS should be avoided as much as possible inorder to increase efficiency of rehabilitation.
DS duration in our patients widely varied from 43
min to 550 min despite staying in the same rehabilitation facility. The fact suggests that multiple factors
may affect with long DS of patients in rehabilitation
facility. In general, insufficient NS, obesity, depression

Asian J Occup Ther 19: 22−29, 2023

apathy, dementia and administration of hypnotics are
considered to be important risk factors of excessive
daytime sleepiness [8, 24]. The majority of patients inthe current study, however, had sufficiently long NS,
and none of them complained of insomnia during thestudy period. Mean NS efficiency 87.7% also suggestthat the majority of our patients were free from insomnia. Furthermore, there was no significant correlation
between DS and NS durations in our patients. The results are taken to indicate that insufficient NS is not the
major factor of excessive DS in our patients. Obesity is
another important risk factor of excessive DS. Obesity
is commonly associated with obstructive sleep apnea
which likely brings about insufficient NS and excessive
daytime sleepiness [24]. In the current study, only threepatients had mild obesity. DS duration in these three patients with mild obesity was the same as that in the other
patients without obesity. Thus, obesity is apparently
not the cause of excessive DS in our patients. Daytime
sleepiness is known to be an important symptom of depression. In the current study, eight patients were judged
depressive on the basis of SDS. Yet, DS duration in the
depressive patients was not significantly different fromthat in the non-depressive patients. The results suggestthat depression is not the major factor causing excessive
DS in our patients. Prior to the beginning of the current
study, we assumed that the locomotive faculty might be
an important factor causing excessive DS. Locomotive
dependency was likely connected with inactiveness
which might easily lead patients to fall asleep during thedaytime. Yet, DS duration in 10 patients with locomotive dependency was the same as that in seven patientswith locomotive independency. It must be concluded
that locomotive dependency was not the major factor
causing excessive DS in our patients.
Rehabilitation facility is a closed environment inwhich the patients have to spend 24 hours for eating
meals, going toilets, working on rehabilitation tasks andsleeping at night. It is unfortunate that therapist-guided
rehabilitation is performed only for a few hours. Several workers previously investigated the hospital lifeof patients in rehabilitation facility [2, 3]. Quite a few
patients spent a long non-therapeutic time for lying on
beds. The posture lying on beds easily leads patients
to fall asleep unless the effort is made to keep awake.
Thus, the circumstance with enormously long free time
but nothing to do may be the major causative factor ofexcessive DS in patients undergoing inpatient rehabilitation as assumed by us prior to the current study. How
can we prove the validity of this assumption? Idlenessduring the long non-therapeutic time may be distracted
by two types of actions, one recreational activities andthe other the self-exercise. Provided either one or both

Nakagawa Y et al.

27of them shortens DS duration, then it can be declaredthat idleness is the major causative factor of excessive
DS in patients. On the basis of such a consideration, we
attempted to clarify whether two types of actions canshorten DS duration.
Ten of our patients performed self-exercise suchas walking around the wards by themselves, whereas
the other seven had no such self-exercise. DS durationin the self-exercise group (157 min) was significantly
shorter as compared with that in the non-self-exercisegroup (285 min). The results suggest that self-exercise
may be effective for preventing DS. In order to confirm
the validity of this view, we further looked into moredetails of 10 patients with self-exercise, since the selfexercise time largely varied among them. Three patients
had quite a long self-exercise for two hours or more(long-self-exercise group) and the other seven had only
a short self-exercise for three to 30 min (short selfexercise group). Mean DS duration in the long selfexercise group (90 min) was considerably shorter thanthat in the short self-exercise group (188 min), although
no statistical analysis was undertaken. Mean DS duration was, thus, the shortest in the long self-exercisegroup (90 min) followed by the short self-exercise group(188 min) and the longest in the non-self-exercise group(285 min). These results strongly support the view that
self-exercise plays important role in the prevention ofexcessive DS. It should be noted here that more than ahalf of the patients with self-exercise had locomotive
independency, while the majority of patients without
self-exercise had no locomotive independency. The
patients with locomotive independency are more advantageous than those without locomotive independency
for conducting self-exercise because of more freedom
to choose the time and location of exercise. Locomotive
independency and self-exercise seem to be closely
related with each other. Yet, it is still true that four patients without locomotive independency conducted selfexercise in spite of the restriction of time and place forexercise. The locomotive independency is an importantfactor but not a prerequisite for self-exercise.
The majority of our patients spent the time forrecreational activities. We then divided the patients into
two groups according to the duration of recreational
activities, one a group with short recreational activities
for less than two hours and the other a group with long
recreational activities for more than two hours. Yet,no significant difference in DS duration was foundbetween the two groups. The results suggest that therecreational activities are not effective for preventing
daytime sleepiness. According to the study of Yan et al.,low intensity activities provided little effects on daytime
sleepiness [26]. All the recreational activities chosen in

28

FACTORS RELATING WITH EXCESSIVE DAYTIME SLEEP IN ELDERLY STROKE INPATIENTS

the current study consume small amount of energy. Such
low intensity activities may not be as powerful as highintensity activities for the prevention of daytime sleepiness. Personal space of hospitalized patients is limited
to the bed and the surrounding area. This environmental
limitation forces the patients to choose the recreational
activities in a lying or sitting position, such as listening
to music or watching television. Occupational therapists
are encouraged to improve the hospital environment
taking patients to meeting rooms or areas other than personal bed area so that patients can engage in more active
leisure activities.
The mean duration spent for self-exercise (31 min)was considerably shorter than that spent for recreational
activities (162 min). Nevertheless, the self-exercise
was seemingly more effective for preventing excessive
DS than the recreational activities. The reason for thisdifference is not quite clear. The self-exercise likely
consumes higher amount of energy as compared withthe recreational activities. Higher intensity activities
may be more effective than lower intensity activities forthe prevention of daytime sleepiness regardless of theduration as suggested by Yan et al. [26]. Recreational
activities, such as watching television and listening
to music, can be classified passive-type entertainment
which does not require strong enthusiasm. On the other
hand, self-exercise, such as walking around the wards,
is classified active-type performance, which needs
strong motivation. Such a difference in enthusiasm mayunderlie in DS preventive mechanisms between the recreational activities and the self-exercise.
Limitations of study
There were some limitations in the current study.
First, a long single nap and a few shorter naps were notdistinguished in the current study; only the total timeof daytime sleep was analyzed as DS duration. A single
long nap may be detrimental, while a few shorter naps
may be beneficial. These two types of naps would bebetter analyzed separately in the future study. Second,
the present study was performed as a preliminary study
with small samples to explore possible factors contributing to the excessive DS in elderly stroke patients undergoing inpatient rehabilitation. Because of small sample
size, some influential factors may have been dismissed
due to statistical insignificance. Further investigation
with larger sample size using more detailed analysis isneeded to confirm the present results in the future. We
are preparing such a study.
Conclusions
Patients undergoing inpatient rehabilitation haveextremely large amount of free time and are sufferingfrom idleness, which leads them to excessive DS. The
self-exercise appears to reduce idleness and effectively
prevent excessive DS. Therapists are encouraged toprovide self-exercise menu matched for each patient andto check whether the patients can continue self-exercise
properly.
Statement Regarding Informed Consent
Informed consent was obtained from all individual
participants included in the study.
Statement Regarding Ethical Approval
The study was approved by the ethics committeeof A Hospital (Committee approved number: 201806). All procedures performed in the study involving
human participants were in accordance with the national
research committee as well as these of the 1964 Helsinki
declaration and its later amendments.

References[1] Toyoizumi T, Hiraoka T, Seki S, Metani H, Tsubahara A,
Hanayama K. Effects of revisions to the health insurance
system on the recovery-phase rehabilitation ward. Kawasaki Med J. 2018; 44: 19–25.
[2] Alessi CA, Martin JL, Webber AP, Alam T, Littner MR,
Harker JO, et al. More daytime sleeping predicts lessfunctional recovery among older people undergoing inpatient post-acute rehabilitation. Sleep. 2008; 31: 1291–
300.
[3] Skibitsky M, Edelen MO, Martin JL Harker J, Alessi C,
Saliba D. Can standardized sleep questionnaires be used
to identify excessive daytime sleeping in older post-acuterehabilitation patients? J Am Med Dir Assoc. 2012; 13:
127–35.
[4] Hayashi N, Watanabe M, Hori T. The effects of a 20-min
nap in the mid-afternoon on mood, performance and EEG
activity. Clin Neurophysiol. 1999; 110: 272–9.
[5] Tietzel AJ, Lack LC. The short-term benefits of brief andlong naps following nocturnal sleep restriction. Sleep.
2001; 24: 293–300.
[6] Hilditch CJ, Dorrian J, Banks S. Time to wake up: reactive countermeasures to sleep inertia. Ind Health. 2016;
54: 528–41.
[7] Wallace DM, Ramos AR, Rundek T. Sleep disorders andstroke. 2012; 7: 231–42.
[8] Slater G, Steier J. Excessive daytime sleepiness in sleep
disorders. J Thorac Dis. 2012; 4: 608–16.
[9] Martin JL, Webber AP, Alam T, Harker JO, Josephson
KR, Alessi CA. Daytime sleeping, sleep disturbance,and circadian rhythms in the nursing home. Am J Geriatr
Psychiatry. 2006; 14: 121–9.
[10] Fetveit A, Bjorvatn B. Bright-light treatment reduces actigraphic-measured daytime sleep in nursing home patientswith dementia: a pilot study. Am J Geriatr Psychiatry.

Asian J Occup Ther 19: 22−29, 2023

2005; 13: 420–3.
[11] Martin JL, Hakim AD. Wrist Actigraphy. Chest. 2011;
139: 1514–27.
[12] Jean-Louis G, Kripke DF, Cole RJ, Assmus JD, Robert
D. Langer RD. Sleep detection with an accelerometer
actigraph: comparisons with polysomnography. Physiol
Behav. 2001; 72: 21–8.
[13] Linacre JM, Heinemann AW, Wright BD, Granger CV,
Hamilton BB. The structure and stability of the Functional Independence Measure. Arch Phys Med Rehabil. 1994;
75: 127–32.
[14] Dodds TA, Martin DP, Stolov WC, Deyo RA. A validation of the Functional Independence Measurement and its
performance among rehabilitation inpatients. Arch Phys
Med Rehabil. 1993; 74: 531–6.
[15] Hamilton BB, Laughlin JA, Fiedler RC, Granger CV. Interrater reliability of the 7-level Functional independence
measure (FIM). Scand J Rehabil Med. 1994; 26: 115–9.
[16] Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The
reliability of the functional independence measure: aquantitative review. Arch Phys Med Rehabil. 1996; 77:
1226–32.
[17] Zung WWK. A self-rating depression scale. Arch Gen
Psychiatry. 1965; 12: 63–70.
[18] Starkstein SE, Mayberg HS, Preziosi TJ, Andrezejewski
MA, Leiguarda R, Robinson RG. Relaibility, validity,
and clinical correlates of apathy in Parkinson’s disease. J
Neuropshyatry Clin Neurosci. 1992; 4: 134–9.
[19] Okada K, Kobayashi S, Aoki K, Suyama N, Yamaguchi

Nakagawa Y et al.

29

S. Assessment of motivational loss in poststroke patientsusing the Japanese version of Starkstein’s Apathy Scale.
Jpn J Stroke. 1998; 20: 318–23.
[20] Seiji H, Hidehisa Y, Masaya S, Atsuko W, Keiko H,
Yasuo T, et al. Sitting balance as an early predictor offunctional improvement in association with depressive
symptoms in stroke patients. 2007; 61: 543–51.
[21] Hisashi K, Takashi I, Rika O, Yoichi S, Hirohiko H,
Shuichi O. The effectiveness of beauty care on self-rated
health among community-dwelling older people. Nihon
Ronen Igakkai Zasshi. 2016; 53: 123–32.
[22] Satoshi T, Kazushi H, Keisuke F, Koichi I, Tomoyuki M,
Yoshihiko F, et al. Impact of apathy on physical activity
in community-dwelling elderly. Japanese Journal of
Health Promotion and Physical Therapy. 2020; 10: 73–9
(in Japanese ).
[23] Evans BD, Rogers A. 24-hour sleep/wake patterns inhealthy elderly persons. Appl Nursing Res. 1994; 7: 75–
83.
[24] Ding Q, Whittemore R, Redeker N. Excessive daytime
sleepiness in stroke survivors. An integrative review. Biol
Res Nurs. 2016; 18: 420–31.
[25] Sterr A, Herron K, Dijk D-J, Ellis JG. Time to wake-up:
Sleep problems and daytime sleepiness in long-term
stroke survivors. Brain Inj. 2008; 22: 575–9.
[26] Yang Y, Shin JC, Li D. An R. Sedentary behavior andsleep problems: A systematic review and meta-analysis.
Int J Behav Med. 2017; 24: 481–92.

■ORIGINAL ARTICLE

Neurobehavioral Impairment Scale of the A-ONE J:
Rasch Analysis and Concurrent Validation
Yasuhiro Higashi1, 2, Shinichi Takabatake3, Asako Matsubara4,
Koji Nishikawa5, Toshikatsu Kaneda1, 2, Kazuyo Nakaoka6,
Yuta Somei2, and Guðrún Árnadóttir7, 8
1

Faculty of Health Sciences, Morinomiya University of Medical Sciences
Department of Rehabilitation, Kansai Rehabilitation Hospital
3
Faculty of Health Sciences, Kyoto Tachibana University
4
Department of Rehabilitation, Hiroshima City Rehabilitation Hospital
5
Department of Rehabilitation, Kanazawa Kobu Memorial Hospital
6
Graduate School of Rehabilitation Science, Osaka Metropolitan University
7
Department of Occupational Therapy, Landspítali, The National University Hospital of Iceland
8
Faculty of Medicine, University of Iceland
2

Abstract: Background: The ADL-focused Occupation-based Neurobehavioral Evaluation (A-ONE) is used to evaluate both performance of ADL tasks and neurobehavioral impairments (NBIs) that interfere with ADL performance ofclients with neurological disorders. Its Japanese translation is referred to as A-ONE J. This study examined the psychometric properties of the Neurobehavioral Impairment (NB) Scale of A-ONE J for persons with cerebral vascular accident (CVA).
Methods: Rasch analysis was performed on NB scale data from 185 participants with CVA, as well as from right CVA(RCVA) and left CVA (LCVA) data separately. The values of the obtained Rasch indicators were compared with resultsfrom previous A-ONE studies.
Results: Unidimensionality was obtained for 55 item CVA scale for the entire group as well as for 55 item RCVA scale
and 53 item LCVA scale. Separation reliability for item and person calibrations was high for all three scales. Most comparisons of Rasch indicators concurrently met set criteria.
Conclusion: The psychometric properties of the NB scale of A-ONE J were determined. The obtained unidimensionality of the NB scale items for Japanese people with CVA provides an opportunity for quantitative measurement of a wide
range of NBIs interfering with their ADL performance.
Keywords: activities of daily living, assessment, cerebral vascular accident, occupational therapy, outcome(Asian J Occup Ther 19: 30−37, 2023)

Introduction
One of the most common types of evaluation usedby occupational therapists to evaluate patients who have
had a cerebral vascular accident (CVA) is that of activities of daily living (ADL) [1–3]. In the ADL evaluation,
it would be of benefit to assess not only ADL perforReceived: 25 April 2022, Accepted: 28 September 2022
Corresponding to: Yasuhiro Higashi, Faculty of Health Sciences,Mori­nomiya University of Medical Sciences, 1-26-16, Nankokita,
Suminoe, Osaka, 559-8611, Japane-mail: yasuhiro_higashi@morinomiya-u.ac.jp©2023 Japanese Association of Occupational Therapists

mance, but also impairments, such as motor, sensory,
cognitive, and perceptual impairments that limit performance of the ADL. Evaluation of these impairments is
usually performed separately from ADL assessment [1].
However, deficit specific tests of neurological functions
and neuropsychological test batteries intended to evaluate presence of impairments do not reflect the impact of
the impairments on occupational performance such as
ADL performance. Further, such tests have been reported to present with low to moderate ecological validity[4]. Thus, the importance of assessing neurobehavioral
impairments (NBIs), which interfere with ADL performances in natural contexts, has gained support in the
rehabilitation literature [5].

Asian J Occup Ther 19: 30−37, 2023

The ADL-focused Occupation-based Neurobehavioral Evaluation (A-ONE) was the first instrument developed in the field of occupational therapy to assess theimpact of NBIs on occupational performances. It was
further the only assessment providing opportunity toevaluate a wide range of NBIs that interfere with ADL
performance in naturalistic contexts [6].
The A-ONE is an ADL instrument developed byan Icelandic occupational therapist, Guðrún Árnadóttir
in 1990 [1]. By administering this tool, occupational
therapists can identify the level of clients’ ADL ability
and NBIs that interfere with ADL performances throughnaturalistic ADL observation. When NBIs are identified
by use of the A-ONE, clinical reasoning and neurological knowledge are applied. The A-ONE comprises two
scales representing two different hypothetical constructs.
Both scales, i.e., the Functional Independence scale (FIscale) and the Neurobehavioral Impairment scale (NB
scale), were developed as criterion-referenced ordinalrating scales [1, 7, 8].
The original purpose of the A-ONE was not tomeasure the clients’ ability by using total scores, but to
set goals and plan interventions by using the descriptive
information obtained from the ordinal rating scales [1].
Ordinal scale scores cannot be used to generate total
scores as if they were measures based on interval scores[8, 9]. To avoid misuse of ordinal scores, Rasch analysis
based on modern measurement theory, has been usedin rehabilitation medicine to examine the propertiesof existing ordinal-level instruments and validate theirmeasurement potential. Application of Rasch analysis
thus provides a potential for converting the total score
to measures [10]. Consequently, Rasch analysis wasapplied in several studies to examine the potential forusing both the FI and the NB scales of the original
A-ONE as outcome measures. The results of thosestudies revealed that the ordinal scale scores of both FI[1, 8, 14] and NB scale items could be converted tovalid measures [1, 5, 11, 12]. Four of these publications
include reviews of the psychometric properties of the
NB scale of the A-ONE for persons diagnosed with
CVA. These include a CVA-NBI scale [1, 12], as well as
two additional scales, one for persons with RCVA andthe other persons with LCVA [1, 5, 11,].
Rasch analysis is used to estimate an individual’sability to assess the difficulty of items expressed in log
odds units (logits) on a single continuous scale. The
term unidimensionality refers to the concept that theitems included on the scale comprise a single construct.
Unidimensionality of items needs to be examined before
constructing a measure [10, 11]. It is also possible touse Rasch analysis to examine whether the hierarchicalorder of scale items represents sequential item difficulty

Higashi Y et al.

31

[10].
For validating the measurement potential of a scaleunidimensionality can be examined by different types ofanalyses. Goodness-of-fit analyses is used to evaluate fitof all people and items, to the Rasch model. It includes
evaluation of infit mean-square (MnSq), outfit MnSq,
as well as standardized z (Zstd) values, indicating
the degree of matching between actual and expected
responses [10]. Principal component analysis (PCA) of
Rasch based residuals is another type of possible analysis of unidimensionality used to examine the assumptionthat all data can be explained by the latent measure. Thisis different from PCA in classical test theory, which isa correlation model to identify factors in the scale [11,13].
Finally, in Rasch analysis the person and item
reliability need to be explored. The person reliability
index represents the reproducibility of the ordering of
the individual’s ability logit score if the same sample
of persons were given another set of parallel items.
The item reliability index shows the repeatability of theordering of items along a path when the items are given
to another sample of the same size that behaves in thesame way [10].
In Japan, the Japanese A-ONE study group translated the Japanese version of the A-ONE (A-ONE J) fromthe original A-ONE items and definitions, simultaneously addressing cultural differences [14]. This process
is described under Instrumentation. Subsequently, we
examined the psychometric properties of the FI scale of
the A-ONE J by using Rasch analysis [12]. However,
the NB scale of the A-ONE J has not yet been examinedby application of Rasch analysis. The purpose of thepresent study was thus to examine the psychometricproperties of the NB scale of the A-ONE J for people
with CVA and to confirm whether a total score can begenerated as an outcome measure for that diagnostic
group. An additional purpose was to qualitatively
compare the obtained Rasch indicators of the study toprevious results from the original Rasch analyses of the
NB scale of the A-ONE.

Methods
ParticipantsThis was a multicenter study conducted between
October 2015 and June 2019. The participants were recruited from nine different acute and rehabilitation hospitals in Japan to which the A-ONE-trained occupational
therapists belonged. Each participant or their familygave informed written consent before participating inthis study. The study was approved by the School ofComprehensive Rehabilitation Osaka Prefecture Univer­32

RASCH ANALISIS OF THE NEUROBEHAVIORAL IMPAIRMENT SCALE OF THE A-ONE J

Table 1 Demographic Information of Participants.

Age (years)
M
SD
Range
Sex
Male
FemaleDiagnosis
Infarction
Hemorrhage
Days after onset
M
SD
Range

ALL
(n = 185)

RCVA(n = 87)

LCVA(n = 76)

BCVA(n = 22)

71.8
12.5
39–96

72.2
12.6
41–96

71.9
12.8
39–93

69.8
11.6
46–87

116
69

58
29

44
32

14
8

110
75

54
33

42
34

14
8

77.3
55.4
2–298

80.1
58.9
2–298

68.5
49.8
4–215

96.5
56.1
25–187ALL = all participants; RCVA = participants with right cerebral vascular accident; LCVA = participants with left cerebral vascular accident;
BCVA= participants with bilateral cerebral vascular accident.

sity (approval number: 2016–209) as well as the Research Ethics Committees of each participating hospital.
Ten therapists and their attending physicians selected participants for inclusion based on (a) the presenceof cognitive or perceptual dysfunction as a result of
CVA, as revealed by a medical examination, and (b)the person’s medical readiness for an ADL evaluation.
Individuals who were not medically stable or not able toperform any ADL task were excluded.
The total number of participants who were selectedaccording to above criteria was 185. Eighty-seven werediagnosed with right CVA (RCVA), 76 with left CVA(LCVA), and 22 with bilateral CVA. The CVA resulted
from infarction in 110 participants and from hemorrhage
in 75. The mean time from the onset of stroke was 77.3
days. Detailed participant demographic information ispresented in Table 1. A sample size of at least 30 was
required in each diagnostic group for Rasch analysis,as this number would be sufficient to provide a 95%
confidence interval for the stability of the estimated itemdifficulty calibrations within an absolute value of 1.0
logit [11, 15, 16].
Instrumentation
The A-ONE is commonly used for adults that haveacquired central nervous system dysfunction. As noted
earlier, the A-ONE comprises two scales, the FI scale
and the NB scale. The FI scale consists of 20 ADL items
in four domains: dressing (D), grooming and hygiene(G), transfer and mobility (T), feeding (F) and two
communication (C) items. A rating scale with categories
ranging from 0 to 4 is used to score the observed levelof assistance needed. The NB scale is used to evaluate

the impact of NBIs that interfere with ADL task performance. It contains two subscales, the Neurobehavioral
Specific Impairment subscale (NBSIS) comprised of 46
rating scale items, with scores ranging from 0 to 4 (0 =absence of errors, 4 = maximum physical assistance toovercome errors), and the Neurobehavioral Pervasive
Impairment subscale (NBPIS), comprised of 31 dichotomous items. The NBSIS items are evaluated for each
ADL domain (e.g., D-motor apraxia, G-motor apraxia,
T-motor apraxia, F-motor apraxia). It is scored basedon the type of assistance required to overcome the performance errors (NBI) during ADL performance. The
NBPIS items are evaluated only once, based on errors
observed in at least one ADL task. The A-ONE manualcontains conceptual and operational definitions of all
items and detailed criteria for scoring. To use A-ONE inclinical practice and research, a five-day training course
where therapists practice clinical reasoning and differentiation of impairments is required. [5, 8, 11, 14]. Further
information on A-ONE training courses for occupational
therapists can be obtained from https://www.a-one.is/.
All the items of both the FI and NB Scales of the
A-ONE J had been translated to Japanese, as well as all
the conceptual and operational definitions of the neurobehavioral terms. The details of the translation process
were described in a previous study [14]. Two changes
were made to the FI scale of the original A-ONE to accommodate Japanese culture. The item “Wash face andupper body” was simplified to “Wash face and hands”
and the item “Use knife to cut and spread” was changed
to “Use chopsticks to manipulate and carry food.” As
the impact of NB items on the A-ONE is scored basedon task performance on the FI scale, this change may
potentially affect the NB scores in the grooming andhygiene domain as well as in the feeding domain. There
were no other item changes made from the original
A-ONE.
Procedures
At each hospital, the therapists who had completed
the 5-day A-ONE training course evaluated the participants according to the standardized procedure describedin the manual. The raw scores were analyzed using theWINSTEPS Rasch computer software program (Version
4.5.0) [17]. In line with the preceding Rasch studiesof the NB scale of the A-ONE [1, 5, 11], the five-level
rating scale of the NBSIS items was dichotomized prior
to data analysis such that 0 = absent and 1 to 4 = present.
Dichotomization was used so that all items would bescored consistent with the current scoring of the NBPIS
items. For item inclusion, we used 55 items which were
the same items as used for Rasch analysis in the previous studies [1, 5]. The 55 items are listed in Table 2.

Asian J Occup Ther 19: 30−37, 2023

Higashi Y et al.

participants into those with RCVA and those with LCVA
and analyzed these subgroups separately in accord withthe preceding study [5]. As noted before, for applying
Rasch analysis, at least 30 participants are required [11,15, 16], therefore, data for participants with bilateral
CVA were not analyzed, due to the small number ofparticipants in this group. For RCVA and LCVA we
examined, by the same methods as the first phase, thepsychometric properties using simple Rasch analyses.

Table 2 Retained Scale Items for the Rasch Analysis
Item
Motor apraxia
Ideational apraxia
Unilateral body neglect
Spatial relations
Unilateral spatial neglect
Motoric
Organization and sequencing
Perseveration
Topographical disorientation
Sensory aphasia
AnomiaParaphasia
Dysarthria
Expressive aphasia
Lability
ApathyDepression
Irritability
Frustration
Restlessness
Insight
Judgment
Confusion
Attention
Distraction
Initiative
Motivation
Performance Latency
Working memory
Confabulation
Number of items

D
D
D
D
D
D
D
D

G
G
G
G
G
G
G
G

T
T
T
T
T
T
T
T
T

F
F
F
F
F
F
F
F

C
C
C
C
C
C

33

P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P

55

Item domains: D = dressing, G = grooming and hygiene, T = transfersand mobility, F = feeding, C = communication. P = Pervasive scale
items.

We then proceeded to analyze the data using thesimple Rasch model for dichotomous data. The analysis progressed in two phases. In the first phase, we
examined the psychometric properties of a total CVA
scale including all the CVA participants. We examinedunidimensionality by means of goodness of fit andomitted items one at a time until all items demonstrated
acceptable goodness of fit. In accord with the precedingstudies [1, 5, 11], fit statistics of MnSq > 1.4 associatedwith Zstd > 2.0 were taken as an indication of an item
misfit. We decided to remove the items based on infit
MnSq and infit Zstd values. Infit statistics are an information-weighted indicator of misfit. Outfit statistics are
not weighted and are relatively sensitive to the impact ofout-of-range scores (individual performance away fromthe item’s location). Abnormal infit statistics usuallycause more concern than do large outfit statistics [10].
As in the previous study, we only used infit statistics inthe present study [14]. In the second phase, we divided

Data Analysis
Structural Validity and Reliability
Unidimensionality.
Unidimensionality was examined by goodness-offit analyses based on the Rasch model and PCA of Rasch
based residuals [13]. When applied to the NB scale of
the A-ONE J, in accord with the Rasch analysis of theoriginal NB scale of the A-ONE in the previous study[5, 11], the Rasch model was based on the following two
assertions. First, the more neurobehaviorally disableda participant is, the more profound errors (NBIs) will
be scored as present; second, errors that emerge withmild NBIs are more likely to be scored as present for allparticipants than are those that emerge only with severe
NBIs.
First, unidimensionality was examined by the
goodness-of-fit analyses with above mentioned criteria.
We also evaluated unidimensionality by means of PCAof Rasch based residuals by using the five-level quality
criteria described by Fisher [18], to determine whether
additional factors were likely to be present. According
to the criteria, the proportion of unexplained varianceaccounted for by the first contrast (the largest secondary
dimension) needs to be less than 15% to be classified as“fair” [18]. The variance explained by the measures ina PCA of Rasch based residuals has further been used
for evaluating unidimensionality in the past [18]. The
criterion for the proportion of the variance explained by
the measures was more than 50%. However, this criterion was revised because the variance explained by themeasures changes with the targeting of the items on the
persons. Thus, at present, there is no published set rangeof values useful for assessing scale functioning [18].
Therefore, in terms of PCA of Rasch based residuals,
we applied only the part of the criteria referring to the
proportion of unexplained variance accounted for by the
first contrast.
Reliability
Both person and item reliability were analyzed. The
relevant indicator is the reliability of these separationindexes, which indicates the degree of confidence in the
reproducibility of these estimates [10]. The value of the

34

RASCH ANALISIS OF THE NEUROBEHAVIORAL IMPAIRMENT SCALE OF THE A-ONE J

coefficient varies from 0 to 1 (a value greater than 0.8 isconsidered good and that greater than 0.9 is consideredvery good) [18].
Finally, the obtained values of psychometricproperties of the present study were compared with thefindings of the original Rasch analyses indicators of
the A-ONE NB scale. Several such analyses have been
performed, exploring both combined diagnostic samples(CVA and dementia) as well as subgroups of thosesamples [1, 5]. Qualitative comparisons with the A-ONE
NB scale were restricted to the CVA, RCVA and LCVA
scales. The comparisons took aim of Fishers [18] quality
criteria.

Results
Phase one: CVA scale
Unidimensionality
All the items of the CVA scale fitted the Raschmodel. This finding indicates that there were no misfit
items detected on the CVA scale. PCA of Rasch based
residuals revealed that 45.9% of the variance could be
explained by the Rasch dimension. Unexplained variance was 5.9%, which met the unidimensional criteria(Table 3). Item calibration values for all participants arepresented in Table 4.
Reliability
The person separation index was 2.31, and theperson reliability coefficient was 0.84. The item separation index was 6.03, and the item reliability coefficient
was 0.97.
Phase two: RCVA and LCVA scales
Unidimensionality
For RCVA, in the goodness-of-fit analysis, all theitems fitted the Rasch model. This finding indicates that
there were no misfit items detected on the RCVA scale.
PCA of Rasch based residuals revealed that 52.7% of
the variance could be explained by the Rasch dimension.
Unexplained variance was 7.1%, which met the unidimensional criteria (Table 3).
For LCVA, in the goodness-of-fit analysis, two items“Dysarthria” and “Paraphasia” did not fit the Raschmodel and therefore these items were omitted. Afteromitting these items, all the items of the LCVA scale
fitted the Rasch model. This finding indicates that there
were no misfit items detected on the LCVA scale. PCAof Rasch based residuals revealed that 50.9% of thevariance could be explained by the Rasch dimension.
Unexplained variance was 5.3%, and it satisfied the unidimensional criteria (Table 3). Item calibration values
for RCVA and LCVA hierarchies are presented in Table 4.

Table 3 Values of Principal Components Analysis (PCA)

PCA: Rasch factor
PCA: First contrast

ALL

RCVA

LCVA

45.9%
5.9%

52.7%
7.1%

50.9%
5.3%

ALL = all participants; RCVA = participants with right cerebral vascular accident; LCVA = participants with left cerebral vascular accident.

Reliability
For RCVA, the person separation index was 2.52,
and the target person reliability coefficient was 0.91. The
item separation index was 3.21, and the item reliability
coefficient was 0.91.
For LCVA, the person separation index was 2.38,
and the target person reliability coefficient was 0.91. The
item separation index was 3.19, and the item reliability
coefficient was 0.91.
Comparison with the original A-ONE results
The Rasch indicators resulting from this study of
the A-ONE J were compared with results from Raschanalyses of the original A-ONE. Before the qualitative
comparison of Rasch indicators, results from all thestudies were interpreted according to Fisher’s quality
criteria [18]. Table 5 summarizes comparisons of theresults for all three scales.

Discussion
In this study, we confirmed by use of Rasch analyses
the presence of unidimensionality for the NB scale of
the A-ONE J when evaluating persons with CVA. On the
A-ONE J CVA scale and RCVA scale all 55 items wereretained in the analysis, and all but two items formed
the 53 items LCVA scale. In other words, the NBIs thatinterfered with ADL performance can be arranged in aunidimensional hierarchy on the A-ONE J, finding that
had been obtained previously in Rasch analyses studiesof the original A-ONE [1, 5]. The reason for why theoriginal RCVA and LCVA scales have fewer items (51and 42 respectively) relates to use of more stringent
criteria in previous studies. This includes that no item
misfit was allowed resulting in item deletion. It also
applied to the variance explained by the measures (Rasch
factor < 60%) in the previous studies [5, 11], in accord
with accepted statistical rules of the time, as opposed touse of no value criteria for the Rasch factor in the present study, this being based on Fisher’s revised criteria[18]. The results of PCA of Rasch based residuals for the
CVA scale, as well as for the RCVA and LCVA scales of
the A-ONE J satisfied the unidimensional criteria.
We succeeded in constructing a valid and reliableAsian J Occup Ther 19: 30−37, 2023

Higashi Y et al.

35

Table 4 Item Difficulty of All Items for Three Scales
CVA scale

RCVA scale

LCVA scale

Item

Item
Difficulty

Item

Item
Difficulty

ApathyF-Perseveration
F-Unilateral body neglect
Confusion
F-Ideational apraxia
Lability
Frustration
Restlessness
Motivation
T-Ideational apraxia
T-Perseveration
C-Perseveration
Confabulation
Depression
Irritability
D-Ideational apraxia
Initiative
T-Motor apraxia
F-Spatial relations
Performance latency
F-Unilateral spatial neglect
C-Paraphasia
D-Unilateral spatial neglect
G-Perseveration
D-Perseveration
G-Unilateral spatial neglect
G-Ideational apraxia
G-Unilateral body neglect
G-Spatial relations
C-Broca aphasia
D-Unilateral body neglect
C-Anomia
T-Spatial relations
D-Motor apraxia
T-Unilateral spatial neglect
G-Motor apraxia
T-Unilateral body neglect
F-Motor apraxia
T-Topographical disorientation
F-Organization and sequencing
C-Sensory aphasia
Distraction
D-Spatial relations
Insight
C-Dysarthria
Attention
Working memory
T-Organization and sequencing
Judgment
G-Organization and sequencing
D-Organization and sequencing
F-Motoric
G-Motoric
D-Motoric
T-Motoric

3.12
2.70
2.40
2.42
1.97
1.82
1.80
1.80
1.80
1.65
1.65
1.65
1.65
1.52
1.40
1.01
1.01
0.93
0.85
0.85
0.77
0.77
0.70
0.57
0.51
0.51
0.39
0.39
0.18
0.18
0.08
0.08
0.03
−0.15
−0.15
−0.32
−0.32
−0.32
−0.36
−0.40
−0.47
−0.62
−0.99
−1.18
−1.33
−1.60
−1.66
−2.10
−2.45
−2.83
−3.06
−4.00
−4.67
−4.81
−5.33

D-Ideational apraxia
T-Ideational apraxia
F-Ideational apraxia
C-Paraphasia
C-Perseveration
ApathyT-Motor apraxia
F-Perseveration
C-Broca aphasia
Restlessness
G-Ideational apraxia
Frustration
Confusion
Confabulation
F-Unilateral body neglect
Lability
Irritability
T-Perseveration
C-Anomia
Depression
Motivation
G-Perseveration
G-Motor apraxia
F-Motor apraxia
C-Sensory aphasia
Initiative
Performance latency
D-Motor apraxia
D-Perseveration
T-Topographical disorientation
F-Spatial relations
F-Unilateral spatial neglect
D-Unilateral spatial neglect
F-Organization and sequencing
Distraction
G-Unilateral body neglect
G-Spatial relations
G-Unilateral spatial neglect
D-Unilateral body neglect
T-Spatial relations
Insight
Working memory
T-Unilateral body neglect
T-Unilateral spatial neglect
C-Dysarthria
T-Organization and sequencing
Attention
Judgment
D-Spatial relations
G-Organization and sequencing
D-Organization and sequencing
F-Motoric
D-Motoric
G-Motoric
T-Motoric

4.61
4.61
4.61
4.61
4.61
4.61
3.38
3.38
2.65
2.65
2.21
2.21
2.21
2.21
1.88
1.88
1.88
1.62
1.62
1.62
1.62
1.41
1.22
1.22
1.05
1.05
0.90
0.76
0.76
0.76
0.39
0.08
−0.01
−0.01
−0.11
−0.28
−0.36
−0.36
−0.53
0.60
−0.90
−1.12
−1.19
−1.19
−1.19
−1.73
−1.73
−2.20
−2.33
−2.68
−2.98
−4.73
−5.23
−5.45
−5.71

Item

Item
Difficulty

G-Unilateral spatial neglect
F-Unilateral body neglect
ApathyD-Unilateral spatial neglect
F-Unilateral spatial neglect
Confusion
G-Unilateral body neglect
T-Spatial relations
T-Unilateral spatial neglect
T-Perseveration
F-Spatial relations
F-Perseveration
Lability
Frustration
Motivation
G-Spatial relations
Confabulation
Depression
Irritability
Restlessness
Initiative
D-Unilateral body neglect
D-Spatial relations
T-Unilateral body neglect
F-Ideational apraxia
Performance latency
T-Ideational apraxia
C-Perseveration
D-Perseveration
D-Ideational apraxia
G-Perseveration
T-Motor apraxia
G-Ideational apraxia
F-Organization and sequencing
C-Anomia
D-Motor apraxia
T-Topographical disorientation
C-Broca aphasia
Distraction
F-Motor apraxia
G-Motor apraxia
C-Sensory aphasia
Insight
Attention
Working memory
T-Organization and sequencing
Judgment
G-Organization and sequencing
D-Organization and sequencing
F-Motoric
G-Motoric
D-Motoric
T-Motoric

4.21
4.21
4.21
2.96
2.96
2.96
2.20
2.20
2.20
2.20
2.20
2.20
2.20
2.20
2.20
1.74
1.74
1.40
1.40
1.40
1.40
1.13
1.13
1.13
1.13
1.13
0.70
0.52
0.36
0.07
0.07
−0.06
−0.50
−0.50
−0.79
−0.97
−1.05
−1.05
−1.05
−1.14
−1.30
−1.46
−1.46
−1.46
−2.12
−2.42
−2.72
−2.95
−3.28
−3.93
−4.52
−4.82
−5.61

Note: High positive scores refer to that the item is rarely seen impacting performance, and low negative scores refer to that performance errors/
items are observed impacting performance more frequently.

36

RASCH ANALISIS OF THE NEUROBEHAVIORAL IMPAIRMENT SCALE OF THE A-ONE J

Table 5 Comparison of the psychometric properties of the A-ONE J NB scales and the original A-ONE NB scales
CVA Scale

Persons (n)Items (i)Number of categories
Item model fit MnSq
PCA: Rasch factor
PCA: First contrast
Person separation index
R (persons)
Item separation index
R (items)

RCVA Scale

LCVA Scale

A-ONE J

A-ONE

A-ONE J

A-ONE

A-ONE J

A-ONE

185
55
2
≤ 1.4
45.9%
5.9%
2.31
0.84
6.03
0.97

215
53
2
≤ 1.4
79.2%
1.7%
2.20
0.83
6.93
0.98

87
55
2
≤ 1.4
52.7%
7.1%
2.52
0.91
3.21
0.91

108
51
2
≤ 1.4
89.7%
1.6%
2.57
0.87
4.98
0.96

76
53
2
≤ 1.4
50.9%
5.3%
2.38
0.91
3.19
0.91

114
42
2
≤ 1.4
91.1%
1.3%
1.94
0.79
4.43
0.95

Criteria

Comparison of results
A-ONE J/A-ONE

30
–
–
–
–
< 15%
>2
> 0.8
>2
> 0.8

Less than A-ONE
almost same
samevery good/very good*
Less than A-ONE
Good/Excellent*
Fair/Fair ∙ Poor*
Good/Good ∙ Fair*
Very Good/Very Good*
Excellent/Excellent**Interpretation based on Fisher’s quality criteria.
Note: Comparison of psychometric qualities of Rasch analyzed versions of the Neurobehavioral Scale on the A-ONE J and the original A-ONE.

A-ONE J CVA scale meeting the previously set criteria.
From a research perspective, the CVA scale could be
useful for making comparisons between subgroups of
CVA clients [5, 12]. However, the PCA (Rasch factor)
for the A-ONE J CVA scale was less than for either the
RCVA or LCVA scales. The wider the spread of thepersons and items, the higher the Rasch factor becomes[19]. Thus, as the CVA scale has the narrowest spreadof the three A-ONE J NB scales, it can be expected tobe less precise than both the RCVA and LCVA scales.
Therefore, depending on the purpose of measuring,when measuring change in impact of NBIs on ADL task
performance over time, using either the RCVA or the
LCVA subscales may turn out to be a more precise alternative than the CVA scale. The CVA scale on the other
hand is useful when comparing performance of RCVA
and LCVA persons.
Regarding the hierarchy, for all three A-ONE J NB
scales, the logit value of the item labeled “Motoric”
referring to impaired motor function was the lowest
value on the hierarchy; thus, performance errors related
to diminished motor function were the most likely errors
to be detected during the ADL task performance. The
participants in this study were diagnosed with CVA andhospitalized in acute and rehabilitation hospitals. Thisfinding of impaired motor function such as paralyses
is thus not surprising and consistent with the literature
where impaired motor function has been identified as
one of the most frequently detected impairment limiting
ADL performance [20]. This finding is also consistent
with results from previous studies of the NB scale of
the A-ONE for the stroke population [1]. Subsequently,
the right hemisphere functions such as unilateral spatial
neglect and spatial relations were frequently apparent
on the RCVA scale, and the frequency of items related
to left hemisphere function such as ideational apraxia

and aphasia was low. For the LCVA scale, motor andideational apraxia as well as language impairments werecommonly detected as opposed to neglect items thatwere very unlikely to be detected. These results werereasonable considering the characteristics of right andleft hemisphere function [12].
For an overall analysis of the participants, we analyzed the data of 185 individuals; however, when weanalyzed the RCVA and LCVA separately, the data wasdivided into 87 RCVA and 76 LCVA cases. Although
the minimum sample size criterion was satisfactory,
more stable results would be obtained by analyzing 150
participants for each of the RCVA and LCVA scales toobtain 99% confidence interval for estimated item difficulty calibrations remaining within the absolute valueof 0.5 logit [15, 16]. Thus, it would be desirable to raise
the number of participants in future studies.
Limitations and future considerations
Our right and left CVA samples were < 100 persons
in each group. To obtain more stable results 150 participants are required [16, 17]. We therefore plan to enlarge
the sample size to 150 participants and reanalyze thedata including analyses of differential item functioning
between RCVA and LCVA in future studies.
As pointed out in the previous study [5], the
A-ONE and A-ONE J include only ADL tasks. Thus,
the findings of this study cannot be generalized to theperformance of other tasks, such as IADL, without further investigations. The original A-ONE was intended to
be used for clients with different types of neurologicaldiagnoses including, for example, dementia and headtrauma in addition to CVA. In this study of the A-ONE J,
the sample only included people with CVA as opposed
to studies of the original A-ONE that also include analysis of performance of people with dementia. Therefore,

Asian J Occup Ther 19: 30−37, 2023

our recommendation for future studies is to include
more diverse diagnostic categories in the analyses of the
A-ONE J.
Finally, in this study, we chose to dichotomize all
items in accord with the previous study [5]. However,
the original NBSIS scale is a five-category rating scale,and this procedure may have reduced the separation of
the participants. We further plan to explore the use thepartial credit Rasch model with the five-category rating
scale in future studies and compare the results withresults from the dichotomous analysis.

Conclusion
In this study, we demonstrated that the NB scale ofthe translated A-ONE J can be used as an outcome measure. We converted the NB rating scale into a dichotomous scale and subsequently developed three separate
scales, a 55 item RCVA scale and 53 item LCVA scale
as well as a 55 item CVA scale. By using these Raschanalyzed NB scales of the A-ONE J, we confirmed thefindings of earlier A-ONE studies regarding the possibility of quantitatively measuring the changes in a wide
range of NBIs that interfere with ADL task performance.

Acknowledgements
We would like to thank the clients who participatedas research participants for their valuable contribution
to this study. We would also like to acknowledge the occupational therapists that used the A-ONE J to evaluate
their clients. The study was supported by grants fromthe Japanese Association of Occupational Therapists in2016.

References[1] Árnadóttir G. Measuring the impact of body functions
on occupational performance: Validation of the ADLfocused Occupation-based Neurobehavioral Evaluation(A-ONE). Doctoral dissertation, Umeå University, Sweden.
Medical Dissertations, New Series No. 1322; 2010.
[2] Gillen G. Cerebrovascular accident/stroke. In: Pendleton
HM, Schultz-Krohn W, editors. Pedretti’s Occupational
Therapy: Practice Skills for Physical Dysfunction. 7th ed.
St. Louis, MO: Mosby Elsevier; 2013. p. 844–80.
[3] Steultjens EM, Dekker J, Bouter LM, van de Nes JCM,
Cup EHC, van den Ende CH. Occupational therapy forstroke patients: a systematic review. Stroke. 2003; 34:
676–87.
[4] Chaytor N, Schmitter-Edgecombe M. The ecologicalvalidity of neuropsychological tests: a review of the literature on everyday cognitive skills. Neuropscyhol Rev.

Higashi Y et al.

37

2003; 13: 181–97.
[5] Árnadóttir G, Löfgren B, Fisher AG. Neurobehavioral
functions evaluated in naturalistic contexts: Rasch analysis of the A-ONE Neurobehavioral Impact Scale. Scand J
Occup Ther. 2012; 19: 439–49.
[6] Gillen G. A fork in the road: an occupational hazard? Am
J Occup Ther. 2013; 67: 641–52.
[7] Árnadóttir G. Impact of neurobehavioral deficits on activities of daily living. In: Gillen G & Nilsen DM, editors.
Stroke Rehabilitation: A Function-Based Approach, 5thed. St Louis, MO: Elsevier; 2021. p.556–92.
[8] Árnadóttir G, Fisher AG. Rasch analysis of the ADL scaleof the A-ONE. Am J Occup Ther. 2008; 62: 51–60.
[9] Merbitz C, Morris J, Grip JC. Ordinal scales and foundations of misinference. Arch Phys Med Rehabil. 1989; 70:
308–12.
[10] Bond TG, Yan Z, Heene M. Applying the Rasch model:
Fundamental measurement in the human sciences. 4th ed.
New York; Routledge; 2021.
[11] Árnadóttir G, Fisher AG, Löfgren B. Dimensionality ofnonmotor neurobehavioral impairments when observedin the natural contexts of ADL task performance. Neuro­
rehabil Neural Repair. 2009; 23: 579–86.
[12] Árnadóttir G, Löfgren B, Fisher A. Difference in impact
of neurobehavioral dysfunction on activities of dailyliving performance between right and left hemispherestroke. J Rehabil Med. 2010; 42: 903–7.
[13] Linacre JM. Detecting Multidimensionality: Which
residual data-type works best? J Outcome Meas. 1998; 2:
266–83.
[14] Higashi Y, Takabatake S, Matsubara A, Nishikawa J,
Shigeta H, Árnadóttir G. Reliability and Validity of theJapanese version of the ADL-focused Occupation-based
Neurobehavioral Evaluation (A-ONE J): Applying Rasch
Analysis Methods. Hong Kong J Occup Ther. 2019; 32:
32–40.
[15] Linacre JM. A User’s Guide to WINSTEPS MINISTEP
Rasch model computer programs: Program manual 4.5.3.
2020.
[16] Linacre JM. Sample size and item calibration stability.
Rasch Measurement Transactions. 1994; 7: 328.
[17] Linacre JM. Winsteps (Version 4.5.0) [Computer software]. Chicago, IL: Winsteps.com.; 2020.
[18] Fisher WPJ. Rating scale instrument quality criteria.
Rasch Measurement Transactions. 2007; 21: 1095 (Revised February 1, 2018, p.1095).
[19] Linacre JM. Variance in Data Explained by Rasch Measures. Rasch Measurement Transactions. 2008; 22(1):1164.
[20] Nilsen DM, Gillen G, Geller D, Hreha K, Osei E, Saleem
GT. Effectiveness of interventions to improve occupational performance of people with motor impairments
after stroke: an evidence-based review. Am J Occup Ther.
2015; 69(1): 1–9.

■ORIGINAL ARTICLE

Experiences of Male Stroke Survivors
with Higher Brain Dysfunction after Discharge
from a Rehabilitation Hospital:
A Qualitative Study 6 Months after Hospital Discharge
Fumio Sakimoto1, 2, Mizuho Fujiwara3
1

Kobe Rehabilitation Hospital, Rehabilitation Section
Graduate School of Rehabilitation, Kobe Gakuin University
3
Faculty of Rehabilitation, Kobe Gakuin University
2

Abstract: Background: Stroke survivors face various problems after discharge from rehabilitation hospitals. This
study aimed to clarify the post-discharge experiences of male stroke survivors with attention deficits, a form of higher
brain dysfunction.
Methods: The subjects of this study were three male stroke survivors who were discharged from a convalescent rehabilitation ward and their spouses. Semi-structured interviews were conducted 1, 3, and 6 months after discharge. Data
were qualitatively analyzed using Trajectory Equifinality Modeling to depict the post-discharge pathways experienced
by stroke survivors.
Results: The Obligatory Passage Points of post-discharge pathways experienced by stroke survivors were as follows:
feeling “difference” in daily life, becoming aware of higher brain dysfunction through interaction with others, and becoming able to “organize my thoughts” through an occupation and interacting with others. In addition, the Bifurcation
Points were “increased occupation away from the wife” and “occupation with the wife continues,” and the Equifinality
Point was “select occupation autonomously.”
Conclusion: Although the stroke patients were suspected of being attention deficit during the evaluation that performed
during their hospitalization, they were unaware of it during their hospitalization and immediately after discharge. However, the stroke survivors became aware of their higher brain dysfunction through interactions with others other thantheir wives, and their insight into their disability increased as they participated in occupations. These results suggest theimportance of including occupations that challenge stroke survivors and in which others, besides the wife, participate in
the occupational therapy program.
Keywords: stroke, higher brain dysfunction, qualitative study, Trajectory Equifinality Modeling(Asian J Occup Ther 19: 38−45, 2023)

Introduction
Stroke is a disease that causes a variety of changes
and losses due to acquired functional impairment [1].
The Japanese Ministry of Health, Labour and Welfare
has defined “higher brain dysfunction” as a disorder that
limits daily life and social activities due to cognitive
Received: 11 November 2021, Accepted: 12 November 2022
Corresponding to: Sakimoto Fumio, Kobe Rehabilitation Hospital,
Rehabilitation Section, 1-18, Shiawase-no-mura, Kita-ku, Kobe-shi,
Hyogo 651-1106, Japane-mail: fumio.s0713@gmail.com©2023 Japanese Association of Occupational Therapists

dysfunction caused by organic brain pathology [2].
Higher brain dysfunction includes aphasia, apraxia,
memory impairment, executive dysfunction, attention
deficits, and psychomotor impairment [3]. Among these,
attention deficits appear in 46%–92% of patients after
acute stroke [4]. They are difficult to recognize, and such
“hidden” symptoms may be misinterpreted by others as
laziness [5]. A previous study reported that the discomfort patients felt, such as the feeling that their home “didnot feel like home” after discharge from the hospital,
may also be an effect of attention deficits [6]. Therefore,
patients with attention deficits may experience difficulties after discharge from the hospital, even if they
are independent in Activity of Daily Living (ADL) inAsian J Occup Ther 19: 38−45, 2023

the controlled hospitalization environment. In addition,family members may be confused and find it challenging
to accept attention deficits and higher brain dysfunctionthat appear in daily life [7].
Therefore, it is crucial to clarify the experiences ofstroke survivors with attention deficits after discharge
from hospital such as how they start living at home andhow they adjust to life at home. It has been reported thatstroke survivors with attention and memory impairments
struggled with anxiety in their daily lives one year after
stroke onset, and leisure activities were necessary forcoping with anxiety [5, 8]. However, these reports werecross-sectional surveys conducted one year after the
onset. Longitudinal studies on how patients experienceanxiety immediately after hospital discharge are necessary.
The present longitudinal study aimed to investigate
how stroke survivors with attention deficits experience
life after hospital discharge. We believe the findings will
help provide post-discharge support and discharge guidance during hospitalization in rehabilitation hospitals.

Methods
Methodology
To describe the experiences of stroke survivors,
we used Trajectory Equifinality Modeling (TEM) tovisualize their experiences [9, 10]. TEM is a qualitative
research methodology developed by Sato et al. that
depicts the path of actions and choices experienced
by people over time. Arrows indicate the flow of timeas “Irreversible Time,” characterized by the setting ofimportant “points” in drawing the path of experience.
The “Obligatory Passage Point (OPP)” is the point thatmost people are expected to experience action or choice,and the “Bifurcation Point (BFP)” is the point where
the paths of each individual diverge due to the selectionof different values in the flow of time. The point of
convergence under the influence of various contexts isthe “Equifinality Point (EFP),” and the point of value
conflict with the EFP or not experienced is the “Polarized
EFP (P-EFP). The “virtual path” is depicted as a theoretically possible path that has not occurred, allowing fora richer understanding of the diversity and complexityof experience. “Social Guidance (SG)” refers to thesurrounding support and forces that promote individual
choice and action toward EFP. In contrast, “Social
Direction (SD)” refers to the restraining forces fromthe surroundings that inhibit individual choice and leadaway from EFP.
ParticipantsParticipants in this study were stroke survivors

Sakimoto F et al.

39with attention deficits who were discharged home froma convalescent rehabilitation ward and their primary
caregivers. In the present study, we included primary
caregivers as participants to obtain a multidimensionalview of the living conditions of stroke survivors [12].
To focus primarily on the impact of attention deficits on
their lives, we required that participants were independent in ADLs during hospitalization. The inclusion criteria for stroke survivors were: (1) first stroke, (2) a scoreof 21 or higher on the revised Hasegawa Disability Test
(HDS-R) at the time of discharge, (3) below the cutoff
for each age group on the Trail Making Test (either partA or part B), (4) a score of 5 or higher on the motor itemof the Functional Independence Measure at discharge, (5)no aphasia or apraxia and no communication problems,and (6) stroke survivors living with their spouse after
hospital discharge. The inclusion criteria for the primary
caregiver were: (1) spouse of a stroke survivor and (2)no communication problems.
Five stroke survivors and their spouses were included using these criteria; however, due to the spreadof COVID-19, two subjects withdrew, and three were
ultimately eligible. All participants were male stroke
survivors. The Kobe Gakuin University Research Ethics
Review Committee approved this study (No. 19–16).
Data collection
Information at the time of admission was collectedfrom the therapist in charge. Interviews were conductedat home, where the research participants talked to thepatient three times (one, three, and six months after
discharge). A semi-structured interview guide was set
up, and the participants were asked to freely talk about:(a) difficulties in their current life, (b) what they were
doing well after discharge, and (c) how the rehabilitation
at the hospital had been helpful. In response to abstract
answers, we tried to deepen the content by asking
follow-up questions such as “When did you experience
that?” or “Why do you think so?”. The interviewer was
the first author. The interviewer mainly interviewed thestroke survivors. Their wives were also interviewed
for supplementary information. The Barthel Index (BI)was used to assess the progression of ADLs in stroke
survivors. Stroke patients responded to 10 items of basic
ADLs on a scale consisting of “independent”, “partiallyassisted”, and “fully assisted”. The Frenchay Activities
Index (FAI) was used to assess Instrumental Activityof Daily Living (IADL). Respondents were asked toindicate the frequency of performing 15 items related
to applied daily tasks and social life on a 4-point scalefrom 0 to 3. The total scores ranged from 0 (inactive) to45 (active) [13]. The data collection period was between
January 2019 and December 2020.

40

EXPERIENCES OF STROKE SURVIVORS WITH HIGHER BRAIN DYSFUNCTION

Table 1 Participant characteristics and data collection
Stroke Survivors

Mr. A

Mr. B

Mr. C

Diagnosis
Age
Employed at time of stroke (Contents of work)
First interview time after onset
HDS-R
TMT-J A/B
FIM
Motor/Cognitive
BI1
1 month
3 months
6 months
FAI1
1 month
3 months
6 months

CH, left hemiplegia
40s
Yes (Automobile selling)
4 months
29
139 sec/190 sec
90/35
100
100
100
24
26
27

CI, left hemiplegia
50s
Yes (Electrical construction)
4 months
26
116 sec/Not feasible
88/31
95
95
95
3
3
5

CI, left hemiplegia
70s
No
5 months
29
70 sec/131 sec
90/35
100
100
100
22
18
33

40s
full-time

50s
part-time

70s
homemaker

Wife
Age
Work

CI: Cerebral infarction; CH: Cerebral hemorrhage; TMT-J: Trail Making Test, Japanese edition; FIM: Functional Independence Measure.
Maximum scores: HDS-R: Hasegawa dementia rating scale-revised = 30; BI: Barthel Index = 100; FAI: Frenchay Activities Index = 45.
1
After the interview, the interviewer evaluated the stroke survivors according to the evaluation table.

Data analysis
A verbatim transcript was created from all interview data. The verbatim transcripts were imported
into MAXQDA Analytics Pro 2020 for management
and analysis. They were divided into semantic clusters
and assigned a heading. Headed content clusters werecompared and categorized based on similarities andrelationships to create categories [14]. The categories
were repeatedly modified using the MAXQDA tree
structure. TEM diagrams were created at the end of eachinterview, and they were checked with the participants atthe beginning of the next interview to ensure the accuracy of the results. After the second interview, the sameprocedure was used to create another TEM diagram,and the second TEM diagram was added to the TEM
diagram obtained in the first interview. After the third interview, the same procedure was followed to complete a
set of TEM diagrams. The sets of TEM diagrams of thethree patients were then laid out, and the characteristics
and commonalities of each path were used to generate
OPP and BFP. The first author first prepared the TEM
diagrams, and then the possible theoretical paths andconcepts were entered into the TEM diagrams with theco-authors. The interview data were checked whenevera question arose.

Results
Characteristics of the participants, ADLs, andIADLs are shown in Table 1. The three stroke survivors
received occupational therapy during their hospitalization, which included functional restoration training andinstruction on how to cope with attention deficits in ADL
situations. After discharge from the hospital, all threeparticipants were almost independent in ADLs. Mr. B
had not been performing household chores since before
the onset of the disease, and his FAI was low. The following is a description of the post-discharge process ofthe three participants based on the TEM diagram (Fig. 1).
Mr. A’s post-discharge process (total interview time 185
minutes)He had a strong desire to return to work before hisdischarge from the hospital. He continued outpatient
rehabilitation to recover his physical function after
discharge. In his post-discharge life, he felt “differences”
from his pre-disease life such as “it used to take me one
or two minutes to change my clothes, but now it takes
me five minutes” (OPP). As he discussed his return towork with his workplace supervisor and occupational
physician, his anxiety grew because of the ambiguity of
his work hours and the fact that he could not obtain permission to commute to work by private car (SD). Thisanxiety came to him as “waves”.
Three months after discharge from the hospital,
he returned to work but was too occupied to perform
his duties. At work, he found that he was “confused”
when his coworkers “said this and that” to him (OPP).
Despite this confusion, he became accustomed to his job
and accumulated daily tasks. He hoped to return to his
old life in about one year. He also enjoyed coaching his
youth baseball team, which he had been doing before his
illness. However, when the team’s coaches asked him
to prioritize taking care of his body, he decided to quit

Return to work

A "wave" of anxiety

Enjoy time with wife and friends

Select occupation autonomously

diagram

Attend daytime rehabilitation

Resumption of tennis

EFP

Select occupation autonomously:Social Direction: Category-based experience

Point

OPP

:Social Guidance: Obligatory Passage Pointin daily life

Falling for the first time

BFP
Increased occupation away from wife

Select occupation autonomously: Virtual Path

P-EFP Limited in ability to take autonomous actions

EFP

Make the most of his failure: Bifurcation Point

SG

SG
Wife worries less

OPP Becoming able to "organize my thoughts" throughoccupation and interacting with others

Time with grandchildren becomes a pleasure

Coronavirus makes hobbies impossible

Time with grandchildren becomes "talking" and "brain exercise"

OPP Becoming aware of higher brain dysfunction
through interaction with others

Frustrated that grandchildren do not understand the story

Teaches his grandchildren to study

Resume rehabilitation as taught in the hospital

Feel difficulty in speaking

OPP

Completing rehabilitation

BFP
Occupation with wife continues

BFP

TEM diagram
Returning home from convalescent rehabilitation hospital: Pathways derived from data

Fig. 1. TEM diagram of three people showing the route after discharge.

: Polarized Equifinality Point

P-EFP: Equfinality Point

SG

SG

BFP
Increased occupation away from wife

P-EFP Limited in ability to take autonomous actions

BFP
Occupation with wife continues

OPP Becoming able to "organize my thoughts" throughoccupation and interacting with others

More chances to interact with tennis coaches and coworkers

Wife will stop him

Tells wife that he is going to tennis

Bored with day rehabilitation

OPP Becoming aware of higher brain dysfunction
through interaction with others

Feeling anxious about not being able to talk well with co-workers

SD
Restrictions imposed by
wife

OPP
Restricted from going out alone

Returning home from convalescent rehabilitation hospitalCompleting rehabilitation

EFP

P-EFP Limited in ability to take autonomous actions

EFP

Take reasonable action

BFP
Increased occupation away from wife

More work is entrusted to the patient

OPP Becoming able to "organize my thoughts" throughoccupation and interacting with others

Lose his hobby

Quit his hobby

Ability to control the pace of work

OPP Becoming aware of higher brain dysfunction
through interaction with others

BFP
Occupation with wife continues

6 months

OPP

Continue outpatient rehabilitation

Discuss with the company about returning to workSD
Consultation with Supervisor

3 months

TEM diagram

Returning home from convalescent rehabilitation hospitalCompleting rehabilitation

1 monthAsian J Occup Ther 19: 38−45, 2023
Sakimoto F et al.
41

42

EXPERIENCES OF STROKE SURVIVORS WITH HIGHER BRAIN DYSFUNCTION

coaching. The loss of his role led him to take a trip withhis wife and try boat fishing with his friends, which hesaid he wanted to do before he became ill again. At thistime, he said, “I had more time to relax.”
Six months after discharge from the hospital, he
could “think of all the priorities in my head” at work
(OPP). He said: “Even if I have something to do in
between, I will also think about that.” He was gradually
entrusted with more and more work at his workplaceand became involved with many other people, and theamount of occupation he did away from his wife increased (BFP). By this time, he had come to feel that hedid not have to force himself to work, saying, “I thinkthat I can quit my job anytime I want, and that makes
me feel better.” Rather than viewing his stroke experience pessimistically, he seemed to be choosing to takepart in occupation autonomously (EFP) while accepting
his condition. Through these experiences, he reached
EFP.
Mr. B’s post-discharge process (total interview time 156
minutes)
One month after discharge from the hospital, hesaid that he sometimes “gets stuck in his thoughts,” but“nothing is troubling me.” However, as the interview
continued, he said, “When I went to the bathroom, myleft shoulder hit the wall a little” (OPP). Moreover, hiswife had restricted him from going out because it was
dangerous for him to do so alone (SD).
Three months after being discharged from thehospital, he began attending day-care rehabilitation on
his wife’s advice (SG). He also noticed higher brain dysfunction (OPP) due to his experience of not being able
to talk well with his co-workers and had vague concerns
about whether he would be able to return to work.
Six months after discharge from the hospital, hebecame bored with the repetition at the day rehabilitation center (BFP). His only opportunities to go out were
to attend rehabilitation and take walks with his wife.
He became frustrated with these restrictions as well.
He suddenly told his wife, “I’m going to play tennis
tomorrow” (BFP). His wife was surprised, but she
made a reservation at her old tennis club and resumed
playing tennis (SG). Looking back on that time, hiswife said, “I had told him not to because I was afraid,
but I felt that for my husband’s sake, I could not justforbid him to play.” Around this time, he began to havemore opportunities to talk with his friends who came tosee him at home, his colleagues at work, and his tennis
school coach. Through these relationships with others
besides his wife, he could “organize my thoughts” andwas no longer troubled by conversations (OPP). He alsobegan to do more occupation away from his wife (BFP).

During tennis practice, he used the metaphor of a ballflying from the left side as an invisible “magic ball” andsaid, “I don’t force myself to return a ball that I can’t
catch up with. I give up.” Despite previously saying
he had no trouble, the patient gradually understood his
condition and took action (EFP). Through these experiences, he reached EFP.
Mr. C’s post-discharge process (total interview time 166
minutes)During his hospitalization, his therapist pointed
out that he was at risk of falling due to poor balance;
however, he did not understand why. Therefore, his wife
accompanied him on his walks after he was discharged
from the hospital and reminded him to take a rest fromtime to time (SG). After being discharged from thehospital, he experienced difficulty encountering people
suddenly during a walk and difficulty speaking withhis wife. These experiences that he did not experienceduring his hospitalization made him “different” in how
he viewed and communicated his illness (OPP). This
led him to resume the rehabilitation he had been taught
at the hospital. Furthermore, he resumed teaching his
grandchildren who lived nearby how to study, which hehad been doing for some time.
Three months after leaving the hospital, he foundhimself feeling “frustrated” (OPP) because he had
difficulty communicating with his grandchildren. On
the other hand, he also noticed that time with his grandchildren was an exercise in talking and “mental gymnastics.” During this next period, because he could not go
to his hobby of karaoke due to COVID-19 restrictions(SD), he looked forward to spending time with his
grandchildren, saying, “teaching my grandchildren how
to study is also good practice for my speech.”Six months after discharge, he was more relaxedin his daily life and “able to think and prioritize one
thing while doing another” (OPP). Gradually, he began
to walk by himself more often (BFP), and his wife felt
comfortable letting him go out as long as he was closeby (SG). When he went shopping alone at a local supermarket, he fell for the first time since being discharged
from the hospital. However, he laughed as he recounted
the incident and calmly analyzed the reason for his fall.
Since then, he has been going out alone without anotherfall. He could analyze and act on his fall, which was an
unexpected failure. The experience of being away fromhis wife allowed him to think about actions and choicesthat would lead to future successes (EFP).

Asian J Occup Ther 19: 38−45, 2023

Discussion
Post-discharge experience of male stroke survivors withattention deficits
Yasuda et al. reported that in an analysis of four ±one subjects, “diversity of experience is drawn” using
TEM [11]. Diversity is the breadth of experience, and by
drawing the paths of multiple people using TEM, we cansee the diversity of paths among the patients and capture
overlaps and common paths and points [11]. From ourfindings, we believe that our report was able to depict a
small amount of post-discharge diversity in male stroke
survivors with attention deficits. In this study, based on
the post-discharge experience of male stroke survivors
with attention deficits in a rehabilitation hospital, three
OPP of passage were identified: feeling “difference” indaily life, becoming aware of higher brain dysfunction
through interaction with others, and becoming able to“organize my thoughts” through occupation and interacting with others. Furthermore, “increased occupation
away from the wife” and “occupation with the wife continued” were identified as BFP, and “select occupation
autonomously” as EFP.
Feeling “difference” in daily life
In previous longitudinal studies after stroke, it
has been reported that mild stroke survivors encountered “differences” from before [1, 6]. It has also beenreported that stroke survivors with impaired attention
and memory may differ from others’ evaluations of
their abilities and experience increased sensitivity andunpredictability to environmental conditions [5, 8]. The
participants in this study commonly experienced that amonth after discharge from the hospital as an OPP, theyrealized that they were “different” from before and thatthey could no longer do things the same way they hadlearned to do during their hospitalization.
Becoming aware of higher brain dysfunction throughinteraction with others
Experiences of “confusion (A),” “anxiety (B),”and “frustration (C)” in interactions with others wereperceived to be the effects of higher brain dysfunction.
Crosson et al. reported that there is a hierarchy ofawareness in higher brain dysfunction, with intellectual
awareness (basic knowledge of brain injury and its
effects) at the bottom, and emergent awareness (theability to recognize when a problem is occurring) andanticipatory awareness (the ability to anticipate the possibility of a problem occurring) at higher levels [15]. It
is possible that the stroke survivors’ intellectual and experiential awareness was enhanced by their involvementwith others. In addition, creating “planned failures” has

Sakimoto F et al.

43

been recommended to promote such awareness [16].
However, Richardson reported that family members
do not always point out a patient’s errors because they
do not want to hurt the person’s feelings, and patients
often do not accept these points [17]. This suggests thatoccupational therapists should design planned “failures”
from the time of hospitalization and that reflecting onthese failures with the stroke survivor promotes awareness. Furthermore, after discharge from the hospital,
it is important to accumulate new experiences throughinteractions with familiar others. The three stroke survivors were also prompted to have “awareness” of theirinteractions with others other than their wives after discharge from the hospital, suggesting that, similar to theprevious literature, attention deficits may be less likely
to surface in habitual daily life.
Becoming able to “organize my thoughts” throughoccupation and interacting with others
The stroke survivors resumed specific occupations
around three months after discharge, which included
a new occupation for one patient (A: boat fishing withfriends), and occupations that the participants had previously performed for two patients (B: tennis as a hobby,
C: teaching his grandchildren how to study). A systematic review of the literature on the role of occupationof head trauma patients indicates that participation in
occupation enhances insight into awareness of disability,
and continued participation in occupation may not only
enhance one’s awareness but may also contribute toimproved occupation capacity [18]. These experiencesof interacting with others and engaging in an occupation
were thought to have led to “organizing my thoughts,”
in which information was summarized, things were prioritized, and reflection took place.
Increased occupation away from the wife, occupation
with the wife continues, select occupation autonomously,
limited in ability to take autonomous action
In the present study, the BI and FAI of stroke survivors did not change significantly during the six months
studied. However, from the interview analysis, we could
capture a path of experience that BI and FAI could not
capture. A cross-sectional study of community-based
stroke patients reported that TMT assessment correlatedwith ADLs and IADLs, but recommended a combinationof pen-and-paper and performance-based assessments
for more accurate assessment [19]. This suggests that inaddition to the various assessments, it is also important
to consider qualitative analysis that focuses on the experiences of the parties involved.
After discharge from the hospital, the three OPP
led to a BFP of increased occupation away from their

44

EXPERIENCES OF STROKE SURVIVORS WITH HIGHER BRAIN DYSFUNCTION

wives/continued occupation with their wives. In otherwords, the stroke survivors’ experiences after discharge
from the hospital may be viewed as a re-establishmentof the relationship with their spouse. With this BFP, allthree participants in this study increased their occupation away from their wives and their opportunities for
self-selection, leading to EFP. Autonomy includes executional autonomy, in which one can act as one wishes,and decisional autonomy, in which one can make decisions without being constrained by external factors [20].
However, as Mr. B’s wife said, if her husband was restrained by her, such as her telling him, “No, I’m afraid”
or “It’s prohibited,” and he “continued occupation withthe wife,” there is a possibility that he would be “limited
in ability to take autonomous action.” By assuming thisP-EFP, we could show the importance of supporting not
only the autonomy of the stroke survivors but also theprocess of transformation by the primary caregiver andthe patient.
Support for stroke survivors with attention deficits andtheir primary caregivers
We found that the subjects in this study experienced
the same OPP simultaneously in different and diverse
experiences. This can contribute to support for stroke
survivors and primary caregivers. For example, after
repeated practice in the same environment during hospitalization, the participants may be able to experiencesome of the “differences” expected after discharge
from the hospital by performing tasks that incorporate“planned failures” in an environment similar to real-lifesituations. It has been reported that the effectiveness oferrorless learning or trial-and-error learning for stroke
survivors with higher brain dysfunction may depend on
the nature of the task [21]. An important issue is whatbalance of “planned failure” to incorporate. In addition,around six months after discharge from the hospital,
the patients could “organize my thoughts” and makeself-selections through interactions with others close
to them. The hypothetical pathway the three pairs did
not go through this time was the pathway of continued
behavioral restrictions from the wife to avoid danger orthe stroke patient’s inability to act independently fromhis wife, leading to P-EFP. All three wives were happy
to have time to work on occupation. Mr. A tried to takeit easy when he was alone, and Mr. C reflected on his
fall and prepared for the next one. We believe that risk
management and self-monitoring skills for dangerous
environments that may be encountered as the occupation
expands are important occupational therapy supports
during this period.

Limitations of study
The first limitation of this study is the small numberof study participants. Three pairs of male stroke survivors and their wives were included in the study, whichis the minimum number to portray a diversity of experiences. A previous study reported that nine ± two people
are needed to ascertain the typology of pathways [11];thus, future research should be conducted with a larger
sample size. Second, future studies are needed to compare the results with female stroke survivors because thestroke patients in the present study were all male. Third,
the present study could not assess unilateral spatial
neglect (USN) other than attention deficits in detail.
Although marked USN was not suspected at the time of
the interview, it can be inferred from Mr. B’s narrative,
such as his left shoulder hitting the wall, that he may
have had symptoms of USN. A further detailed evaluation is needed.

Conclusions
This study qualitatively analyzed the life experiences of male stroke survivors with attention deficits froma rehabilitation hospital in the first six months after discharge using TEM. Attention deficits, which stroke survivors were largely unaware of during hospitalization,
became apparent in activities involving interpersonal
interaction immediately after discharge. The stroke survivors became aware of their higher brain dysfunction
through interactions with others other than their wives.
Each participant gained deeper insight into their disorderthrough participation in occupation. These results suggest the importance of involving others besides the wife
through daily tasks in occupational therapy programs forstroke survivors.

References[1] Salter K, Hellings C, Foley N, Teasell R. The experienceof living with stroke: a qualitative meta-synthesis. J Rehabil Med. 2008; 40(8): 595–602.
[2] Hiraoka T. Interpretations and applications of the term,“higher brain dysfunction”. Jpn J Compr Rehabil Sci.
2021; 12: 1–3.
[3] Hachisuka K, Kato N, Iwanaga M, Okazaki T. Incidenceof higher brain dysfunction in Japan (in Japanese). Higher
Brain Function Research. 2011; 31(2): 143–50.
[4] Stapleton T, Ashburn A, Stack E. A pilot study of attention deficits, balance control and falls in the subacutestage following stroke. Clin Rehabil. 2001; 15(4): 437–
44.
[5] Carlsson GE, Moller A, Blomstrand C. A qualitative
study of the consequences of ‘hidden dysfunctions’ one

Asian J Occup Ther 19: 38−45, 2023

year after a mild stroke in person < 75 years. Disabil
Rehabil. 2004; 26(23): 1373–80.
[6] Sakimoto F, Fujiwara M. The process by which a clientwith attention disturbance has come to feel “Familiarity”
with the life after discharge home- Analyzing with
Trajectory Equifinality Modeling (TEM) (in Japanese).
Community Based Rehabilitation. 2018; 13(8): 638–48.
[7] Onose T, Suzuki T, Onaka K, Suzuki K, Yamamoto Y.
Support of families with higher-order brain dysfunction:
Changing how family members identify disabilities (inJapanese). JOTR. 2019; 38(4): 396–404.
[8] Carlsson GE, Moller A, Blomstrand C. Managing an everyday life of uncertainty – A qualitative study of copingin person with mild stroke. Disabil Rehabil. 2009; 31(10):773–82.
[9] Sato T, Hidaka T, Fukuda M. Depicting the dynamics
of living the life: the trajectory equifinality model. In:
Valsiner J, Molenaar P, Lyra M, Chaudhary N, editors.
Dynamic process methodology in the social and developmental sciences. New York: Springer; 2009; 217–40.
[10] Arai S, Fukase Y, Okii A, Suzukamo Y, Suga T. Selection
process for botulinum toxin injections in patients withchronic-stage hemiplegic stroke: a qualitative study. BMC
Med Inform Decis Mak. 2019; 19(1): 280.
[11] Yasuda Y, Nameda A, Fukuda M, Sato T. TEA theoreticalsection: Learn the basics of the Trajectory Equifinality
Approach (in Japanese). Tokyo: Shin–yo–sya; 2015.
[12] Cai Y, Towne SD Jr., Bickel CS. Multi-Level Factors
Associated with Social Participation among Stroke Survivors: China’s Health and Retirement Longitudinal Study(2011–2015). Int J Environ Res Public Health. 2019;16(24): 5121.

Sakimoto F et al.

45[13] Shiratsuchi M, Saeki S, Hachisuka K. Japanese version of
the self-rating Frenchay Activities Index and its clinicalapplication and standard values (in Japanese). General
Rehabilitation. 1999; 27(5): 469–74.
[14] Nochi M. Studies in clinical psychology 6: Qualitative
research methods (in Japanese). Tokyo: University ofTokyo Press; 2011; 250–61.
[15] Crosson B, Barco PP, Velozo CA, Bolesta MM, CooperPV, et al. Awareness and compensation in postacute head
injury rehabilitation. J Head Trauma Rehabil. 1989; 4(3):46–54.
[16] Fleming JM, Ownsworth T. A review of awareness interventions in brain injury rehabilitation. Neuropsychol
Rehabil. 2006; 16(4): 474–500.
[17] Richardson C, McKay A, Ponsford JL. Dose feedback
influence awareness following traumatic brain injury?.
Neuropsychol Rehabil. 2015; 25(2): 233–53.
[18] Klepo I, Sangster Jokić C, Tršinski D. The role of occupational participation for people with traumatic brain
injury: a systematic review of the literature. Disabil
Rehabil. 2022; 44(13): 2988–3001.
[19] Lipskaya-Velikovsky L, Zeilig G, Weingarden H, RozentalIluz C, Rand D. Executive functioning and daily living ofindividuals with chronic stroke: measurement and implications. Int J Rehabil Res. 2018; 41(2): 122–7.
[20] Cardol M, Jong BA De, Ward CD. On autonomy and participation in rehabilitation. Disabil Rehabil. 2002; 24(18):970–4.
[21] Mount J, Pierce SR, Parker J, DiEgdio R, Woessner R, etal. Trial and error versus errorless learning of functional
skills in patients with acute stroke. NeuroRehabilitation.
2007; 22(2): 123–32.

■ORIGINAL ARTICLE

Cross-Regional Validation of the Assessmentof Positive Occupation 15:
Differential Item and Test Functioning Analysis
Takuya Noguchi1, Makoto Kyougoku2, Mutsumi Teraoka2
1
2

Zikei Hospital, Occupational Therapy Section
Department of Occupational Therapy, School of Health Sciences, Kibi International University

Abstract: Aims: This study aimed to validate the Assessment of Positive Occupation 15 (APO-15) by differential item
functioning (DIF) and differential test functioning (DTF).
Method: Participants were to obtain research cooperation from individual clinics, community healthcare institutions,and home-visit rehabilitation services. The inclusion criteria for participants were people between the ages of 20 and 90
years who were diagnosed with mental illness, physical illness, or geriatric illness and agreed to participate in the study.
In this study, the face sheet and APO-15 were distributed to the participants, and they were asked to respond.
Results: A total of 3003 participants were included in this study. The mean age was 67.41 (±16.63) years (≥ 75; 1168
and ≤ 74; 1835). Regarding the gender of participants, 1565 were males and 1438 were females. Considering illness,1184 participants had a mental illness, 897 had a physical illness, and 922 had a geriatric illness. The results of the DIF
and DTF suggested that the APO-15 did not differ in the response pattern of the scale due to the influence of subgroups(illness, gender, and age).
Conclusion: The APO-15 suggests the potential to provide measurement results with a good level of scale validity androbustness.
Keywords: well-being, occupational participation, evaluation scale, validity, occupational engagement(Asian J Occup Ther 19: 46−54, 2023)

Introduction
The occupational therapy field has emphasized theimportance of promoting well-being through meaningful occupation for clients [1, 2]. Several self-reportassessments have been developed to evaluate the relationship between occupation and well-being, including
the Canadian Occupational Performance Measure andOccupational Self-Assessment [3, 4]. By using theseevaluations in the occupational therapy process, occupational therapy practitioners and researchers can identify
meaningful occupations for clients, develop occupationbased intervention plans, and enhance the well-being
Received: 14 June 2022, Accepted: 3 December 2022
Corresponding to: Takuya Noguchi, Zikei Hospital, Occupational
Therapy Section, 100-2, Urayasuhonmachi, Okayama city, Okayama
702-8026, Japane-mail: n.takuya19780822@gmail.com©2023 Japanese Association of Occupational Therapistsof clients. However, an occupation that enhances wellbeing includes participation in an occupation that ismeaningful to the individual client and designed to improve or maintain well-being [5, 6]. Thus, occupational
therapists need to be able to assess participation in an
occupation related to the development, management,
and maintenance of well-being in daily activities [7].
Well-being is defined as the perceived state ofharmony in all aspects of one’s life [1]. Dodge et al.
(2012) [8] also define it as the balance point between
an individual’s resource pool (psychological, social,
and physical) and the challenges faced (psychological,
social, and physical). Therefore, well-being, as usedin this study, is defined as a state of balance with thechallenges faced in a good physical, mental, and social
state, with or without illness. Furthermore, well-being
is an important outcome according to the fourth editionof the Occupational Therapy Practice Framework:
Domain and Process (OTPF-4), which establishes acommon understanding of occupational therapy [9]. The

Asian J Occup Ther 19: 46−54, 2023

OTPF-4 was developed to articulate the core conceptsof occupational therapy and proposes the categories ofoccupations, including work, play, leisure, activities
of daily living, instrumental activities of daily living,education, social participation, health management, rest,and sleep [9]. The OTPF-4 also suggests interventions
to enhance well-being, including occupations, activities,
interventions to support occupations, education, andtraining [9]. The OTPF-4 emphasizes the role of occupational therapy in achieving the outcome of well-being
through these occupations. However, in the occupational
therapy field, self-report assessments are focused on
assessing meaningful occupations for individual clientsin occupation-focused assessments. Therefore, the occupational therapy field needs to develop a scale that canmeasure participation in occupations that are designed
to improve or maintain human well-being.
To contribute to the above challenges, we havedeveloped the Assessment of Positive Occupation 15(APO-15) to measure participation in occupations that
promote human well-being [10–12]. The theoreticalbackground of the APO-15 is the PERMA model inpositive psychology. The PERMA model is a theory
attempting to understand the state of well-being inindividuals based on five domains: P (positive emotion),E (engagement), R (relationship), M (meaning), andA (achievement) [13]. The APO-15 is unique in thatit uses occupations that promote well-being as scale
items based on the findings of positive psychology. The
APO-15 was examined for scale characteristics based on
statistical evidence, validity [exploratory factor analysis,
confirmatory factor analysis, and hypothesis testing(convergent validity, discriminant validity, and criterion
validity)], reliability [internal consistency reliability anditem response theory (IRT)], and interpretability [receiver operating characteristic and latent rank theory].
The APO-15 can be used in the areas of mental illness,
physical illness, and geriatric illness [10–12].
In previous studies, differential item functioning(DIF) has been reported in occupation-related assessments used in occupational therapy, and cultural differences have been reported to be influential in causing this
[14–17]. Culture is the integrated pattern of human behavior that includes thoughts, communications, actions,customs, beliefs, values, and institutions of a racial,ethnic, religious, or social group [18]. Additionally, factors that affect DIF are not only culture but also gender,
age, and illness [14–17]. Because of the above factors,
it is expected that the APO-15 will also allow DIF anddifferential test functioning (DTF), but this has not beenverified. If DIF is found, it threatens validity because thescale may be measuring something different from theconstruct it is trying to measure. Methods for detecting

Noguchi T et al.

47

DIF can be broadly classified into those based on IRT
and those that are not [19]. Representative methods notbased on IRT include the Mantel-Haentszel [20] andlogistic methods [21]. On the other hand, representative
methods based on IRT include the Lord method [22], theRaju method [23], and the likelihood ratio test method[24]. In the detection of DIF, the choice between the two
methods is determined by the sample size. The method
based on IRT is superior to the method not based on IRT
in the interpretation of results because it detects DIF
with high test power, but it requires a large sample size[19]. In addition, the one-dimensionality of the scalemust be assumed when using IRT-based methods. Someof the measures that confirm one-dimensionality are, forexample, confirmatory factor analysis, local independence, latent monotonicity, and polynomial correlation
coefficients [25–28]. It is also important to check for
DTF as well as DIF. DTF is important because it isbased on the performance of the entire test, not just individual items [29, 30]. However, the APO-15 at this stage
has not been translated into English, for example, so thatit can be used by people from different cultures. Therefore, we first need to examine measurement invariancein Japanese clients to see if there are any differences intheir tendency to respond to the constructs measured by
the APO-15. Thus, this study aims to clarify whether
the response pattern of APO-15 is affected by subgroups(illness, gender, and age) and clarify the validity of thescale by examining the DIF and DTF. More specifically,
we aim to contribute to the validation of the usefulnessof the APO-15 by answering the following researchquestions:
1. Do the APO-15 item difficulty calibrations differ insubgroups (illness, gender, and age)?
2. Does it affect the quality of the APO-15 measurement
results (i.e., is there evidence of DTF)?

Methods
Ethics statement
This study was approved by the Ethical Review
Committee of Zikei Hospital No.124 (29-2). This study
was conducted by explaining the outline of the study
at the conference and recruiting cooperating facilities.
Those facilities that agreed to cooperate in the study
were asked to introduce other cooperating facilities bypurposive selection so that research cooperation could
be obtained from many participants. Both written andverbal informed consent was provided by all participants
before participation. Participation was voluntary, andparticipants had the right to withdraw from the researchat any time without providing any reason. The study
period was from May 2017 to August 2020. This study

48

CROSS-REGIONAL VALIDATION OF THE APO-15

was conducted in accordance with the Declaration of
Helsinki.
Participants and procedures
In this study, data were collected from individuals
who were diagnosed by doctors as having a mental
illness, physical illness, or geriatric illness (e.g., angina
pectoris, arteriosclerosis obliterates, hypertension, diabetes, renal insufficiency, cancer) and who use hospitals,
institutions, and home-visit rehabilitation services.
The selection criteria included (1) those who had been
diagnosed with the above-mentioned illnesses, (2) those
who were between 20 and 90 years of age, and (3) those
who agreed to participate in this study. The exclusion
criteria included (1) those who were having an unstable
medical condition and those who were judged by thedoctor or facility manager as impossible to cooperateand (2) those who did not agree with this study. For the
recruitment of the subjects, posters showing the outlineof the study were displayed in the hall and other easily
visible places, and subjects were asked to participate of
their free will. Also, subjects who expressed interest in
the study were individually presented, a guide describing the study’s content was reviewed with them, andtheir consent was obtained. The research assistants wereregistered, occupational therapists.

Measures
Demographic information
Demographic information, including age, gender,
and living environment, was collected. The researchcollaborator wrote the participant’s name of a diagnosis
and level of care on the survey form.
APO-15The APO-15 is a self-report assessment of occupational participation to promote well-being (Table 1). The
APO-15 is a 15-item measure of the state of positive
occupational participation based on four factors, namely,
positive relationship (5 items), achievement (4 items),
meaning (3 items), and engagement (3 items). Positive relationship is defined as deriving happiness andsatisfaction from human relationships. Achievement isdefined as an attempt to complete a target in life. Meaning is defined as significance found in activities and life.
Engagement is defined as the flow experienced and theprocess leading to it. The APO-15 assesses 15 items on
a 4-point Likert scale (1 = disagree and 4 = agree). High
total scores are related to a higher degree of well-being
through positive occupational participation [10–12].

Table 1 15 items of APO
1. I have the motivation to fulfill my hope
2. I have a goal that I want to achieve
3. I’m currently making efforts to achieve my goal
4. I can communicate well with people and work with them toachieve my goals
5. I can make an effort to achieve my long-term goals rather thanmy momentary profits
6. I feel supported by the people surrounding me
7. I can concentrate on my favorite activities
8. I live my life the to the fullest
9. I live my life according to my values
10. When I come across people who are in trouble, I want to help
them immediately
11. I feel fulfilled when we can help each other with the people
around me
12. I’m making an effort to be able to concentrate
13. I can concentrate on my hobbies
14. I always try to see the bright side of things
15. I take an active role in making decisions that shape my life
Note. The four factors of the APO-15 are positive relationship (items= 4, 6, 10, 11, 14), achievement (items = 1, 2, 3, 5), meaning (items =8, 9, 15), and engagement (items = 7, 12, 13).

Statistical analysis
We conducted analyses to examine the validity ofthe scale in the APO-15 to (1) confirmation of one-dimensionality and (2) detect DIF and DTF based on IRT.
Sample characteristics
Regarding the age of the participants, the mean andstandard deviation were calculated. Also, frequencies
and percentages were calculated for participants’ gender,
illness, diagnosis, living environment, and care level. The
statistical software used was HAD 16 (http://norimune.
net/had).
Confirmation of one-dimensionality
In this study, we checked whether APO-15 meets theconditions for IRT-based DIF detection. IRT measuresa single latent variable. Therefore, we checked whether
the APO-15 met the conditions for one-dimensionality
using confirmatory factor analysis (CFA), local independence, latent monotonicity, and polynomial correlation
coefficient of item scores.
1) Structural validity
The one-factor solution of APO-15 was determinedby performing CFA using a weighted least squares
estimation with mean and variance (WLSMV), withmissing data. WLSMV is suitable for the analysis of categorical data. We used three indices to assess the model
fits of CFA based on APO-15 factor structures. The firstindex was the root mean square error of approximation(RMSEA), with critical values of 0.08–0.10, indicating

Asian J Occup Ther 19: 46−54, 2023

a mediocre fit, and those of < 0.08 indicated a good fit[31]. The second and third indices were the comparative
fit index (CFI) and the Tucker-Lewis index (TLI), withcritical values above 0.95 [32]. The statistical software
lavaan 0.6–9 in R 3.2.3 (https://www.r-project.org).
2) Local independence
Local independence was estimated using Yen’s Q3statistic. Yen’s Q3 statistic is the correlation between theresiduals of categorical factor analysis. The judgment of
the results is that the assumption of local independence
is satisfied if the absolute value is less than 0.36 [33].
The statistical software mirt 1.34 in R 3.2.3.
3) Latent monotonicity
Latent monotonicity refers to a situation in which
items are in a monotonic relationship with the construct,and each response category has the largest probability of
selection on a unique interval. That is, we check to see
if a situation is established in which people with higher
characteristic values choose higher alternatives thanpeople with lower values. In this study, we used manifest
monotonicity to check latent monotonicity by mokken
scaling analysis (MSA), a one-model of nonparametric
IRT [34]. The judgment of MSA is that if the H coefficient is large and the rejection rate of the assumptionof latent monotonicity is low, it indicates manifest
monotonicity. The criterion values for the H coefficientare judged to be > 0.3 [weak], > 0.4 [medium], and > 0.5[strong] [34]. The statistical software mokken 3.0.6 in R
3.2.3.
4) The polynomial correlation coefficient of item scores
Polynomial correlation coefficients of item scores
determined that the scale was unidimensional if thecriterion value was 0.2 or higher [28]. The statisticalsoftware used was Exametrika 5.3 (http://antlers.rd.dnc.
ac.jp/~shojima/exmk/index.htm).
DIF and DTF detection
The COnsensus-based Standards for the selectionof health Measurement INstruments (COSMIN) considers DIF as one of the validity studies [35]. In this study,
the DIF detection based on IRT was performed using thestatistical software EasyDIF (http://irtanalysis.main.jp)[36]. EasyDIF can be used for IRT parameter estimation
with a graphical user interface so that users can use it
without feeling the barrier of complicated analysis [36].
EasyDIF calculates the index K through the detectionof DIF based on IRT [36]. Index K is the area of theregion between the two sets (maximum and minimum)of item expectation category characteristic functions
in multi­level data, weighted by the overall population

Noguchi T et al.

49

distribution [36]. It represents the expected value of thedifference in response patterns among subpopulations
for each item. The criterion value for index K is as follows: (number of categories –1) × 0.1. Items exceeding
this value are considered DIF items [36]. The index Kshows a very high correlation with the conventionallyused DIF detection methods, confirming the results as areliable index [36].
In this study, the data collected by the APO-15 wereanalyzed for the detection of DIF based on IRT by dividing the data into three subgroups: illness (three pairs:
mental illness, physical illness, or geriatric illness),
gender (two pairs: male or female), and age (two pairs:≥ 75 or ≤ 74). The reason why the age group is divided
into 75 years old is that many people consider 75 years
old or older to be elderly according to the survey by the
Cabinet Office [37]. The APO-15 used in this study is
divided into four categories, so if the index K is ≥ 0.3,
it is considered a DIF item. In the detection of DIF
based on IRT, it is difficult to obtain stable results unlessthe sample size is large [19]. Therefore, the sample
size of the two groups combined should be > 500, andthe sample size of the group with a smaller number ofpeople should be > 100 [38]. The statistical software
lordif 0.3–3 in R 3.2.3 was used to plot the DTF fromthe aggregated APO-15 total scores.

Results
Sample characteristics
Participants lived in seven of the eight Japaneseregional categories. A total of 3003 participants were
included in this study. The overall age was 67.41 ±16.63 years: age ≥ 75; 1168 (38.89%) and age ≤ 74;
1835 (61.11%) (Table 2). As regards the gender ofthe participants, 1565 (52.11%) were males and 1438
(47.89%) were females. The participants were classified
by illness: mental illness 1184 (39.43%), physical illness
897 (29.87%), and geriatric illness 922 (30.70%). In thisstudy, the number of participants met the sample size
required for the detection of DIF in all subgroups (illness,gender, and age). The other results are shown in Table 2.
Confirmation of one-dimensionality
1) Structural validity
The CFA of the one-factor solution in APO-15
provided a good estimate of the goodness of fit of themodel (RMSEA = 0.063; CFI = 0.971; TLI = 0.966).
2) Local independence
The local independence of APO-15 met the criterion with Yen’s Q3 statistic ranging from −0.222 to 0.360.

50

CROSS-REGIONAL VALIDATION OF THE APO-15

Table 2 Participant Characteristics (n = 3003)
Characteristics

Mean (±SD)

Total (%)

Age

Overall≥ 75≤ 74

67.41 (±16.63)

GenderMale
Female63.39 (±16.01)
71.84 (±16.17)

1565 (52.11%)
1438 (47.89%)

Illness

Mental illness
Physical illness
Geriatric illness

55.28 (±14.61)
66.94 (±12.22)
83.57 ( ±5.50)

1184 (39.43%)
897 (29.87%)
922 (30.70%)

Diagnostics

Mental
Cerebral nerve
Orthopedic
Internal
Neurology
Other1224 (40.76%)
698 (23.24%)
670 (22.31%)
167 ( 5.56%)
166 ( 5.53%)
78 ( 2.60%)

Care level

No certification
Support 1
Support 2
Care 1
Care 2Care 3Care 4Care 51396 (46.47%)
251 ( 8.36%)
312 (10.39%)
336 (11.19%)
426 (14.19%)
175 ( 5.83%)
81 ( 2.70%)
26 ( 0.87%)

Living environment

Single life
Living together with family
Hospital & Facilities

509 (16.95%)
1635 (54.45%)859 (28.60%)

1168 (38.89%)
1835 (61.11%)

Note. SD = Standard Deviation
By most common diagnoses; Mental (schizophrenia, mood disorder, pervasive developmental disorder), Cerebral nerve (cerebrovascular disease, cerebral contusion, subdural hematoma, spinocerebellar degeneration), Orthopedic (fracture, spinal canal stenosis, deformed knee joint), Internal(hypertension, diabetes, renal insufficiency, interstitial pneumonia, respiratory insufficiency, cancer),
Neurology (myasthenia gravis, multiple sclerosis, Guillain-Barre syndrome), Other (rheumatism,hyperthyroidism, scleroderma, heart failure, angina pectoris, arteriosclerosis obliterates)

3) Latent monotonicity
The H coefficients of the APO-15 showed manifest
monotonicity of > 0.3 for 3 items (item = 6, 10, 13)[weak], and > 0.4 for all other items [medium]. In addition, the proportion rejecting the assumption of latentmonotonicity was 0.000 for all items. In other words, allitems of the APO-15 were confirmed to be latent monotonicity.
4) The polynomial correlation coefficient of item scores
The one-dimensionality of the APO-15 was confirmed by the item score polyserial correlation coefficient, which showed that all items were > 0.2 (0.581 to
0.755). In other words, the APO-15 was shown to satisfy
the condition of one-dimensionality.
DIF detection
The analysis showed that the APO-15 had no DIF
items from the influence of subgroups (illness, gender,

and age) in all items. Regarding illness, the results
showed that all items of the APO-15 were item discrimination (mean: mental illness = 1.003, physical illness= 1.110, and geriatric illness = 1.052), item difficulty(mean: mental illness = −2.012 to 0.759, physical illness = −2.016 to 0.777, and geriatric illness = −1.963
to 0.831), and index K (0.066 to 0.290). There was nodifference in the response patterns by illness (Table 3).
Gender showed item discrimination (mean: male =1.069 and female = 0.963), item difficulty (mean: male= −2.183 to 0.716 and female = −2.069 to 0.665), andindex K (0.018 to 0.198) for all items of the APO-15.
There was no difference in response patterns by gender(Table 4). Age showed item discrimination (mean: age ≥75 = 1.026 and age ≤ 74 = 0.995), item difficulty (mean:age ≥ 75 = −2.072 to 0.750 and age ≤ 74 = −2.149
to 0.726), and index K (0.045 to 0.291) for all itemsof the APO-15. There was no difference in response
patterns by gender (Table 4). These results suggest that

Asian J Occup Ther 19: 46−54, 2023

Noguchi T et al.

51

Table 3 DIF detection (illness)
Item

K

item 1item 2
item 3
item 4
item 5
item 6
item 7
item 8
item 9item 10item 11
item 12
item 13
item 14
item 15
Mean

Mental illness

Physical illness

Geriatric illness

slope

step1

step2

step3

slope

step1

step2

step3

slope

step1

step2

step3

.127
.290
.154
.160
.066
.220
.243
.155
.132
.146
.096
.118
.226
.206
.144

1.183
.944
1.132
.905
1.174
.731
.977
1.083
1.352
.715
.855
1.130
.855
.908
1.103

−1.525−1.767−1.679−1.736−1.788−2.734−2.350−2.101−1.740−2.760−2.563−1.710−2.000−1.871−1.853

−.402
−.689
−.640
−.376
−.427
−1.528−1.182−.969−.626−1.080−1.238
−.562
−.785
−.182
−.526

.944
.545
.744
1.297
1.080
.316
.193
.392
.681
.898
.492
.757
.601
1.481
.961

1.215
1.008
1.280
1.068
1.380
.765
.974
1.371
1.397
.878
1.053
1.157
.785
1.170
1.149

−1.637−1.738−1.725−1.790−1.657−3.333−2.510−2.043−1.932−2.486−2.363−1.648−1.809−1.690−1.877

−.536
−.691
−.718
−.614
−.477
−2.243−1.102
−.904
−.603
−.925
−1.102
−.428
−.422
−.284
−.505

1.001
.669
.672
.964
.996
−.144
.435
.384
.819
.901
.656
.971
.999
1.232
1.096

1.111
.801
1.065
1.097
1.339
.728
1.023
1.158
1.202
.967
1.217
1.138
.806
1.046
1.075

−1.582−1.567−1.556−1.706−1.526−3.321−1.739−2.619−2.190−2.206−2.115−1.545−1.525−2.069−2.184

−.386
−.300
−.544
−.567
−.401
−2.066−.729−1.276
−.890
−.991
−.956
−.387
−.441
−.495
−.823

1.307
1.181
.939
.931
1.028
−.150
.592
.207
.647
.491
.487
.960
.930
1.039
.892

.166

1.003

−2.012

−.747

.759

1.110

−2.016

−.770

.777

1.052

−1.963

−.750

.831

Note. slope = item discrimination, step = item difficulty, K = index K
The results of the analysis showed that the index K of all items of APO-15 was below the standard value (> 0.3) by illness.
Table 4 DIF detection (gender and age)
Item

K

item 1item 2
item 3
item 4
item 5
item 6
item 7
item 8
item 9item 10item 11
item 12
item 13
item 14
item 15

male

female

slope

step1

step2

step3

slope

step1

step2

step3

.158
.198
.104
.114
.018
.167
.096
.109
.034
.164
.143
.088
.169
.065
.034

1.329
1.099
1.292
.977
1.318
.705
1.009
1.207
1.364
.774
.937
1.148
.817
.978
1.078

−1.652−1.810−1.697−1.836−1.885−3.261−2.477−2.283−2.032−2.759−2.608−1.869−2.214−2.155−2.203

−.583
−.746
−.740
−.532
−.532
−1.867−1.240−1.070−.778−1.041−1.179
−.659
−.827
−.392
−.729

.798
.503
.587
1.137
.974
.224
.268
.354
.594
.929
.646
.779
.669
1.337
.945

1.009
.707
.968
.988
1.177
.763
.878
1.039
1.204
.804
.983
1.071
.758
1.014
1.087

−1.711−1.896−1.897−1.927−1.708−2.962−2.206−2.486−1.994−2.684−2.506−1.668−1.680−1.806−1.901

−.464
−.613
−.761
−.713
−.551
−2.051−1.046−1.330−.821−1.332−1.388
−.485
−.531
−.423
−.675

1.245
.916
.839
.874
.972
−.352
.337
.109
.691
.450
.256
.839
.837
1.071
.885

Mean

.111

1.069

−2.183

−.861

.716

.963

−2.069

−.879

.665

Item

K

item 1item 2
item 3
item 4
item 5
item 6
item 7
item 8
item 9item 10item 11
item 12
item 13
item 14
item 15
Mean

Age ≥ 75age ≤ 74

slope

step1

step2

step3

slope

step1

step2

step3

.130
.291
.091
.070
.045
.069
.228
.141
.105
.098
.045
.069
.173
.199
.130

1.134
.837
1.088
1.015
1.277
.711
1.044
1.092
1.236
.807
1.063
1.134
.821
1.059
1.065

−1.617−1.656−1.711−1.795−1.701−3.213−1.952−2.630−2.180−2.689−2.433−1.624−1.688−2.047−2.147

−.440
−.470
−.670
−.626
−.534
−2.052−.862−1.323−.892−1.196−1.148
−.487
−.510
−.512
−.843

1.211
.986
.846
1.000
.985
−.076
.511
.215
.651
.641
.492
.885
.902
1.081
.915

1.189
1.020
1.165
.925
1.180
.752
.874
1.158
1.311
.761
.838
1.055
.735
.889
1.066

−1.670−1.929−1.781−1.884−1.890−2.962−2.763−2.094−1.848−2.680−2.640−1.924−2.269−1.928−1.978

−.547
−.842
−.739
−.484
−.459
−1.742−1.434−.941−.627−1.018−1.303
−.608
−.858
−.175
−.479

.824
.397
.622
1.149
1.077
.091
.116
.390
.731
.892
.541
.828
.646
1.553
1.033

.126

1.026

−2.072

−.838

.750

.995

−2.149

−.817

.726

Note. slope = item discrimination, step = item difficulty, K = index K
The results of the analysis showed that the index K of all items of APO-15 was below the standard value (> 0.3) bygender and age.

52

CROSS-REGIONAL VALIDATION OF THE APO-15

Fig. 1. DTF of APO-15.
Note. θ = latent ability level, TCC = Test Characteristic Curve
Test characteristic curves for all items of the APO-15 are shown for the subgroup (by illness, gender, and age). APO-15 is its
focus on the level of participation in positive occupation. 0 more of the clients having a positive value is determined to be able
to participate in the positive occupation. On the other hand, clients with a negative value of 0 or less are judged to be constrained
from participating in positive occupations. The DTF for APO-15 confirmed that there was no difference between subgroups (byillness, gender, and age) according to the latent characteristic values of the clients, even when the overall performance of the test
was used as a reference.

the APO-15 does not differ in response patterns for all
items, even if there is an influence of subgroups (illness,gender, and age). Furthermore, we checked the DTF plot
and confirmed that the total score of all APO-15 items
was also measured without any subgroup effects (Fig. 1).

Discussion and implications
Consideration of one-dimensionality
In this study, we confirmed whether APO-15 candetect IRT-based DIF. Specifically, we used CFA, local
independence, latent monotonicity, and polynomial correlation coefficients of item scores to check whether the
APO-15 meets the condition of one-dimensionality. The
results showed that the APO-15 satisfied the conditionof one-dimensionality in all analyses. In other words,
APO-15 was considered to be applicable for IRT-based
DIF detection.
Consideration of DIF and DTF
This study aimed to determine whether the response
patterns of the APO-15 were affected by subgroups (illness, gender, and age) and determine the validity of thescale by examining DIF and DTF. In other words, thestudy hypothesized that, regardless of client subgroup(illness, gender, and age), the tendency to respond to any
item on the APO-15 would be the same.
The study results revealed that APO-15 did notshow DIF items the reference value of index K (≥ 0.3) tothe influence by subgroup (illness, gender, and age). The
DTF of the APO-15 was also found to be adequate in theoverall test performance without being affected by the
subgroups. In other words, the APO-15 was likely able
to capture the construct of “positive occupational participation” as the same concept across different subgroups.
These results suggest that the APO-15 is composed ofitems that are not influenced by client subgroups (illness,gender, and age) as patient-reported outcomes and may
not be region-dependent.
The reason for this may be that the DIF items were
not found in the APO-15 because the clients who wereparticipants in this study belonged to the same cultural
background. Culture is an integrated pattern of humanbehavior that includes the thoughts, communication,
behaviors, customs, beliefs, values, and institutions ofa social group, as described above [18]. In occupational
therapy, there is a belief that occupations have meaning,reflect cultural values, and shape an individual’s identity,role, and perception of independence [39, 40]. That is,
the participants in this study belonged to the same cultural background and did not differ in their perceptionsof personal identity, role, and independence, which may
have been reflected in their APO-15 response trends.
Furthermore, the IRT-based DIF analysis results showedsimilar trends in item difficulty scores for all threesubgroups (illness, gender, and age). In other words, theAPO-15 scale items may be able to measure each client’s state of participation in occupations that promote

Asian J Occup Ther 19: 46−54, 2023

well-being according to their abilities, beyond the influence of the three subgroups (illness, gender, and age).
Considering these factors, the measurement resultsof the APO-15, despite being limited to Japan at thisstage of the investigation, may meet contemporary
measurement standards while maintaining its integrity
as an instrument for use in occupational therapy. Thatis, the APO-15 can be used as an occupation-focused
assessment instrument that ensures fairness in testing inclinical and research settings.
Clinical implications
The results of this study support the absence ofbias in APO-15 measurements by region, illness, age,or gender for occupational therapists using the APO-15
in Japan. In other words, the APO-15 suggests that thescale may have a good level of validity and robustness.
Therefore, when the APO-15 is used in occupational
therapy practice, it may contribute to clinical reasoning
for supporting client participation in occupations that
promote well-being according to the client’s lifestyle.

Limitations
This study design has several limitations. First, only
three different subgroups (illness, gender, and age) could
be examined in the detection of DIF. Second, this study
was conducted among rehabilitation clients living inJapan. Therefore, it is considered necessary to develop
the APO-15 to be used for English-speaking clients inthe future to consider international surveys.

Conflict of Interest
The authors declare there are no potential conflictsof interest with respect to the research, authorship, or
publication of this article.

Acknowledgment
We would like to thank our clients who participatedin this study and the cooperating institutions for theircooperation.

References[1] Hammell KRW. Belonging, occupation, and human wellbeing: an exploration. Can J Occup Ther. 2014; 81(1):39–50.
[2] Law M, Steinwender S, Leclair L. Occupation, health andwell-being. Can J Occup Ther. 1998; 65: 81–91.
[3] Law M, Baptiste S, McColl M, Opzoomer A, Polatajko
H, Pollock N. The Canadian occupational performance

Noguchi T et al.

53

measure: an outcome measure for occupational therapy.
Can J Occup Ther. 1990; 57(2): 82–7.
[4] Kielhofner G, Dobria L, Forsyth K, Kramer J. The Occupational Self Assessment: Stability and the Ability to
Detect Change over Time. OTJR: Occupation, Participation and Health. 2010; 30(1): 11–9.
[5] Christiansen C. Identity, personal projects and happiness:
Self construction in everyday action. J Occup Sci. 2000;
7(3): 98–107.
[6] Reitz SM, Scaffa ME, Dorsey J. Occupational Therapy
in the Promotion of Health and Well-Being. Am J Occup
Ther. 2000; 74(3): 7403420010p1–7403420010p14.
[7] Law M. Participation in the occupations of everyday life.
Am J Occup Ther. 2002; 56(6): 640–9.
[8] Dodge R, Daly AP, Huyton J, Sanders LD. The challenge
of defining wellbeing. IJW. 2012; 2(3): 222–35.
[9] American Occupational Therapy Association. Occupational Therapy Practice Framework: Domain and Process. 4th
ed. Am J Occup Ther. 2020; 74(Suppl. 2): 7412410010p1–
7412410010p87.
[10] Noguchi T. Latent rank structure in the assessment of
positive occupation 15 (APO-15) (in Japanese). The Japanese Journal of Clinical Occupational Therapy. 2021; 8:
57–64.
[11] Noguchi T, Kyougoku M. Psychometric properties of theAssessment of Positive Occupation 15 final version in
individuals with mental disabilities. Hong Kong J Occup
Ther. 2021; 34(1): 3–12.
[12] Noguchi T, Kyougoku M, Teraoka M. Development of
the Assessment of Positive Occupation (APO) participation to promote the Well-being (in Japanese). Sogo
Rihabiriteshon. 2016; 44: 1097–106.
[13] Seligman MEP. Flourish: A Visionary New Understanding of Happiness and Well-being. New York: Simon &Schuster; 2011; 5–29.
[14] Berg B, Atler K, Fisher AG. Is it possible to develop across-country test of social interaction? Scand J Occup
Ther. 2017; 24(6): 421–30.
[15] Gilworth G, Emery P, Gossec L, Vlieland TV, Breedveld
FC, Hueber AJ, et al. Adaptation and cross-cultural validation of the rheumatoid arthritis work instability scale(RA-WIS). Ann Rheum Dis. 2009; 68(11): 1686–90.
[16] Kottorp A, Malinowsky C, Larsson-Lund M, Nygård L.
Gender and diagnostic impact on everyday technology
use: a differential item functioning (DIF) analysis of theEveryday Technology Use Questionnaire (ETUQ). Disabil Rehabil. 2019; 41(22): 2688–94.
[17] Munkholm M, Berg B, Löfgren B, Fisher AG. Crossregional validation of the School Version of the Assessment of Motor and Process Skills. Am J Occup Ther.
2010; 64(5): 768–75.
[18] U.S. Department of Health and Human Services, Officeof Minority Health. National standards for culturally andlinguistically appropriate services in health care: Finalreport (Contract No. 282-99-0039). (cited 2022 January 1)
Available from: http://minorityhealth.hhs.gov/assets/pdf/
checked/finalreport.pdf.

54

CROSS-REGIONAL VALIDATION OF THE APO-15[19] Toyota H. Item response theory (Intermediate) (in Japanese). Tokyo: Asakura Publishing Co; 2013; 78–118.
[20] Mantel N, Haenszel W. Statistical aspects of the analysisof data from retrospective studies of disease. J NatlCancer Inst. 1959; 22(4): 719–48.
[21] Swaminathan H, Rogers HJ. Detecting differential item
functioning using logistic regression procedures. J Educ
Meas. 1990; 27(4): 361–70.
[22] Lord FM. Applications of item response theory to practical testing problems. Hillsdale, NJ: Lawrence Erlbaum
Associates; 1980.
[23] Raju NS. The area between two item characteristic
curves. Psychometrika. 1988; 53(4): 495–502.
[24] Thissen D, Steinberg L, Wainer H. Detection of differential item functioning using the parameters of item
response models. Holland PW, Wainer H (Eds.), Differential item functioning. New Jersey: Lawrence Erlbaum
Associates; 1993; 67–113.
[25] De Ayala RJ, Hertzog MA. The Assessment of Dimensionality for Use in Item Response Theory. Multivariate
Behav Res. 1991; 26(4): 765–92.
[26] Edwards MC, Houts CR, Cai L. A diagnostic procedure
to detect departures from local independence in item
response theory models. Psychol Methods. 2018; 23(1):
138–49.
[27] Junker BW, Sijtsma K. Latent and Manifest Monotonicity
in Item Response Models. Appl Psychol Meas. 2000;
24(1): 65–81.
[28] Toyota H. Item response theory (case study): A new wayof constructing psychological tests (in Japanese). Tokyo:
Asakura Publishing Co; 2009; 60–78.
[29] Nugent WR. Understanding DIF and DTF: Description,
methods, and implications for social work research. J Soc
Social Work Res. 2017; 8(2): 305–34.
[30] Pae TI, Park GP. Examining the relationship between
differential item functioning and differential test functioning. Language testing. 2006; 23(4): 475–96.
[31] MacCallum RC, Browne MW, Sugawara HM. Power
Analysis and Determination of Sample Size for Covari-ance Structure Modeling. Psychological Methods. 1996;
1(2): 130–49.
[32] Kline RB. Principles and practice of structural equation
modeling. 3rd ed. New York: Guilford Press; 2011.
[33] Smits N, Zitman FG, Cuijpers P, den Hollander-Gijsman
ME, Carlier IV. A proof of principle for using adaptive
testing in routine Outcome Monitoring: the efficiencyof the Mood and Anxiety Symptoms QuestionnaireAnhedonic Depression CAT. BMC Med Res Methodol.
2012; 12(1): 1–10.
[34] Mokken RJ. Nonparametric models for dichotomous
responses. In van der Linden WJ, Hambleton RK (Eds.),
Handbook of modern item response theory. New York:
Springer; 1997; 351–67.
[35] Mokkink LB, Prinsen CAC, Patrick DL, Alonso J, BouterLM, de Vet HC, et al. (2019) COSMIN checklist manual[online]. (cited 2022 January 1) Available from: https://www.cosmin.nl/wp-content/uploads/COSMIN-studydesigning-checklist_final.pdf.
[36] Kumagai R. A new method for estimating differential
item functioning (DIF) for multiple groups and polytomous items: Development of index K and the computer
program “EasyDIF” (in Japanese). Shinrigaku Kenkyu.
2012; 83(1): 35–43.
[37] Ouchi Y, Rakugi H, Arai H, Akishita M, Ito H, Toba K,
et al. Redefining the elderly as aged 75 years and older:proposal from the Joint Committee of Japan Gerontological Society and the Japan Geriatrics Society. Geriatr
Gerontol Int. 2017; 17(7): 1045–7.
[38] Prinsen CA, Mokkink LB, Bouter LM, Alonso J, Patrick
DL, De Vet HC, et al. COSMIN guideline for systematic
reviews of patient-reported outcome measures. Qual Life
Res. 2018; 27(5): 1147–57.
[39] Bonder BR, Martin L, Miracle AW. Culture emergent in
occupation. Am J Occup Ther. 2004; 58(2): 159–68.
[40] Clark F. Occupation embedded in a real life: interweaving occupational science and occupational therapy. 1993
Eleanor Clarke Slagle Lecture. Am J Occup Ther. 1993;
47(12): 1067–78.

■ORIGINAL ARTICLE

Discriminating Brain Activation State in a Patientwith Duchenne Muscular Dystrophy
Using Near-Infrared Spectroscopy for Communication:
An Exploratory Case Study
Akira Masuo1, 2, Takuto Sakuma2, Shohei Kato2
1
2

Shubun University Junior College
Graduate School of Engineering, Nagoya Institute of Technology

Abstract: Introduction: Maintaining means of communication is an extremely important issue in occupational therapy
for patients with intractable neurological disease. A brain-computer interface (BCI) is a device control technology for
utilizing physiological signals, and is eagerly awaited for application in occupational therapy as a communication aid
for patients with severe motor dysfunction. As an exploratory study for the development of BCI, we examined the accuracy of discriminating brain activation state using near-infrared spectroscopy (NIRS) signals and the effects of cognitive
tasks on subjective burden through case study.
Methods: One 21-year-old male with Duchenne muscular dystrophy participated in the experiment. We measured
NIRS signals with16 channels in the prefrontal cortex during three cognitive tasks: mental arithmetic (MA), figure rotation imagery (FRI), and Japanese word chain (JWC). Using support vector machine, a supervised machine learning,
we constructed a classification model that discriminate type of cognitive task from features in the NIRS signals. In addition, the state-trait anxiety inventory and visual analogue scale were conducted to assess subjective burden associatedwith performing cognitive tasks.
Results: The classification accuracy of the MA versus FRI tasks was 73.1% ( p = .03). The subjective evaluation scoresshowed the JWC had the lowest burden, and the MA and FRI were also rated as low anxiety tasks.
Conclusion: In this participant, we could identify whether the MA or FRI was being performed with 73.1% accuracy.
These results suggest that brain activation state may be applicable as a means of communicating intentions.
Keywords: duchenne muscular dystrophy, near-infrared spectroscopy, assistive technology, cognitive task, braincomputer interface(Asian J Occup Ther 19: 55−62, 2023)

Introduction
Duchenne muscular dystrophy (DMD) is a neuromuscular disease characterized by atrophy of skeletal
muscle throughout the body due to a defect in the geneencoding the cytoskeletal protein dystrophin [1]. DMD
causes limited communication owing to severe motor
paralysis. For patients with severe motor dysfunction,
occupational therapists give support to them to acquiremeans of communication through device control that
Received: 28 March 2022, Accepted: 5 January 2023
Corresponding to: Akira Masuo, Shubun University Junior College, 6
Nikko-cho, Ichinomiya, Aichi, 491-0938, Japane-mail: masuo.akira.4t@gmail.com©2023 Japanese Association of Occupational Therapists

utilizes their few remaining functions, such as eye
movement. However, as the disease progresses, there arepatients with locked-in syndrome (LIS) [2] who retain
consciousness and mental function but have difficultycommunicating due to loss of motor function. Therefore,
the establishment of new means of communication support for people with severe motor dysfunction is eagerly
awaited in clinical practice.
A brain-computer interface (BCI) is a technology
for enabling the control of external devices using brain
signals generated by cognitive activities [3]. A BCI
system generally consists of a brain function measurement, preprocessing, feature selection and extraction,
classification, and device control [4]. After filtering out
unwanted components such as noise from the physiological signals acquired by the brain function measurement,

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BRAIN STATE DISCRIMINATION FOR COMMUNICATION

feature selection and extraction are performed to extract
information highly relevant to brain activity. Then, bypattern recognition of the information obtained using
machine learning, it is possible to control equipmentusing physiological signals. The medical application of
BCI has the potential to provide a new means of communication using physiological signals for people withsevere motor dysfunction.
Previous studies on BCI have used P300, the eventrelated potential component of electroencephalography[5], and near-infrared spectroscopy (NIRS) [6–8].
However, P300 measurements are vulnerable to noisefrom body movements, making it difficult to apply tosubjects with neurological disorders prone to involuntary movements by abnormal muscle tone or spasticity.
In addition, BCI systems that require responses toexternally presented visual stimuli are difficult to adapt
to late-stage patients with LIS. In contrast, NIRS has
a lower temporal resolution, but has the advantage ofrequiring low constraints during measurement and canbe applied to patients who are prone to involuntary
movements. Therefore, it is considered a useful method
for measuring physiological signals in studies aimed at
medical applications of BCI systems.
In related studies on NIRS-based BCI [6, 7], theclassification performance and usability of the BCI
system were evaluated by cross-validation using support
vector machine (SVM) on healthy subjects for BCI
construction. We also have conducted experiments using
NIRS signals from healthy subjects to identify brain
activation states and investigated the accuracy and theappropriate types of cognitive tasks [8]. However, to examine the possibility of constructing BCI, it is necessary
to investigate the performance of brain activation state
discrimination and usability in patients with intractableneurological diseases based on the findings of studies
on healthy subjects, but there are few such case studies.
Because improvement of lost motor function cannot be
expected in the field of intractable neurological diseases, it is very valuable to explore occupational therapy
approaches that utilize remaining brain function as acompensatory method.
Therefore, the purpose of this study was to examine(i) the accuracy of discriminating brain activation statesusing NIRS and (ii) the effects of cognitive tasks formeasuring NIRS signals on subjective burden through acase study, as a basic study for constructing a BCI thatcan be applied to communication support for patientswith intractable neurological diseases. This study was
conducted following the ethical principles of the Helsinki
Declaration and was reviewed and approved by the
Ethics Committee of Nagoya Institute of Technology(Approval No. 2019–017), and consent of the participant

was obtained.

Methods
Participant
The participant was one 21-year-old male with
DMD, whose dominant hand was determined to be righthanded based on the Edinburgh handedness Test [9].
The participant was diagnosed with DMD at the ageof 11 due to difficulty walking, began using an electric
wheelchair, and currently lived in a welfare facility.
Concerning DMD severity, the upper extremity function
scale by Brooke [10], which rates patients on a scalefrom 1, indicating the ability to abduct both upper extremities and touch above the head, to 6, indicating nouseful hand function, was 5, indicating that the patient
could not raise both hands to the mouth but could hold apen. The lower extremity function scale by Vignos [11],which rates patients on a scale of 1, indicating the ability
to walk and climb stairs without assistance, to 9, indicating being confined to a wheelchair or bed, was 9. The
functional independence measure (FIM) score was 26
points for motor FIM and 29 points for cognitive FIM.
The participant required maximum physical assistancein all activities of daily living but was able to communicate through spontaneous speech and still had sufficient
intellectual function for daily living. The participant
could also communicate independently by writing.
Near-Infrared Spectroscopy Signals Recording
The OEG-SpO2 (Spectratech Inc., Yokohama, Japan)
system was used to measure the NIRS signals. Figure
1 shows the equipment used for NIRS signal measurement. Following the international 10–20 method, theheadset was mounted so that the nine-channel part was
located directly above the frontal pole, and 16-channel
measurement was performed with the region of interest
being the prefrontal cortex. The distance between adjacent optodes was 3 cm, and the changes in the concentration of oxygenated hemoglobin were measured at asampling interval of 0.082 seconds.
Overview of Proposed BCI-Based Communication
MethodFigure 2 shows an overview of the proposed BCI
system and the evaluation procedure of system performance. BCI consists of the learning phase and performance evaluation phase. First, in the learning phase,
two types of cognitive tasks are performed and NIRS
signals are acquired. Before measuring the NIRS signal,
occupational therapist instructs the participant on thecorrespondence between the type of cognitive task andthe BCI output, e.g., performing MA means YES andAsian J Occup Ther 19: 55−62, 2023

Masuo A et al.

57

Fig. 1. Overview of the equipment used. (a) OEG-SpO2 system. (b) The configuration of sources, detectors, and channels

Fig. 2. Proposed BCI-based communication method (example using MA and FRI tasks).
MA: mental arithmetic, FRI: figure rotation imagery, NIRS: near-infrared spectroscopy.

FRI means NO, respectively. Then, labels indicating
the type of cognitive task are assigned to the measured
NIRS signals to construct a dataset with supervised
data. Thus, we construct a learned model that recognizes
the correspondence between the type of cognitive task
and the pattern of variation in the NIRS signal using
machine learning. Next, in the performance evaluation
phase, based on the correspondence between cognitive
tasks and BCI outputs, participant select and perform
a cognitive task that corresponds to the intention. Notethat in this experiment, participant is asked, e.g., “Please
perform the MA to output YES”, so that the true answerof the participant can be known. The measured NIRS
signal is classified by the learned model and output as aprediction, i.e., YES or NO. Finally, the accuracy of the
BCI output is evaluated by comparing the true answer tothe BCI output.
Cognitive Tasks
Referring to previous studies [12, 13], we used threecognitive tasks that participants could perform: mentalarithmetic (MA), figure rotation imagery (FRI), andJapanese word chain (JWC). Before the measurement,
participant practiced cognitive tasks. We confirmedthat the cognitive tasks were feasible for MA and JWC
by having them perform the task aloud, and for FRI
by interviewing. The following paragraphs provide thedefinitions of each cognitive task.

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BRAIN STATE DISCRIMINATION FOR COMMUNICATION

Fig. 3. Diagram of the block design used measuring physiological signals.

1. MA: A task in which participants are asked to add aseries of small numbers (e.g., 3) by rote (e.g., 3, 6, 9,
12, ...). The numbers were selected randomly to avoid
habituation.
2. FRI: A task of imagining the rotational motion of a
2-D figure. The direction and speed of rotation werearbitrarily set by the participant.
3. JWC: A word chaining task in which the participant
had to name an arbitrary word and repeatedly name a
new word starting from the last symbol (in Japanese)of that word. The participant was asked to refrainfrom using words whose last symbol was “n” so thatthe task would not be terminated. In addition, to avoid
habituation, the same word was not repeated.
Experimental Protocol
Figure 3 shows the experimental protocol used tomeasure the NIRS signals. We used a block design witha 30-second rest and task repetition. One session consistsof a total of three trials, with rest and task as one trial.
Three sessions were conducted each day, one session foreach cognitive task. Then, to avoid bias in the acquired
NIRS signals, we measured NIRS signals in five days
with a one-week interval between measurements. The
experiment was conducted in the living room of theparticipant, in a resting seated position on an electric
wheelchair. The participant performed the tasks byfollowing an instruction screen on a display placed 70
cm in front of him. The experiment was controlled sothat the participant performed the cognitive task whilegazing at a fixed viewpoint on the display. The orderof the cognitive tasks was randomized to minimize theeffects of fatigue.
Subjective Evaluation
State-Trait Anxiety Inventory
We conducted the State-Trait Anxiety Inventory
Form JYZ (STAI) [14] to measure the mental burden
perceived from the performance of the cognitivetask. State anxiety is defined as a transient situational
response to an event that arouses anxiety regarding“exactly how you feel right now”. The state anxiety

test consists of a total of 20 questions with 10 anxietypresent items (P-item) and 10 anxiety-absent items(A-item). It is a self-rating scale; the participant chooses
the most applicable of the four levels (1 to 4), and thehigher the score, the higher the state anxiety. The sumof scores and the five-grade scale from very low (Stage
1) to very high (Stage 5) were evaluated for A-item,
P-item, and all-item.
Visual Analogue Scale
Eight evaluation items related to the practicalityof the cognitive task were set by referring to previous
studies [4, 15, 16]: flexibility, ease of performance, practicality, ease of understanding, difficulty, discomfort,
concentration, and sleepiness. The subjective evaluationof each cognitive task was conducted according to thevisual analogue scale (VAS). Each item was scorednumerically on a 100-point scale, with a high score indicating high practicality. The scores for each item andoverall average were calculated.
Data Analysis
Preprocessing and Feature Extraction
For the preprocessing, we applied the hemodynamic separation method [17] to the NIRS signals toseparate the skin blood flow components, and then the
NIRS signals of each channel were standardized by zscore transformation. Z-score is the transformed NIRS
data so that the mean of the 5-second pre-task restingdata for each trial is 0 and the standard deviation is 1.
The first 5 seconds of the task interval were excluded
from the analysis to account for the inherent delay of the
NIRS signal. For the data of the 25-second task interval, a 3-second time window with a step width of 0.5second were used to divide the data into the 45 samples.
Then, we calculated the temporal features using seventypes of statistics (arithmetic mean, standard deviation,
maximum, minimum, slope, kurtosis, and skewness).
The NIRS signals were labeled according to the type ofcognitive task. Thus, we constructed a dataset consistingof 675 samples and 112 features per cognitive task.
Classification
The SVM [18], a supervised machine learning, wasused to construct the classification model. Considering
the time-series characteristics of the acquired NIRS
signals and the calibration procedure in actual operation,
the classification model was constructed and evaluatedusing time-series cross-validation (TSCV) as shown in
Fig. 4. TSCV is a method to evaluate the generalization
performance of a classification model against unknown
data by dividing the data along the time axis, with thelast data being used as the test data (striped cell in Fig.

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Masuo A et al.

59

Fig. 4. Overview of performance evaluation by time-series cross-validation (TSCV)4), the data most recent to the test data being used as thevalidation data (gray cell in Fig. 4), and all other data
being used as the training data (shaded cell in Fig. 4).
The dataset is divided into 15 parts while maintaining
the time-series, and the first cross-validation is performed with the first trial as training data, the second
trial as validation data, and the third trial as test data.
Then, one trial of NIRS data is sequentially added tothe training data for each cross-validation, and theclassification performance is evaluated by 13-fold crossvalidation. The evaluation index was the sum of decisionfunction values in each class representing the confidence
level of predictions in the model. The kernel parameters
were linear and radial basis functions, and the hyper­
parameters C and γ were tuned by grid search in therange of 10−2, 10−1, …, 102. Under these conditions, weevaluated the correct answer rate of the model’s output
for each combination of MA, FRI, and JWC. The data
analysis was performed using python 3.7.4 and thepython machine learning library. For the statistical analysis, the binomial test was used to compare the correct
answer rate of the constructed classifiers and chancelevel, and a two-sided test was used with a significancelevel α of .05.

Results
NIRS Signals
Figure 5 shows the grand averaged waveforms of
all channels and 15 trials of standardized NIRS data foreach cognitive task. In Fig. 5, the NIRS data were preprocessed with bandpass filtering in frequency bands of
0.01–0.2 Hz for visualization. The MA and JWC showed
fluctuations that peaked at the end of the task interval,
whereas the FRI showed an increasing trend with a peakFig. 5. Grand averaged NIRS waveforms measured duringmental arithmetic (MA), figure rotation imagery (FRI),
and Japanese word chain (JWC).

at about 20 seconds followed by a decreasing trend.
Classification Performance
Table 1 shows the classification performance ofeach classification model.
The highest rate of the correct answer was 73.1%
for TSCV with MA versus FRI, which was significantly
higher than the chance level ( p = .03). In contrast, theclassification models using MA versus JWC and FRI
versus JWC showed no significant difference in classification performance at 61.5% ( p = .33) and 53.8% ( p =.85), respectively.
Subjective Evaluation
Figure 6 (a) and (b) show the results from the STAI
and the VAS, respectively. In the STAI, the scores of allitem were 38 (Stage 2), 33 (Stage 2), and 25 (Stage 1)

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BRAIN STATE DISCRIMINATION FOR COMMUNICATION

Table 1 Performance evaluation of binary classification using each cognitive task combination

Correct answer rate, n (%)
Total of A and B (n = 26)
A (n = 13)
B (n = 13)

MA versus FRI

MA versus JWC

FRI versus JWC

19 (73.1)*
7 (53.8)
12 (92.3)

16 (61.5)
10 (76.9)
6 (46.2)

14 (53.8)
10 (76.9)
4 (30.8)

A and B represent type of task in the binary classification of task A versus task B.
*: binomial test, p < .05.
Data are presented as numbers (percent).
MA, mental arithmetic; FRI, figure rotation imagery; JWC, Japanese word chain.

Fig. 6. Results of subjective evaluation by (a) State-Trait Anxiety Inventory (STAI) and (b) visual analogue scale (VAS)

for the MA, FRI, and JWC, respectively. The score ofA-item and all-item showed that JWC was the task withthe lowest mental load. Although MA was the highest
mental load of the three types of tasks, it was a Stage 2
and low anxiety task. As a result of the VAS, the meanscores of the eight items were 72.1, 67.8, and 88.1 forthe MA, FRI, and JWC, respectively, showing that JWC
was the most preferred task. In addition, JWC had thehighest rating in all items, whereas FRI was the least
practical task in the overall average.

owing to overfitting. Therefore, it is important to construct models considering the time-series characteristics
of NIRS and evaluate the classification performance
following actual operational procedures. TSCV, in contrast, divides the data along the time axis and evaluates
the model performance. Considering the operationof the BCI system, the evaluation results obtained by
the TSCV are considered more valid than those of thecross-validation, which does not consider the time-series
characteristics of the data.

Discussion

Psychological Burden
The STAI and VAS showed the JWC was the mostpractical task with the least psychological burden for theparticipants. Bos et al. [19] reported the importance of
selecting tasks that are less burdensome for users to use
the BCI stably. Considering the constraint of having toperform a cognitive task for every communication opportunity, the chosen cognitive task should have as low
mental load as possible. In general, as JWC is a familiartask in daily life, it is easy to perform and is not likely tocause anxiety. Therefore, using a familiar cognitive task
could lead to the construction of BCI with less mental
burden for a user.
In contrast, the STAI showed MA was the task that
increased the state of anxiety the most. The VAS alsoClassification Performance
The results of the classification performance evaluation showed that TSCV with MA versus FRI could guess
the type of cognitive task being performed from the
NIRS data with a 73.1% accuracy. Shin et al. [6] reported
the accuracy of an SVM based on 10 times 5-fold crossvalidation was 77.0%, and Naseer et al. [7] reported theaccuracy of an SVM based on 10-fold cross-validation
was 82.1%. However, when cross-validation is applied
to NIRS signals, it includes a condition, i.e., that dataacquired later than the validation or test data is assigned
to the training data. Such a method causes the possibilityof estimating a higher accuracy than the actual accuracy

Asian J Occup Ther 19: 55−62, 2023

showed FRI was the task with the lowest perceived
practicality. Weyand et al. [20] reported the importanceof evaluating usability and classification performanceof BCI. For this participant, MA and FRI may not havebeen preferred because they have less of a leisure activity component and involve mental loads related to intellectual functions. However, STAI showed both MA andFRI were stage 2, thereby categorized as low-anxiety
tasks. Additionally, if the sense of burden is reduced bypractice performing the task, it may become a cognitive
task with a sufficiently acceptable psychological burden
for this participant. Although occupational therapy for
intractable neurological diseases has mainly treatedmotor functions, the introduction of cognitive rehabilitation program that performs cognitive tasks mightprovide further stabilization of physiological signals andreduction of mental burden.
Possibility of Application to Brain-Computer Interface
SystemMüller-Putz [21] reported 70% is the criterion forpractical performance in binary BCI. The present results,
73.1%, exceed that criterion, suggesting the utility of
the TSCV models with MA and FRI in communication
applications such as yes and no. Considering the BCI
operating procedure, the discriminator should be adjustable to the daily non-stationarity of the NIRS signal. The
TSCV model adopts a verification method that follows
actual operational procedures, i.e., calibration using dataacquired before the operation, followed by the use of
BCI, which is considered a practical design. In addition,
results of the subjective evaluation showed MA and
FRI, although inferior to JWC, were considered to havean acceptable level of mental burden for the participant.
Therefore, these findings could be applied as a BCI
with less psychological burden if limited to applications
where misjudgments are acceptable. Furthermore, it isnecessary to consider the pathological characteristics
of users in designing a BCI. In patients with DMD,
brain functions are maintained but motor functions arelost gradually. Therefore, in this study, we proposed an
independent BCI that utilizes residual brain functions
such as mental tasks, rather than a presented stimulusdependent BCI that requires motor functions such as theexternal eye muscles. Additionally, Schreuder et al. [22]reported the importance of validation with potential
end-users, suggesting the importance of translational
research of BCI with case studies. Because no effective
treatment has been shown for DMD, ensuring alternative means of communication is a critical issue in
occupational therapy. Nevertheless, few BCI studies
have examined the possibility of acquiring means ofcommunication for patients with neurological impair-

Masuo A et al.

61

ments in case study in occupational therapy. Therefore,
these findings will contribute to the promotion of technical development of new communication methods using
BCI for patients with neurological disabilities. NIRS
equipment is expensive and has the disadvantage of low
temporal resolution. For future work, we will investigate
brain regions and NIRS signal lengths, which contributeto classifying brain activity states, and aim to construct a
simple BCI system with fewer channels that can identify
brain activity in shorter time.
Limitations
Because this study focused on means of communication for closed questions, we did not consider open
questions. We also did not examine the effects of thenon-stationarity of the NIRS signals that may occur
with aging or disease severity. For the practical use of
the BCI, the long-term robustness of the classification
model should be investigated. In addition, this study is asingle-case result and may show different trends among
participants. We will increase the number of participantsin the future and longitudinally evaluate the classification performance and subjective burden of the individual-specific model using the same algorithm to verify thegeneralizability.

Conclusions
We performed NIRS signal measurements andsubjective evaluation during MA, FRI, and JWC tasks
on a participant with DMD. As a result of evaluating
the binary classification performance using the NIRS
signals, the TSCV model for MA versus FRI achieved
73.1% accuracy. The STAI and VAS for subjective
evaluation of the cognitive tasks showed that JWC had
the lowest burden, and MA and FRI were rated as low
anxiety tasks. These results indicate the possibility ofapplying NIRS signals as a means of communication for
subjects with intractable neurological diseases.

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

Funding Statement
This work was supported in part by Grants-inAid for Scientific Research from the Japan Society for
the Promotion of Science (KAKENHI grant numbers:
JP19H01137, JP19H04025, and JP20H04018).

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References[1] Birnkrant DJ, Bushby K, Bann CM, Apkon SD, Blackwell A, Brumbaugh D, et al. Diagnosis and managementof Duchenne muscular dystrophy, part 1: diagnosis, andneuromuscular, rehabilitation, endocrine, and gastrointestinal and nutritional management. Lancet Neurol. 2018;17(3): 251–67.
[2] Bauer G, Gerstenbrand F, Rumpl E. Varieties of thelocked-in syndrome. J Neurol. 1979; 221(2): 77–91.
[3] Wolpaw JR, Birbaumer N, McFarland DJ, Pfurtscheller G,
Vaughan TM. Brain-computer interfaces for communication and control. Clin Neurophysiol. 2002; 113(6): 767–
91.
[4] Naseer N, Hong KS. fNIRS-based brain-computer interfaces: a review. Front Hum Neurosci. 2015; 9(3): 1–15.
[5] Farwell LA, Donchin E. Talking off the top of your head:toward a mental prosthesis utilizing event-related brain
potentials. Electroencephalogr Clin Neurophysiol. 1988;
70(6): 510–23.
[6] Shin J, Müller KR, Hwang HJ. Near-infrared spectroscopy (NIRS)-based eyes-closed brain-computer interface(BCI) using prefrontal cortex activation due to mentalarithmetic. Sci Rep. 2016; 6: 1–11.
[7] Naseer N, Hong MJ, Hong KS. Online binary decision
decoding using functional near-infrared spectroscopy forthe development of brain-computer interface. Exp Brain
Res. 2014; 232(2): 555–64.
[8] Masuo A, Kaga S, Kato S. Examination of optimalmental task for brain-computer interface using functional
near-infrared spectroscopy (in Japanese). Journal of Japan
Society of Kansei Engineering. 2020; 19(1): 49–53.
[9] Oldfield RC. The assessment an analysis of handedness:
the Edinburgh inventory. Neuropsychologia. 1971; 9(1):97–113.
[10] Brooke MH, Griggs RC, Mendell JR, Fenichel GM,
Shumate JB, Pellegrino RJ. Clinical trial in Duchenne
dystrophy. I. the design of the protocol. Muscle Nerve.
1981; 4: 186–97.
[11] Vignos PJ, Wagner MB, Karlinchak B, Katirji B. Evaluation of a program for long-term treatment of Duchenne
muscular dystrophy: experience at the university hospi-

tals of Cleveland. J Bone Joint Surg Am. 1996; 78(12):1844–52.
[12] Hwang HJ, Lim JH, Kim DW, Im CH. Evaluation ofvarious mental task combinations for near-infrared spectroscopy-based brain-computer interfaces. J Biomed Opt.
2014; 19(7): 1–9.
[13] Banville H, Gupta R, Falk TH. Mental task evaluation forhybrid NIRS-EEG brain-computer interfaces. Comput
Intell Neurosci. 2017; 2017: 1–24.
[14] Hidano N, Fukuhara M, Iwawaki S, Soga S, Spielberger
CD. Manual for the State-Trait Anxiety Inventory-Form
JYZ (in Japanese). Tokyo: Jitsumu Kyoiku-Shuppan;
2000; 23–9.
[15] Scherer R, Müller-Putz GR, Pfurtscheller G. Flexibility
and practicality: Graz brain-computer interface approach.
Int Rev Neurobiol. 2009; 86: 119–31.
[16] Coyle S, Ward T, Markham C, McDarby G. On the suitability of near-infrared (NIR) systems for next-generation
brain-computer interfaces. Physiol Meas. 2004; 25(4):815–22.
[17] Yamada T, Umeyama S, Matsuda K. Separation of fNIRS
signals into functional and systemic components basedon differences in hemodynamic modalities. PLoS One.
2012; 7(11): e50271.
[18] Cortes C, Vapnik V. Support-vector networks. Machine
Learning. 1995; 20: 273–97.
[19] Plass-Oude Bos D, Poel M, Nijholt A. A study in usercentered design and evaluation of mental tasks for BCI.
International Conference on Multimedia Modeling, 17thed. Berlin: Springer; 2011; 122–34.
[20] Weyand S, Schudlo L, Takehara-Nishiuchi K, Chau T.
Usability and performance-informed selection of personalized mental tasks for an online near-infrared spectroscopy brain-computer interface. Neurophotonics. 2015;
2(2): 025001.
[21] Müller-Putz GR, Scherer R, Brunner C, Leeb R,
Pfurtscheller G. Better than random? a closer look on
BCI results. Int J Bioelectromagn. 2008; 10(1): 52–5.
[22] Schreuder M, Riccio A, Risetti M, Dähne S, Ramsay
A, Williamson J, et al. User-centered design in braincomputer interfaces—a case study. Artif Intell Med.
2013; 59(2): 71–80.

■CASE REPORTS

Difficulty in Counting Similar Juxtaposed Items
after Subarachnoid Hemorrhage: A Case Report
Kaori Inoue1, Miyako Takada2, Yuka Oyama3, Kana Takahashi4,
Hayato Shibuma5, Yumi Suzuki1, Kayoko Yokoi1, Kazumi Hirayama1
1

Department of Occupational Therapy, Yamagata Prefectural University of Health Sciences
Department of Rehabilitation, Sapporo Nishimaruyama Hospital3
Department of Rehabilitation, Yamagata Prefectural Mental Health Medical Center
4
Honamiso Long-Term Care Health Facility
5
Department of Rehabilitation, Yamagata Saisei Hospital2

Abstract: Introduction: Focal brain damage can cause difficulties in counting similar items. It has been hypothesizedthat this visual counting disorder (VCD) is caused by an inability to recall places seen in the immediate past. However,this has not been directly tested. There also have been no studies on the impacts of VCD on patients’ daily lives.
Methods: A 60-year-old, right-handed man visited our hospital complaining of difficulty counting multiple similar objects placed next to each other; for example, accounting errors caused by an inability to read multiple zeros in numbers
in sales receipts. This patient had the problem for 25 years, since an infarction in the right temporoparietal region after a
subarachnoid hemorrhage. To test the recall hypothesis, we performed a visual counting test on the patient and healthy
control subjects. Circles were presented under two conditions: static (rows of circles presented vertically, centered on
the screen) and dynamic (rows of circles presented by scrolling vertically). Subjects were asked to count and report
numbers of circles as soon as each row appeared.
Results: Under the static condition, the patient showed a significantly longer reaction time and more frequent gazeretentions than did the control subjects; however, no differences were observed under the dynamic condition.
Conclusion: These findings directly support the hypothesis. Our patient’s compensatory methods might be useful toother patients.
Keywords: visual counting, daily activities, static, dynamic, saccadic eye movement(Asian J Occup Ther 19: 63−67, 2023)

Introduction
Visual counting tasks that use geometric figures
such as circles of the same color and size, have beenused as a highly sensitive test for detecting simultanagnosia [1]. Three recent reports [2–4] have shown thatvisual counting disorders (VCDs) manifested in the absence of simultanagnosia, and there is a high prevalenceof VCDs in patients with brain injury [4]. Dehaene andLaurent [5] hypothesized that the mechanism by which
VCD occur is related to an inability to recall places seen
Received: 16 January 2022, Accepted: 25 January 2023
Corresponding to: Kayoko Yokoi, Department of Occupational Therapy, Yamagata Prefectural University of Health Sciences, 260 Kamiyanagi, Yamagata city, Yamagata, 990-2212, Japane-mail: kyokoi@yachts.ac.jp©2023 Japanese Association of Occupational Therapists

in the immediate past. Nevertheless, the hypothesis has
not tested in the VCD itself, regardless of the presenceor absence of simultanagnosia. There are also no studies
on the impact of a VCD on a patient’s daily life.

Case report
A right-handed male aged 60 years, with 12 yearsof educational history and who operates a liquor shop
visited our hospital complaining of difficulty counting
multiple similar objects placed next to each other. The
problem started 25 years prior, when the patient had
suffered an infarction, caused by a vasospasm after a
subarachnoid hemorrhage due to rupture of an aneurysm
in the middle cerebral artery.
His computed tomography images showed lowdensity areas in the right temporoparietal region (Fig.
1a). Neurological examination showed no abnormal

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DIFFICULTY IN COUNTING AFTER SUBARACHNOID HEMORRHAGE

Fig. 1. CT image of the patient’s head. Low-density areas shown in the right temporal pole, superior and middle temporal gyrus, insula,supramarginal gyrus, angular gyrus, and medial superior occipital gyrus and their subcortical white matter, as well as in the posterior thalamus.

findings other than left homonymous hemianopia without macular sparing, and mild left hemiplegia. Neuro­
psychological examinations revealed no abnormality(Table 1).
Regarding the difficulty in couting multiple objects,
he said: “If I transfer my gaze, I forget where I havebeen looking at immediately beforehand,” “So, if similar
things are placed next to each other, I get confused because there are no clues to tell me where I was looking
before.”The patient had developed compensatory methods
during the 25 years. As shown in Fig. 2a, the method
differed depending on the condition of the objects to be
counted. If they were within arm’s reach and could be
moved, he arranged them in groups of four or five, thencounted groups. For example, when he counted hooks ina row, he put four hooks in a bundle and calculated how
many bundles he has. When he counted beer bottles at
his liquor shop, he would confirm the number by firstlining up five bottles while counting them, then placing
more bottles behind them sequentially in rows and cuiculated them. For immovable objects, such as symbols
on paper, he located the end of the row, then moved
over the objects in sequence, being careful not to skip
any, checking the count when he reached the opposite
end. While doing this, if the objects could be marked, he

Table 1 Results of neuropsychological examinations
Test
Handedness
Edinburgh Handedness Inventory (max: 100)
General attention (short-term memory)
Digit span
General cognition
Mini-Mental State Examination (max: 30)
Wechsler Adult Intelligence Scale Revised (VIQ)
Episodic Memory
Recall of three words (max: 3)
Immediate
Post-interference
He could give accurate oral descriptions of thecontents of his previous day's training

Performance
100
6
30
111

3
3

Hemispatial neglect
Catherine Bergego Scale (max: 30)
1
Behavioral inattention test
Conventional subtest (max: 146)
135
Line crossing (max: 36)
36
Letter cancelation (max: 40)
37
Star cancellation (max: 54)
52
Figure and shape copying (max: 4)3Line bisection (max: 9)
4
Both leftward and rightward shiftsof midpoints were shown.
Representational drawing (max: 3)
3max, maximum
Abnormal values are indicated in bold.

Asian J Occup Ther 19: 63−67, 2023

Inoue K et al.

Fig. 2. (a) The conditions of objects and compensatory methods. Text inside boxes describes conditions of objects to be counted visually,
and in bold text below are compensatory methods. + indicates a satisfied condition; − indicates a nonsatisfied condition. (b)(c)
Examples of stimuli in the visual counting test. The gray rectangle represents the monitor screen. The diameter of all circles had
a visual angle of 1.5°, and the distance between the centers of two adjoining circles was 2.5°. Under static conditions (b), thearrangement of the circles was vertically symmetrical, centered on the middle of the screen. The circles were presented without
setting time limits. The reaction time corresponded to the time elapsed between the appearance of a stimulus to when the participants started providing the correct answers. Under dynamic conditions (c), rows of circles were presented as scrolling downwards
from the upper edge of the screen and disappearing at the bottom or scrolling upwards from the lower edge of the screen anddisappearing at the top. The moving speed was 5.5°/sec. It took three seconds for each circle to appear and disappear from thescreen. The reaction time started when part of the stimulus appeared on the screen and finished when the participants started providing the correct answers.
We defined “gaze retention” according to Grüsser and Grüsser–Cornehs [6], as a gaze’s moving speed within 50°/s continuousfor ≥ 0.15 s and measured the number of retentions and the duration of each retention. (d)(e) Examples of retention points (centerof each circle), retention time (circle size), and trajectory (straight line connecting the center of a circle) of the patient’s (left) andhealthy participants’ (right) gazes analyzed using an eye tracker. (d) Response under static conditions, and (e) response underdynamic conditions. The white circle (below right) shows the size when the retention time is 1 second.

65

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DIFFICULTY IN COUNTING AFTER SUBARACHNOID HEMORRHAGE

did so while counting. If they could not be marked, hecounted them using fingers to mark his place, provided
that there was sufficient space to do so.
However, when he could not use any of these compensatory methods, he had to count by moving his gaze,
which took a long time and resulted in errors even whenpaying close attention. For example, when he madea sketch of hanging persimmons, he drew the wrong
number of juxtaposed dried persimmons. He frequently
made accounting mistakes by incorrectly reading thenumber of zeros on sales receipts. He failed to pass thetests because he erroneously counted the number of
bubbles in the optical mark recognition sheet and as aresult filled in the wrong bubbles.
We performed a visual counting test using thispatient and 11 healthy controls (10 men, one woman;age 62 ± 5 years; educational history, 15 ± 3 years) as
participants. We showed from one to seven black circles
arranged vertically. The participants were told to countand report, as quickly and accurately as possible, thenumber of black circles as soon as a row appeared on
the screen. The circles were presented under two typesof conditions: static and dynamic (see the details in Figs.
2b, c). A total of 14 trials were conducted under bothconditions. We also recorded the participants’ voices
and gaze movements, using an eye tracker (EMR-9; nac
Image Technology, Tokyo, Japan).
Under static condition, the median (range) reaction
time (RAT), number of gaze retentions (NGR), andretention time (RTT) were 9.3 (1.0–31.4) seconds, 13.0
(1.0–36.0) times, and 0.3 (0.2–3.6) seconds for the patients, respectively, and 1.0 (0.4–3.0) seconds, 1.0 (0.0–
6.0) times, and 0.4 (0.2–3.6) seconds for the healthy
controls, respectively. The median RAT and NGR of thepatients were approximately 10 times greater than thoseof the healthy participants, and the patients showed asignificantly longer RAT ( p < 0.001, Mann-Whitney
U test) and greater NGR ( p < 0.001, Mann-Whitney Utest) than the healthy participants. However, no difference in RTT was observed ( p = 0.12, Mann-Whitney Utest). Under the dynamic condition, the median (range)
RAT, NGR, and RTT were 1.9 (0.8–4.5) seconds, 3.0(1.0–6.0) times, 0.4 (0.2–2.7) seconds for the patientsand 1.7 (0.5–2.6) seconds, 2.0 (0.0–6.0) times, and 0.4(0.2–4.0) seconds for the healthy controls. No differences in the RAT ( p = 0.46, Mann-Whitney U test),
NGR ( p = 0.21, Mann-Whitney U test), or RTT ( p =0.66, Mann-Whitney U test) were observed between thepatients and healthy participants.
Figures 2d, e shows examples of the retention
points and times as well as the trajectory of gaze movements of the patient and a healthy participant for sevencircles under static and dynamic conditions. Under static

conditions, with increasing circle numbers, we haveto transfer their gaze—that is, perform saccadic eye
movements. Therefore, the gaze trajectory shown in Fig.
2d is believed to reflect saccadic eye movements. On
the other hand, under dynamic conditions with moving
black circles, no saccadic eye movements are required.
Even if they must visually track them, they simply needto perform smooth pursuit eye movements without removing their gaze from the circles. The gaze trajectoryin Fig. 2e shows these smooth pursuit eye movements.

Discussion
Our test results showed that, under static conditions, the patient had a longer reaction time than healthy
participants. Furthermore, the reaction time was long
not because the patient spent more time fixating his gazein one place than healthy participants, but because hestopped his gaze more often. This finding coincides withthe patient’s report that he looked at objects one after another, starting from the end, making sure not to skip any
spaces in-between. Under dynamic conditions, on theother hand, the patient’s reaction time was just as shortas that in healthy participants, and there were no other
differences from healthy participants. These findings
directly support the hypothesis by Dehaene and Laurent[5] and the patient’s self-reflection reports. The findings
also suggest that his inability to remember the spatial
position might occur only after performing saccadic
movements, not after smooth pursuit eye movements.
Recommending a patient to use the compensatory
strategies adopted by the patient in this study might beuseful as rehabilitation for VCD. Although we could
not let the current patient do, it might be useful if thepatients with VCD could use a smartphone or otherdevices which are equipped with a function that cancapture an image of objects and scrolls it automatically,in a similar way we did as a dynamic condition in thisresearch.

Ethical statement
The participants provided written informed consent after receiving a detailed description of the study.
This study was approved by the ethical committee of
Yamagata Prefectural University of Health Scienceand conducted in accordance with the Declaration of
Helsinki.

Conflict of interest
The authors declare no conflicts of interest.

Asian J Occup Ther 19: 63−67, 2023

Funding sourceThis research did not receive any specific grantfrom funding agencies in the public, commercial, or notfor-profit sectors.

References[1] Neitzel J, Ortner M, Haupt M, Redel P, Grimmer T,
Yakushev I, et al. Neuro-cognitive mechanisms of simultanagnosia in patients with posterior cortical atrophy.
Brain. 2016; 139(12): 3267–80.
[2] Ashkenazi S, Henika A, Iferganeb G, Shelefc I. Basic
numerical processing in left intraparietal sulcus (IPS)
acalculia. Cortex. 2008; 44(4): 439–48.

Inoue K et al.

67[3] Demeyere N, Lestou V, Humphreys GW. Neuropsychological evidence for a dissociation in counting andsubitizing. Neurocase. 2010; 16(3): 219–37.
[4] Demeyere N, Rotshtein P, Humphreys GW. The Neuroanatomy of visual counting: Differentiating necessary
neural correlates for subitizing versus counting in a neuropsychological voxel-based morphometry study. J Cogn
Neurosci. 2012; 24(4): 948–64.
[5] Dehaene S, Cohen L. Dissociable mechanisms of subitizing and counting: neuropsychological evidence fromsimultanagnosic patients. J Exp Psychol Hum Percept
Perform. 1994; 20(5): 958–75.
[6] Grüsser OJ, Grüsser-Cornehs U. Physiology of vision. In:
Fundamentals of sensory physiology. Schmidt RF Eds.
Springer-Verlag, Berlin, 1986.

■ORIGINAL ARTICLE

Effect of Upper Limb Function Training Combinedwith Goal Setting Using the Aid for Decision-Making
in Occupation Choice for Hand Applicationin Patients with Acute Stroke
Masato Ikegami1, Hitoshi Mutai2, Rika Karasawa1,
Yoshie Yuzawa1, Nobuko Sakai1
12

Department of Rehabilitation, Ina Central Hospital
Department of Health Sciences, Graduate School of Medicine, Shinshu University

Abstract
Background and Purpose: We introduced an intervention that aimed to improve upper limb use in daily life using
Aid for Decision-making in Occupation Choice for Hand (ADOC-H), a monitoring and problem-solving technique, in
addition to conventional occupational therapy for hospitalized patients with acute stroke. This pilot study examined theeffectiveness of this intervention to improve paralyzed upper limb use in daily life and their motor function.
Methods: This comparative study included 28 patients with acute stroke who underwent an intervention based on the
ADOC-H process (ADOC-H group) and 155 participants from a previous study (control group). The paralytic arm participation measure (PPM; scores for eating and toileting items) was used to evaluate upper limb use in daily life, and the
Stroke Impairment Assessment Set (SIAS; knee mouth [K-M] and finger flexion [F-F] tests) was used to evaluate upper
limb motor function. The amount of change in these evaluations was compared between the two groups.
Results: Using propensity score matching, 21 participants were allocated to each group. Comparing the two groups,
significant improvements were observed in the ADOC-H group for all items, as shown by the scores for PPM total (P =0.005, r = 0.43), eating (P = 0.035, r = 0.32), toileting (P = 0.004, r = 0.44), upper limb motor function (P = 0.001, r =0.52), K-M (P = 0.014, r = 0.38), and F-F (P = 0.002, r = 0.48).
Conclusion: This intervention process may be effective for improving the frequency of paralyzed upper limb use andupper limb motor function of the paralyzed upper limbs in patients with acute stroke.
Keywords: acute phase, stroke, use of paralyzed upper limb, Aid for Decision-making in Occupation Choice for Hand,
pilot study(Asian J Occup Ther 19: 68−76, 2023)

1. Introduction
Motor paralysis is a sequela of stroke. Functional
recovery from motor paralysis peaks at 1 month after
onset [1], and delayed rehabilitation, which begins 1
month after the onset of cerebral infarction, does not
sufficiently improve motor performance [2]. Moreover,Received: 2 September 2022, Accepted: 25 January 2023
Corresponding to: Hitoshi Mutai, Department of Health Sciences,
Graduate School of Medicine, Shinshu University, 3-1-1 Asahi, Matsu­
moto, Nagano 390-8621, Japane-mail: hitmutai@shinshu-u.ac.jp©2023 Japanese Association of Occupational Therapists

the severity of motor paralysis in the acute phase is apredictor of activities of daily living (ADL) after theconvalescence phase [3], and early intervention forfunctional recovery of paralyzed upper limbs is important. Paralyzed upper limb use in daily life is the mostimportant factor for functional recovery of the paralyzed
side after stroke [4]. Encouraging paralyzed upper limb
use for ADL in the acute phase of stroke is importantto prevent learned non-use. However, the amount andfrequency of paralyzed upper limb use in patients withacute stroke are small [5]. A previous study noted thatseveral patients with acute stroke can hardly use theirparalyzed upper limb in daily life even if their paralysis
is mild [6].

Asian J Occup Ther 19: 68−76, 2023

Studies have reported the use of robot-assisted
therapy [7], constraint-induced movement therapy(CIMT) [8], virtual reality [9], and accelerometers [10]in promoting paralyzed upper limb use in patients withstroke. CIMT can achieve this promotion by introducing
a transfer package in addition to intensive task-oriented
training [11]. The transfer package focuses on transferring the results obtained in clinical situations in reallife and involves the following: the patient and therapist
develop a behavioral contract for using the paralyzed
upper limb in a specific life situation; oral or descriptive
monitoring of upper limb use in the targeted behavior
is promoted; and guidance on problem-solving methods
for using the upper limb in daily life is provided [12].
However, despite recent reports on the effectivenessof CIMT in the acute phase of stroke, this effectivenessremains controversial [13, 14]. Administering a rigorous
CIMT program in the acute phase is difficult because
general care and stroke treatment are prioritized, and thetime allocated to rehabilitation is limited. Moreover, although the transfer package is effective, a study reported
that setting goals for patients with cognitive impairment
and speech disorders is challenging [15]. Recently, anapplication called Aid for Decision-making in Occupation Choice for Hand (ADOC-H) that allows the visualsetting of goals for using the paralyzed upper limbs indaily life has been developed. This application is easy to
use and can facilitate goal setting, even in patients withcognitive dysfunction and speech disorders [15], and isclinically useful [16]. With ADOC-H, the goal of using
the paralyzed upper limb in daily life can be shared withthe patient, even in the acute phase, promoting paralyzed
upper limb use.
This study aimed to examine the effectiveness ofan intervention that included goal setting for upper limb
use in daily life using ADOC-H and monitoring andguidance on problem-solving techniques for patientswith acute stroke, in addition to conventional occupational therapy. We also explored the effectiveness of thisintervention for patients with cognitive impairment andaphasia.

2. Patients and Methods
2.1 Study design and settingThis study used a comparative design and propensity
score matching to compare current and previous patientswith stroke. At our institution, rehabilitation starts on
the day of hospitalization or on the day following hospitalization, with sufficient risk management. Further,patients undergo rehabilitation for 20–40 minutes/day,
7 days/week. Upper limb function training includes thefollowing exercises performed alone or in combination:

Ikegami M et al.

69

reach movement training, instrument manipulation
training, neuromuscular facilitation training, and therapeutic electrical stimulation. Physical therapy included
basic movement and walking training from early disease
onset, and speech-language training was provided forswallowing dysfunction and speech disorders from early
disease onset.
2.2 Participants
The participants were divided into an intervention(ADOC-H) or control group. The intervention group
comprised inpatients aged ≥ 20 years who were admitted
to the hospital from February 2021 to February 2022 andwere diagnosed with stroke (cerebral infarction, cerebral
hemorrhage, and subarachnoid hemorrhage). The exclusion criteria were as follows: patients (1) diagnosed withtransient ischemic attacks, (2) with limited joint rangeof motion and muscle weakness in the paralyzed upper
limb before the onset of stroke; this information was
obtained through interviews and from patients’ medical
records at the time of admission, (3) with impaired consciousness, i.e., a Glasgow Coma Scale (GCS) less than
E3V1M6, (4) with total aphasia, (5) who were unable toprovide informed consent, (6) with recurrent stroke that
occurred during hospitalization, (7) with ataxia, (8) witha perfect score (3 points) for eating and toileting itemsin the paralytic arm participation measure (PPM) at thetime of admission, (9) with severe motor paralysis of< 1 point as assessed by the knee mouth (K-M) or finger
flexion (F-F) tests of the Stroke Impairment Assessment
Set (SIAS) at the time of admission, and (10) who had
previously participated in this research [6]. The PPM
and SIAS assessments were performed on admission
and discharge. Additionally, details on age, sex, lengthof stay, disease type, paralyzed side, dominant hand,intervention days, duration of occupational therapy
intervention in minutes, GCS score at the time of admission, National Institutes of Health Stroke Scale score,
Functional Independent Measure (FIM) score, and MiniMental State Examination (MMSE) score were obtained
from medical records.
The control group included 155 patients with stroke
who were admitted to our hospital from October 2018 to
October 2019 and had participated in a previous study[6]. The exclusion criteria for the control group were
the same as those used for the intervention group. Additionally, the same patient characteristics retrieved frommedical records of patients in the intervention groupwere obtained for patients in the control group.
2.3 Outcome measures
2.3.1. Stroke Impairment Assessment Set
The SIAS was used to assess stroke dysfunction.

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EFFECT OF UPPER LIMB FUNCTION TRAINING COMBINED WITH GOAL SETTING USING ADOC-H

It comprises 22 items classified into nine types of dysfunctions, and each item is evaluated on a scale of 3 or 5
points: the higher the score, the better the function [17].
Among the upper limb motor functions on the paralyzed
side, the K-M: (0–5), F-F: (0–5), and total: (0–10) scores
were assessed. The lower limb motor function on theparalyzed side (total of hip flexion test, knee extension
test, and foot pad test: 0–15), upper limb sensation (total
of upper limb tactile sensation and upper limb position
sense: 0–6), and language function (0–3) were used.
Evaluation was performed at the time of admission(within 2 days) and discharge (within 2 days).
2.3.2 Evaluation of paralyzed upper limb use in daily life
The Motor Activity Log [18] is generally used as
an evaluation method for paralyzed upper limb use indaily life. However, as we included patients with cognitive and speech impairments in this study, we used thePPM [19, 20]. The PPM is a scale used by occupational
therapists (OTs) to observe and evaluate patients’ paralyzed upper limb use [19, 20]. The PPM consists of 15
items. Each item is assessed on a 4-point scale ranging
from 0 to 3 points (3 points, the paralyzed upper limb
can smoothly perform the desired movement; 2 points,
movement can be performed until the end but is awkward and has a longer duration; 1 point, the limb is partially used; and 0 points, the limb is not used entirely).
In this study, two items were investigated at the time ofadmission (within 2 days) and discharge (within 2 days):
PPM eating (either holding a bowl or maneuveringchopsticks or a spoon) and toileting (two items: lowering the pants to the knees and pulling the pants up to
the waist). Regarding the items selected for the ADOCH, the OT in charge observed the daily life situation ofpatients at the time of discharge and performed a twostage evaluation of whether or not the paralyzed upper
limb was used in daily life. The paralyzed upper limb
was judged as “used in daily life” if it could complete a
movement, even if the movement was awkward, fromthe beginning to the end of the movement.
2.4 Goal-setting tool
ADOC-H was used to set goals for paralyzed upper
limb use. ADOC-H is an application that includes 130
illustrated movements in 16 categories related to ADL
and instrumental ADL [15]. The ADOC-H uses “words,”“letters,” and “illustrations” to communicate specifictasks to patients and therapists that require the use of thehands and to promote the use of paralyzed upper limbs
in daily life situations [15].
We set the goals based on shared decision-making,which is an ideal decision-making model [21, 22]. We
referred to the ADOC-H items presented on the iPad

screen, and both the patient and occupational therapist
selected items for the task of using the paralyzed upper
limb in real life situations, according to upper limb
function, at the time of the interview. Then, the goal was
set based on mutual agreement.

3. Methods
3.1 Intervention protocol for the groups
In the ADOC-H group, goal setting using ADOC-H
and monitoring and problem-solving techniques wereadded to the conventional upper limb function and ADL
training. The control group received only conventional
training.
3.2 Interventions
We referred to the transfer package [12] of the
CIMT and modified the methods that could be implemented at our facility for behavioral contracting, monitoring, and problem-solving. The details of this process
are presented below.
3.2.1 Goal setting and agreement
An OT interviewed the intervention group using
the ADOC-H within 1 week after stroke onset, reacheda consensus with the patient on their preferred tasks toenable paralyzed upper limb use in daily life, and set
goals. The goals that are agreed upon are printed on
paper and placed on the participant’s bedside desk sothat the patient could always check them. Once the goalsetting activities could be used with the paralyzed upper
limb, the OT interviewed the patient again using the
ADOC-H and added new goals as needed.
3.2.2 Monitoring
The transfer package recommends monitoring of
the performance of targeted behaviors using the Motor
Activity Log and a diary [12]. In this study, the OT
encouraged patients’ self-monitoring of difficulty inparalyzed upper limb use for the items provided by
ADOC-H during each intervention. As this study included patients with cognitive impairment and aphasia, in
addition to oral monitoring, we devised ways to enable
patients to recall the activities by using manipulating
tools when necessary.
3.2.3 Problem-solving
The OT discussed how to use the paralyzed upper
limbs with the patient. The therapists then provided
advice, introduced self-help tools, and adjusted the environment as needed, encouraging paralyzed upper limbuse.

Asian J Occup Ther 19: 68−76, 2023

3.2.4 Upper limb function training
The training included reach movement training
using tools such as pegs and manipulation training
using daily items and simulated articles targeted toward
paralyzed upper limb use for items set as targets in the
ADOC-H application. Additionally, the above training
was combined with neuromuscular facilitation andtherapeutic electrical stimulation. The training method
and time differed depending on the patient’s level oftolerance, and almost the same method was performed
for both the intervention and control groups.
3.2.5 ADL training
The patients practiced movements such as toileting,
dressing, and bathing in a simulated or actual environment for ADL training based on their condition.
3.3 Statistical analysis
3.3.1 Propensity score matching
Based on the following items, the propensity score
was calculated using binomial logistic regression analysis: age, sex, length of hospital stay, disease type, total
FIM cognitive item score at admission, total GCS scoreat admission, paralysis of the dominant hand, SIAS subitems score at admission (including K-M and F-F), andPPM subitems score at admission (including eating andtoileting). Factors for calculating the propensity score
were obtained from previous studies [6, 23, 24] andclinical experience. The caliper was set to 0.25.
3.3.2 C omparison between the ADOC-H and control
groupsThe Shapiro–Wilk test was performed to test fornormality. The Wilcoxon signed-rank test was used tocompare the following items at admission and discharge
in the ADOC-H and control groups: SIAS K-M and F-F
and their total score and PPM eating and toileting andtheir total score. The effect size (r) was obtained fromthe Z-value.
3.3.3 Comparison of the ADOC-H and control groups
Patient characteristics at admission were compared
between the ADOC-H and control groups using Fisher’s
exact test, t-test, and Mann–Whitney U test. Additionally, the Mann–Whitney U test was used to compare
the scores of the following items at discharge and theirchanges (the score at discharge minus the score at admission) between the two groups: SIAS K-M and F-F
and their total scores and PPM eating and toileting andtheir total scores. The effect size (r) was calculated using
the Z-value.
For patients in the ADOC-H group with cognitive
decline and an MMSE score of < 24 points or those

Ikegami M et al.

71

with aphasia and an SIAS language function score of≤ 2 points, the propensity score was calculated using
the same factors, and propensity score matching withthe control group was performed. The caliper was set to0.25. Analyses was performed in the same manner as in
Sections 3.3.2 and 3.3.3.
3.3.4 Calculation of the achievement rate for items
selected using ADOC-H
In the ADOC-H group and ADOC-H group withcognitive impairment or aphasia, the number of people
who achieved paralyzed upper limb use with the items
selected by the ADOC-H process at the time of discharge and the achievement rate were calculated.
Regarding the sample size, at least 12 participants
were required for a larger sample size pilot follow-up
study [25], and 28 people were recruited for this study.
Statistical significance was set at P < 0.05. All statistical analyses were performed using Easy R ver. 1.55
(Saitama, Japan) [26].
3.4 Ethics
This study was conducted in accordance with the
ethical standards of the Declaration of Helsinki [27].
This study was approved by the Ethics Review Committee of our hospital (approval number: 20–27; approvaldate: 2021/1/20). All the patients provided written in­formed consent.

4. Results
Figure 1 shows the study flowchart. The ADOC-H
group included 28 patients who selected both eating(chopsticks, spoon/fork, and bowl) and toileting (hikeup/taking-off trouser) among the 31 patients who provided consent, and none dropped out. In the control group,of the 161 patients who provided consent, 6 dropped
out due to death and stroke recurrence after providing
consent; therefore, the study included 155 patients. The
final analysis included 21 propensity matched patients ineach group. Table 1 presents a comparison of the basic
characteristics of all patients between the two groups.
There were no significant differences in any basic
characteristics between the two groups. Table 2 shows
a comparison of the SIAS and PPM in all patients between the two groups. In each group, upper limb motor
function, K-M, F-F, PPM total, eating, and toiletingscores were significantly different after the intervention.
Compared with that noted in the control group, upper
limb motor function, K-M, F-F, PPM total, eating,and toileting scores were significantly improved in the
ADOC-H group. Regarding the items selected by 28
people during the ADOC-H process, the number of

72

EFFECT OF UPPER LIMB FUNCTION TRAINING COMBINED WITH GOAL SETTING USING ADOC-H

ADOC-H group

Control group

Patients with stroke who met theindication criteria and provided
consent (n = 31)

Patients with stroke who met theindication criteria and provided
consent (n = 161)

No selection of both eating(chopsticks, spoon/fork, bowl) andtoileting (hike-up /take-off trouser)
skills in the ADOC-H process (n =3)Pre- intervention assessment

Pre- intervention assessment

Dropouts（n=6）

Post-intervention assessment(n=28)

Post-intervention assessment(n=155)

Propensity score matching

Propensity score matching

Analyzed (n＝21)

Analyzed (n＝21)
Fig. 1. Flowchart of this study

Table 1 Comparison of the characteristics of all patients at admission between the ADOC-H and control groups
Characteristics
Age, years
Sex
Length of hospital stay, days
OT intervention days
Number of minutes of OT intervention per day
Disease type
Affected hand
Dominant hand
Paralysis of the dominant hand
GCS score
NIHSS score
FIM score
Motor
Cognitive
EatingToileting
SIAS score
Lower limb motor function
Upper limb sensory function
Language function

Median year (IQR)
Male/female (%)
Mean ± SD
Mean ± SD
Mean ± SD
Lacunar infarction/other (%)
Right/left (%)
Right/left (%)
Yes/no (%)
Median (IQR)
Median (IQR)
Median (IQR)

ADOC-H (n = 21)

Control (n = 21)P

76.00 (68.00, 82.00)
18 (85.7)/3 (14.3)
25.0 ± 10.02
23.86 ± 9.67
36.07 ± 6.85
2 ( 9.5)/19 (90.5)
6 (28.6)/15 (71.4)
21 (100)/0 (0)6 (28.6)/15 (71.4)
15.00 (14.00, 15.00)
4.00 (3.00, 6.00)

78.00 (67.00, 83.00)
16 (76.2)/5 (23.8)
22.9 ± 10.78
21.00 ± 10.34
35.16 ± 10.16
3 (14.3)/18 (85.7)
6 (28.6)/15 (71.4)
21 (100)/0 (0)6 (28.6)/15 (71.4)
15.00 (14.0, 15.0)
4.00 (3.00, 7.00)

0.724
0.697
0.508
0.361
0.735
1
1
–
1
0.673
0.732

22.00 (18.00, 31.00)
27.00 (21.00, 29.00)
4.00 (1.00, 5.00)
1.00 (1.00, 3.00)

18.00 (14.00, 25.00)
25.00 (20.00, 33.00)
2.00 (1.00, 4.00)
1.00 (1.00, 1.00)

0.283
0.99
0.417
0.858

11.00 (6.00, 12.00)
5.00 (4.00, 6.00)
3.00 (3.00, 3.00)

12.00 (6.00, 14.00)
6.00 (3.00, 6.00)
3.00 (3.00, 3.00)

0.317
0.798
0.655

IQR, interquartile range; SD, standard deviation; GCS, Glasgow coma scale; NIHSS, National Institutes of Health Stroke Scale; FIM, functional
independent measure; SIAS, stroke impairment assessment set; PPM, paralytic arm participation measure; ADOC-H, Aid for Decision-making in
Occupation Choice for Hand; OT, occupational therapist.

0.63
0.004
0.85
< 0.001
0.48
0.002
0.28
PPM, paralytic arm participation measure; SIAS, stroke impairment assessment set; K-M, knee mouth; F-F, finger flexion.

0.071
0.461
3.00
(1.00, 5.00)
1.00(1.00, 4.00)
4.00
2.00
(4.00, 5.00) (1.00, 3.00)
2.00(1.00, 4.00)
SIAS F-F

0.00(0.00, 1.00)

0.64
0.003
0.88
< 0.001
0.38
0.014
0.15
0.311
0.928
4.00
(2.00, 5.00)
3.00(1.00, 4.00)
4.00
1.00
(4.00, 5.00) (1.00, 2.00)
3.00(2.00, 3.00)
SIAS K-M

1.00(0.00, 1.00)

0.73< 0.001
0.88< 0.001
0.52
0.001
0.20
0.195
4.00
7.00
1.00
(2.00, 9.00) (4.00, 10.00) (0.00, 2.00)
9.00
3.00
(7.00, 9.00) (2.00, 4.00)
5.00(3.00, 7.00)
SIAS Upper limb
motor function

0.63

0.55
0.013
0.88
< 0.001
0.44
0.004
0.37
0.017
2.00
(0.00, 6.00)

0.00(0.00, 4.00)
0.00(0.00, 0.00)
6.00
3.00
(4.00, 6.00) (3.00, 6.00)
0.00(0.00, 3.00)
PPM Toileting

0.613

0.61
0.006
0.83
< 0.001
0.32
0.035
0.35
0.023
0.00
(0.00, 3.00)

0.00(0.00, 3.00)
0.00(0.00, 0.00)
3.00
2.00
(2.00, 3.00) (1.00, 3.00)
0.00(0.00, 0.00)
PPM Eating

0.408

0.64
0.003
0.88
< 0.001
0.43
0.005
0.36
0.018
3.00
(0.00, 9.00)

1.00(0.00, 6.00)
0.00(0.00, 0.00)
8.00
6.00
(5.00, 9.00) (5.00, 8.00)

0.308

Ikegami M et al.

PPM Total
0.00(Eating + Toileting) (0.00, 3.00)

r
P
r
P
r
P
r
P
P
Changein score
Postintervention
Preintervention
Changein score
PrePostintervention intervention

ADOC-H groupversus control
group (change
in scores)
ADOC-H group ADOC-H groupversus control
versus control
group (postgroup (preintervention)intervention)
Control group (n = 21)
ADOC-H group (n = 21)

Table 2 Comparison of the PPM and SIAS scores in all patients between the ADOC-H and control groups

Control group
ADOC-H group(pre- versus post- (pre- versus postintervention)intervention)

Asian J Occup Ther 19: 68−76, 2023

73

people who achieved the use of the paralyzed hand at
the time of discharge and their proportions are summarized in Supplementary Table 1. Twenty-one items wereselected, and the total number of people who selectedeach item was 111. The number of people who achieved
paralyzed upper limb use was 94, and the averageachievement rate was 85%.
The MMSE score was evaluated in 27 of the 28 patients. Eleven patients scored < 24 points; three patientswith aphasia had an SIAS language function score of≤ 2; and one patient was common to both. The above 13
participants were classified as the ADOC-H group withcognitive impairment or aphasia, and propensity scorematching was performed with 155 patients in the control
group. Analysis was conducted on 12 participants inboth groups. Table 3 presents a comparison of the basic
attributes of the two groups. There were no significant
differences in any of the basic attributes between the twogroups. Table 4 shows a comparison of the SIAS andPPM scores between the two groups. In the ADOC-H
group, upper-limb motor function, K-M, F-F, PPM total,
eating, and toileting scores were significantly different
after the intervention. In the control group, upper limb
motor function, PPM total, and eating scores weresignificantly different after the intervention, but K-M,
F-F, and toileting scores showed no significant differences. Compared to the control group, upper limb motor
function, K-M, F-F, PPM total, and toileting scores
were significantly improved in the ADOC-H group withcognitive impairment or aphasia. The items selectedduring the ADOC-H process in the 13 participants withcognitive impairment or aphasia, number of people whoachieved those movements at the time of discharge, andtheir ratios are summarized in Supplementary Table 1.
Eleven items were selected, and the total number ofpeople who selected each item was 44. The numberof people who achieved use was 33, and the averageachievement rate was 75%.

5. Discussion
We introduced an intervention of setting goals forupper limb use in daily life using ADOC-H, monitoring,and problem-solving techniques in addition to conventional occupational therapy for hospitalized patients withacute stroke. This intervention resulted in significant
improvement in upper limb use. Moreover, similar significant improvement was observed in participants withcognitive impairment or aphasia. In this intervention,
the average achievement rate for the items selected was
high.

74

EFFECT OF UPPER LIMB FUNCTION TRAINING COMBINED WITH GOAL SETTING USING ADOC-H

Table 3 Comparison of patient characteristics at admission between the ADOC-H group and control groups in patients with cognitive impairment or aphasia
Characteristics
Age, years
Sex
Length of hospital stay, days
OT intervention days
Number of minutes of OT intervention per day
Disease type
Affected hand
Dominant hand
Paralysis of the dominant hand
GCS score
NIHSS score
FIM score
Motor
Cognitive
EatingToileting
SIAS score
Lower limb motor function
Upper limb sensory function
Language function

Median year (IQR)
Male/female (%)
Mean ± SD
Mean ± SD
Mean ± SD
Lacunar infarction/other (%)
Right/left (%)
Right/left (%)
Yes/no (%)
Median (IQR)
Median (IQR)
Median (IQR)

ADOC-H (n = 12)

Control (n = 12)P

78.00 (69.75, 83.50)
11 (91.7)/1 (8.3)
25.33 ± 8.26
23.92 ± 6.96
33.66 ± 6.59
1 (8.3)/11 (91.7)
5 (41.7)/7 (58.3)
12 (100)/0
5 (41.7)/7 (58.3)
14.50 (14.00, 15.00)
4.00 (2.75, 6.25)

76.50 (70.00, 81.25)
12 (100)/0
21.92 ± 14.78
20.08 ± 12.22
32.46 ± 10.03
1 (8.3)/11 (91.7)
5 (41.7)/7 (58.3)
11 (91.7)/1 (8.3)
6 (50)/6 (50)
15.00 (14.75, 15.00)
3.50 (2.75, 7.00)

0.686
1
0.118
0.355
0.732
1
1
1
1
0.348
0.977

21.50 (17.75, 30.50)
21.50 (15.75, 27.75)
4.50 (1.00, 5.00)
1.00 (1.00, 1.50)

20.50 (13.75, 46.75)
25.00 (19.00, 29.00)
4.00 (1.75, 5.00)
1.00 (1.00, 4.25)

0.931
0.664
0.761
0.334

11.00 (5.75, 12.00)
5.50 (3.75, 6.00)
3.00 (2.75, 3.00)

13.50 (5.00, 14.00)
5.00 (3.00, 6.00)
3.00 (3.00, 3.00)

0.281
0.805
0.654

IQR, interquartile range; SD, standard deviation; GCS, Glasgow coma scale; NIHSS, National Institutes of Health Stroke Scale; FIM, functional
independent measure; SIAS, stroke impairment assessment set; PPM, paralytic arm participation measure; ADOC-H, Aid for Decision-making in
Occupation Choice for Hand; OT, occupational therapist.

5.1 Increase in upper limb usage on the paralyzed side
The time for upper limb function training was
shorter in this study than that reported for CIMT, and interventions to promote upper limb use in daily life were
not conducted by written contracts or monitored using
a diary. However, the ADOC-H group showed a significant increase in paralyzed upper limb usage, suggestingthat our intervention is effective for upper limb use in
the daily life of patients with acute stroke.
Further, as shown in the study using the transfer
package in CIMT, we identified that it was importantfor OTs to not only intervene during training but also tointervene to change the behavior regarding upper limb
use in daily life.
We also found a significant increase in the numberof upper limbs used on the paralyzed side in the
ADOC-H group compared with the control group in
patients with cognitive impairment or aphasia. A featureof ADOC-H is that it allows patients and therapists toshare specific tasks involving the use of the hands byusing “words,” “letters,” and “illustrations.” Studies on
ADOC have reported that patients can easily express
their wishes and desires because of the simple processof selecting from the illustrations displayed on the iPad,and most patients and OTs felt encouraged to participate
in the goal-setting process using ADOC [22]. Based on
the above, even in patients with impaired cognitive andlanguage functions, by setting goals from illustrations

provided during the ADOC-H process, patients can be
actively involved in goal setting, and the effect of goal
setting is clearer. Therefore, this intervention method
using the ADOC-H, which can help patients and therapists to visually share goals, can increase the numberof upper limbs on the paralyzed side used in daily life,
even in cases where the transfer package cannot be
adapted. Therefore, this intervention may be applicable
to a wider range of participants.
5.2 Improvement of the function of the paralyzed upper
limb
Upper limb motor paralysis showed significant improvement in the ADOC-H group. In this study, propensity score matching was performed using factors related
to motor paralysis improvement. There was no difference in the duration and quality of occupational therapy
interventions between the two groups. Therefore, theimprovement in motor paralysis by natural recovery wasconsidered similar in both groups. Paralyzed upper limb
use in daily life is important for the functional recoveryof the paralyzed upper limb [4]. It is possible that therecovery of upper limb function was further promotedby the increase in the frequency of paralyzed upper limb
use in daily life owing to the combined intervention inthis study.

0.55
0.089
0.86
0.003
0.61
PPM, paralytic arm participation measure; SIAS, stroke impairment assessment set; K-M, knee mouth; F-F, finger flexion

0.23
SIAS F-F

3.50(0.75, 5.00)
2.00(0.75, 5.00)
4.50
1.50
(3.75, 5.00) (1.00, 2.00)
2.00(1.75, 3.25)

0.00(0.00, 1.00)

0.86

0.247

0.003

0.47
0.129
0.91
0.001
0.69
0.24
0.224
3.00
(1.75, 4.00)
4.00
1.00
(4.00, 5.00) (1.00, 2.00)
3.00(2.00, 3.00)
SIAS K-M

3.50(1.75, 5.00)

4.50
7.00
1.00
(2.50, 9.00) (2.50, 10.00) (0.00, 1.00)
9.00
3.00
(7.75, 9.25) (2.75, 3.25)
5.00(3.75, 6.25)
SIAS Upper limb
motor function

2.00(0.00, 6.00)

0.00(0.00, 1.00)
0.00(0.00, 1.50)
6.00
4.00
(4.50, 6.00) (2.75, 6.00)
0.00(0.00, 0.75)
PPM Toileting

0.00(0.00, 1.00)

0.789

0.001

0.61
0.04
0.90
0.002
0.74
0.17
0.391
1.0

< 0.001

0.47
0.174
0.89
0.002
0.57
0.33
0.099
0.732

0.005

0.59
0.048
0.83
0.004
0.35
PPM Eating

1.00(0.00, 3.00)

0.50(0.00, 2.25)
0.00(0.00, 0.25)
3.00
2.50
(1.75, 3.00) (1.00, 3.00)
0.00(0.00, 0.00)

0.25
0.219
0.306

0.08

0.59
0.049
0.89
0.002
0.51
3.00
(0.00, 9.00)

0.50(0.00, 3.75)
0.00(0.00, 2.25)
8.50
6.00
(4.75, 9.00) (4.75, 8.25)
PPM Total
0.00(Eating + Toileting) (0.00, 2.25)

0.28
0.159
0.783

0.011

r
P
r
P
r
r
P

P

Ikegami M et al.

P
Changein score
Postintervention
Preintervention
Changein score
PrePostintervention intervention

Control group
ADOC-H group(pre- versus post- (pre- versus postintervention)intervention)
ADOC-H groupversus control
group (change
in scores)
ADOC-H group ADOC-H groupversus control
versus control
group (postgroup (preintervention)intervention)
Control group (n = 12)
ADOC-H group (n = 12)

Table 4 Comparison of the PPM and SIAS scores between the ADOC-H and control groups in patients with cognitive impairment or aphasia

Asian J Occup Ther 19: 68−76, 2023

75

5.3 Limitations
This study included patients who had undergone
occupational therapy in the past as controls and performed pseudo-randomization using existing patientcharacteristics and evaluation results that could be collected from medical records. However, since it was nota randomized control, unmeasured confounding factors
and exposure suspicion bias cannot be excluded. In the
future, it will be necessary to increase the number ofpatients and conduct randomized controlled studies toeliminate confounding factors and biases.
We evaluated the frequency of paralyzed upper
limb use, as assessed by the PPM eating and toileting;however, we did not evaluate basic ADL such as dressing and bathing. Moreover, paralyzed upper limb use forother items selected during the ADOC-H process wasinvestigated only for achievement or non-achievementof the task. In the future, to evaluate changes in usage
conditions, evaluating the amount and frequency of use
in stages and patients’ degree of satisfaction and achievement is necessary.
In conclusion, this pilot study demonstrated thatcompared with the conventional occupational therapy,
the combination of techniques improved the frequency
of usage of the upper limbs on the paralyzed side indaily life as assessed by the PPM and the motor function
scores of the SIAS. This result was the same, even inpatients with cognitive impairment or aphasia. The
ADOC-H intervention method used in this study is applicable to a wider range of patients compared to that of
the conventional transfer package and may be effectivein improving the frequency of paralytic upper limb use
and motor function of the paralyzed side in patients withacute stroke. In the future, it will be necessary to verify
these effects with randomized controlled trials.

Conflict of Interest
No potential conflict of interest was reported by theauthors.

Acknowledgements
We are grateful to the staff and patients of our hospital for their support.

References[1] Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet. 2011; 377(9778): 1693–702.
[2] Barbay S, Plautz EJ, Friel KM, Frost SB, Dancause N,
Stowe AM, et al. Behavioral and neurophysiological

76

EFFECT OF UPPER LIMB FUNCTION TRAINING COMBINED WITH GOAL SETTING USING ADOC-H

effects of delayed training following a small ischemic
infarct in primary motor cortex of squirrel monkeys. Exp
Brain Res. 2006; 169(1): 106–16.
[3] Veerbeek JM, Kwakkel G, van Wegen EE, Ket JC,
Heymans MW. Early prediction of outcome of activities
of daily living after stroke: a systematic review. Stroke.
2011; 42(5): 1482–8.
[4] Barker RN, Gill TJ, Brauer SG. Factors contributing
to upper limb recovery after stroke: a survey of stroke
survivors in Queensland Australia. Disabil Rehabil. 2007;
29(13): 981–9.
[5] Lang CE, Wagner JM, Edwards DF, Dromerick AW.
Upper extremity use in people with hemiparesis in thefirst few weeks after stroke. J Neurol Phys Ther. 2007;
31(2): 56–63.
[6] Ikegami M, Mutai H, Yuzawa Y, Sakai N. Factors predicting the use of paralyzed upper limbs in the daily lifeof patients with acute stroke. Asian J Occup Ther. 2022;
18(1): 9–16.
[7] Liao WW, Wu CY, Hsieh YW, Lin KC, Chang WY.
Effects of robot-assisted upper limb rehabilitation on
daily function and real-world arm activity in patientswith chronic stroke: a randomized controlled trial. Clin
Rehabil. 2012; 26(2): 111–20.
[8] Uswatte G, Taub E, Bowman MH, Delgado A, Bryson C,
Morris DM, et al. Rehabilitation of stroke patients with
plegic hands: randomized controlled trial of expanded
constraint-induced movement therapy. Restor Neurol
Neurosci. 2018; 36(2): 225–44.
[9] Mekbib DB, Han J, Zhang L, Fang S, Jiang H, Zhu J,
et al. Virtual reality therapy for upper limb rehabilitationin patients with stroke: a meta-analysis of randomized
clinical trials. Brain Inj. 2020; 34(4): 456–65.
[10] Da-Silva RH, van Wijck F, Shaw L, Rodgers H, BalaamM, et al. Prompting arm activity after stroke: a clinicalproof of concept study of wrist-worn accelerometers witha vibrating alert function. J Rehabil Assist Technol Eng.
2018; 5: 2055668318761524.
[11] Thrane G, Friborg O, Anke A, Indredavik B. A metaanalysis of constraint-induced movement therapy after
stroke. J Rehabil Med. 2014; 46(9): 833–42.
[12] Morris DM, Taub E, Mark VW. Constraint-induced
movement therapy: characterizing the intervention protocol. Eura Medicophys. 2006; 42(3): 257–68.
[13] Dromerick AW, Lang CE, Birkenmeier RL, Wagner JM,
Miller JP, Videen TO, et al. Very early constraint-induced
movement during stroke rehabilitation (VECTORS): asingle-center RCT. Neurology. 2009; 73: 195–201.
[14] Liu XH, Huai J, Gao J, Zhang Y, Yue SW. Constraintinduced movement therapy in treatment of acute and subacute stroke: a meta-analysis of 16 randomized controlled
trials. Neural Regen Res. 2017; 12: 1443–50.
[15] Ohno K, Tomori K, Takebayashi T, Sawada T, Nagayama

H, Levack WM, et al. Development of a tool to facilitate
real life activity retraining in hand and arm therapy. Br J
Occup Ther. 2017; 80(5): 310–8.
[16] Takino T, Takebayashi T, Takeuchi K, Tomori K, Shimada
S. The study of a task-specific approach and a behavioral
strategy by ADOC-H in daily life for a subacute stroke
patient (in Japanese). Japanese Occupational Therapy
Research (sagyouryouhou). 2018; 37(6): 661–8.
[17] Tsuji T, Liu M, Sonoda S, Domen K, Chino N. The stroke
impairment assessment set: its internal consistency andpredictive validity. Arch Phys Med Rehabil. 2000; 81(7):863–8.
[18] Uswatte G, Taub E, Morris D, Vignolo M, McCulloch K.
Reliability and validity of the upper-extremity Motor Activity Log-14 for measuring real-world arm use. Stroke.
2005; 36(11): 2493–6.
[19] Watanabe T, Kinosita Y, Takahasi T, Ito T, Sonoda S.
Further investigation of validity of the Paralytic arm Participation Measure (PPM) and its level of difficulty witheach item (in Japanese). The Japanese Journal of Occupational Therapy (sagyouryouhou journal). 2010; 44(6):489–94.
[20] Sato H, Watanabe T, Onaka T, Watanabe M, Sakamoto R,
Sonoda S. Reliability and validity of the new method toevaluate degree of participation of paralytic arm in activities of daily living (in Japanese). The Japanese Journalof Occupational Therapy (sagyouryouhou journal). 2008;
42(8): 876–9.
[21] Charles C, Gafni A, Whelan T. Shared decision-making
in the medical encounter: what does it mean? (or it takes
at least two to tango). Soc Sci Med. 1997; 44(5): 681–92.
[22] Tomori K, Uezu S, Kinjo S, Ogahara K, Nagatani R,
Higashi T. Utilization of the iPad application: aid for
decision-making in occupation choice. Occup Ther Int.
2012; 19(2): 88–97.
[23] Narai E, Hagino H, Komatsu T, Togo F. Accelerometerbased monitoring of upper limb movement in older adults
with acute and subacute stroke. J Geriatr Phys Ther.
2016; 39(4): 171–7.
[24] Vanbellingen T, Ottiger B, Maaijwee N, Pflugshaupt T,
Bohlhalter S, Müri RM, et al. Spatial neglect predicts
upper limb use in the activities of daily living. Cerebrovasc Dis. 2017; 44(3–4): 122–7.
[25] Moore CG, Carter RE, Nietert PJ, Stewart PW. Recommendations for planning pilot studies in clinical andtranslational research. Clin Transl Sci. 2011; 4(5): 332–7.
[26] Kanda Y. Investigation of the freely-available easy-touse software “EZR” (Easy R) for medical statistics. Bone
Marrow Transplant. 2013; 48: 452–8.
[27] World Medical Association. World Medical Association
Declaration of Helsinki: ethical principles for medical
research involving human subjects. JAMA. 2013; 310:
2191–4.

■ORIGINAL ARTICLE

Reminiscence Content and Quality Among
Community-Dwelling Older Adults in Japan
Yue Zhao1, Kyosuke Yorozuya2, Hideaki Hanaoka3
1

The First Rehabilitation Hospital of Shanghai
Faculty of Rehabilitation and Care, Seijoh University
3
Graduate School of Biomedical and Health Sciences, Hiroshima University
2

Abstract: Objective: It is well known that reminiscence therapy improves mental health by encouraging the elderly torecall past life events; however, the content and how it can contribute to the intervention is still not fully understood.
This study examined the relationship between reminiscence content and the quality of reminiscence and determined
whether the latter was associated with depression, life satisfaction, and self-esteem.
Methods: A total of seventy-one community-dwelling older adults participated in this study. We chose 15 topics to determine whether they could recall the reminiscence contents. Data were collected on mental health using the Japaneseversions of the Geriatric Depression Scale-5, Life Satisfaction Index-Koyano Scale, and Rosenberg Self-esteem Scale.
Multiple imputations were performed to compensate for missing values.
Results: A single regression showed that 10 reminiscence content items were associated with positive reminiscence,
while three predicted lower negative reminiscences. Positive reminiscence was significantly correlated with negative
reminiscence (r = −0.456, p < 0.001), depression (r = −0.299, p = 0.012), life satisfaction (r = 0.315, p < 0.010), andself-esteem (r = 0.400, p < 0.001). Negative reminiscence significantly correlated with depression (r = 0.435, p < 0.001),
life satisfaction (r = −0.423, p < 0.001), and self-esteem (r = −0,345, p = 0.003).
Conclusion: Reminiscence content was associated with positive and negative recalling experiences, which are possible
factors affecting mental health. Understanding the influence of reminiscence content and quality on mental health can
inform strategies to improve mental health.
Keywords: reminiscence contents, quality of reminiscence, depression, life satisfaction, self-esteem(Asian J Occup Ther 19: 77−86, 2023)

Introduction
In recent years, reminiscence therapy has beenrecognized as a type of psychotherapy that is especially recommended for older adults because it has few
adverse effects, is inexpensive, and effective [1]. It
can be broadly defined as a method to encourage older
adults to recall past events and experiences [2]. Unlike
simply remembering the past, reminiscence can evoke
the feelings and thoughts of past events to facilitate
adaptation to the present, resolve past conflicts, establish
self-identity, and improve quality of life [3, 4]. During
Received: 19 May 2022, Accepted: 25 January 2023
Corresponding to: Hideaki Hanaoka, Graduate School of Biomedicaland Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku,
Hiroshima City, Hiroshima, 734-8553, Japane-mail: hhanaoka@hiroshima-u.ac.jp©2023 Japanese Association of Occupational Therapists

this kind of intervention, older adults are asked to share
past memories according to the topics selected by thetherapist with the help of old objects or photographs.
Studies conducted over the past decade have examined the effects of reminiscence therapy on reducing thesymptoms of depression [5], improving life satisfaction[6], and increasing self-esteem [7] among older adults.
With regard to how reminiscence therapy can alleviate
mental health problems, a few researchers have focusedon the quality of reminiscence. When people recall thepast, the mood can be happy and satisfied, also can besad or painful or other. According to the characteristics
of emotions can be basically divided into positive or
negative [8]. It has been reported that older adults are
better able to adapt to life satisfaction and self-esteem
when recalling the past with positive emotions [9, 10].
However, findings from some published studies on
the effect of reminiscence are inconsistent [7, 11, 12]. A
systematic review of research on reminiscence effects

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REMINISCENCE OF OLDER ADULTS IN JAPANamong older adults has suggested that the conflicting
outcomes may be attributed to various reminiscence processes [13]. It is difficult to compare the results of theseadoptions of reminiscence therapy because the processes
are not standardized and the shared contents and factors
are not clear [13]. Elias et al. [14]also concluded thatdiffering processes of reminiscence therapy remain aproblem, and reminiscence content for sessions needs to
be investigated. Until now, however, little attention has
been paid to the reminiscence content. An understandingof the content that can contribute to the effect of reminiscence is still lacking. It is thus necessary to clarify thecriteria based on which the therapist can establish thereminiscence content for future interventions on mental
health.
To this end, this study aimed to explore the relationship between reminiscence content and the qualityof reminiscence to extend the knowledge of the processof reminiscence therapy and to examine whether thequality of reminiscence is associated with depression,
life satisfaction, and self-esteem.

Materials and Methods
ParticipantsThis cross-sectional study was conducted in Hiroshima City, Japan, between October, 2020 and November, 2020. Participants were community-dwelling older
adults who participated in preventive care programs run
by a regional comprehensive support center. A total of
71 individuals were recruited for this study.
The inclusion criteria were as follows: individuals
who were over 65 years of age; those who could answer
the questionnaire and who did not have hearing or visual
impairment; and individuals who agreed to participate inthis investigation.
The researcher explained the purpose and significance of the study to the person in charge of the preventive care program and obtained consent to conduct thequestionnaire survey.
Measurements
The questionnaire contained the following six aspects:
Participant Characteristics
At the beginning of the questionnaire, demographic
characteristics including age, gender, marital status,
living arrangement, economic status, health status, andoutpatient treatment were obtained. For this study, we
created a checklist for older adults and asked them tochoose the option that best matched their current situations. To the question “Are you satisfied with your current economic status?” participants replied by choosing

one of the following options: “very satisfied” “somewhat
satisfied” “somewhat dissatisfied” or “very dissatisfied”
For ease of reviewing the results, “very satisfied” and“somewhat satisfied” were grouped as “good”, while“somewhat dissatisfied” and “very dissatisfied” weregrouped as “bad”. The question “How is your current
physical health?” was answered by the participants bychoosing any one of the following options: “very good”“fair” “not very good” or “very bad”. For ease of reviewing the results, “very good” and “fair” were grouped as“good”, while “not very good” and “very bad” as “bad”.
Reminiscence Content
To explore what older adults may recall in their
daily lives, we referred to the examples of contents forreminiscence sessions proposed by Nomura [15], additionally, we referred to the common topics in Japaneseintervention studies [16]. Since the participants wereJapanese, we selected 15 themes that would be most appropriate to them: “new year,” “Obon dance” (a dancing
style in Japan), “hometown,” “regional festival,” “thesong one used to listen to in one’s youth,” “doing house­work as a child,” “playing with friends,” “memories
about primary school,” “Japanese snack,” “sports one
used to play,” “family,” “summer,” “marriage,” “raisingchildren,” and “jobs.” The contents were carefully
reviewed by the primary, second, and last authors. In
case of disagreements on the choices of the themes,
the primary and second author reviewed the previous
research and held discussions, while the last author
decided whether to reach a consensus. The participants
were asked to answer “Yes” or “No” to questions, suchas “Have you remembered anything about the new year
in your daily life?”
Quality of Reminiscences
After asking about reminiscence content, we used
a self-report checklist which developed by Nomura
and Hashimoto [17] to evaluate the quality of emotions
generated by reminiscence. They reported Cronbach’s αcoefficient of 0.918 and 0.845 for positive and negative
reminiscence, respectively. We used the short form of
the checklist proposed by Nomura and Hashimoto [10].
It contains six positive and six negative items, positive
items are: 1. When I think of the past, I feel happy; 2.
When I think of the past, my heart is peaceful; 3. WhenI think of the past, I feel at ease; 4. When I think of thepast, I feel satisfied; 5. I think my memory of the pastis irreplaceable; and, 6. I feel nostalgic when thinking
about the past. The negative items are: 1. It is painful
to think about the past; 2. I have a past I do not want
to remember; 3. When I looked back at the past, mymood becomes low; 4. I have many bad memories;
5. Until now, there have been unforgettable unhappy
memories; 6. To date, there have been regretful andAsian J Occup Ther 19: 77−86, 2023

Zhao Y et al.

79

reluctant memories. Participants rated each item on a
five-point scale ranging from “Yes, I think so” (5 points)
to “No, I do not think so” (1 point), with a total possible
score of 30 points, with higher scores indicating higher
levels of positive or negative emotions. In this study,
the Cronbach’s α coefficients for positive and negative
reminiscence were 0.94 and 0.93, respectively.
Depression
The Geriatric Depression Scale-5 was used as ascreening tool for depression symptoms, and the Cronbach’s α coefficient was 0.80 [18]. However, we used
the Japanese version designed by Toba [19]. This scale
comprises five questions, such as “Are you basically satisfied with life?” According to the questions, the participants were asked to describe their feelings over the past
week, responding with “Yes” or “No,” The total possible
scores ranged from 0 to 5, with a cutoff point equal toor higher than 2 indicating depressive symptoms. The
Cronbach’s α coefficient in this study was 0.637, whichis acceptable [20].
Life Satisfaction
Koyano et al.’s [21] Japanese version of the Life
Satisfaction Index (LSI-K) was used to assess the levelof life satisfaction. The original study reported a Cronbach’s α coefficient of 0.849, indicating high reliability.
In this study, the coefficient was 0.746. This scale comprises three subscales, including “Satisfaction with life
as a whole,” “Psychological stability,” and “Evaluationof one’s own aging,” composed of nine items. Amongthem, seven items comprised a two-point response
format of “Yes” and “No.” One item had a three-point
response format of “almost nothing,” “not much,” and “alot.” The remaining item also followed a three-point response format of “Satisfied,” “Generally satisfied,” and“Dissatisfied.” The scores range from 0 to 9, with higher
total scores indicating greater life satisfaction.
Self-Esteem
The Rosenberg Self-Esteem Scale (RSE) is themost commonly used and highly reliable instrument
for measuring self-esteem [22]. We used a translated
Japanese version with a Cronbach’s α coefficient of 0.80,
signifying high reliability, to determine participants’feelings of self-worth [23]. In this study, the coefficient
was 0.767. The RSE is composed of 10 items rated on a
five-point scale. The scores on the RSE ranged from 10
to 50, with higher scores indicating higher self-esteem.

analysis (Table 1). Fisher’s exact test and Mann-Whitney
U test were used for the comparisons. Thereafter, we
identified the differences in each item between theparticipants with complete data and those with missing
data, which we decided to address by data completion to
avoid selection bias. Therefore, we performed multiple
imputations, which we consider the most advanced
method for improving the accuracy and statisticalpower of missing data. We created 20 multiple imputed
datasets with missing values to complement incomplete
data containing all variables. Missing at random wasassumed for the data (missing completely at random was
rejected by Little’s test statistic ( p < 0.001)) [24], andmultiple imputation was performed, including the item
scores of each scale, and total scores as well as eachsurvey item. The parameters were estimated individuallyfor each multiple imputed dataset and combined using
Rubin’s [25] rules [26].

Statistical Analyses
Among the responses (n = 71), 14 (24.6%) had
missing values for one or more items. Therefore, wefirst compared each item between complete and incomplete data to check for data bias and determine whether
participants with missing data were excluded from theResults

To analyze the results, first, a single regression
analysis was performed for each explanatory variable,
which comprised the content of the reminiscence andthe scores of positive and negative reminiscence, whichwere the response variables. Second, the correlation
between the scores for positive reminiscence, negative
reminiscence, GDS-5, LSI-K, and RSE were evaluatedusing Spearman’s rank correlation coefficient. Third,
multiple linear regression analysis was performed, andsocial factors were used as explanatory variables, andthe scores of positive reminiscence, negative reminiscence, GDS-5, LSI-K, and RSE were used as response
variables.
The statistical software “R” (version 4.0.5; R Foundation for Statistical Computing, Vienna, Austria), naniar(version 0.6.1) package, “mice” (version 3.13.0) package, “miceadds” (version 3.11-6) package, and “mitml”(version 0.4-1) package were used for statistical analysis. Statistical significance was set at p < 0.05. The“ltm” (version 1.1-1) package was used for calculating
Cronbach’s α.
Ethical Statement
This study was conducted in accordance with theprinciples of the Declaration of Helsinki and was approved by the Ethical Committee for Epidemiology ofHiroshima University (E-2207).

Characteristics of Participants
In total, 71 older adults participated in this study.
Table 1 presents the complete and missing data regarding participants’ characteristics. Most of the participants

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REMINISCENCE OF OLDER ADULTS IN JAPAN

Table 1 Participants’ Characteristics and Comparison Between Participants with Complete and Incomplete Data
Participants who hadcomplete data (n = 57)

Total (n = 71)

Characteristics
Age, year
Female, n (%)
Marital status, married, n (%)
Living arrangement, alone, n (%)
Economic status, good, n (%)
Community activities, yes, n (%)
Health status, good, n (%)
Outpatient treatment, yes, n (%)
Reminiscence contents
New Year’s Day, yes, n (%)
Obon dance, yes, n (%)
Hometown, yes, n (%)
Regional festival, yes, n (%)
Song, yes, n (%)
Housework, yes, n (%)
Playing, yes, n (%)
Primary school, yes, n (%)
Traditional food, yes, n (%)
Sport, yes, n (%)
Family, yes, n (%)
Summer, yes, n (%)
Marriage, yes, n (%)
Raising children, yes, n (%)
Jobs, yes, n (%)
Psychological assessments
Positive reminiscence, score
Negative reminiscence, score
GDS-5, score
LSI-K, score
RSE, score

Numberof valid
responses

SD/%

Numberof valid
responses

Mean/nMean/n

71
71
71
71
71
71
70
68

77.7
62
38
23
51
66
54
61

6.1
87.3%
53.5%
32.4%
71.8%
93.0%
77.1%
89.7%

57
57
57
57
57
57
57
57

71
71
71
71
71
71
71
71
70
71
71
71
71
71
71

56
42
59
55
61
55
59
55
45
43
65
62
58
61
60

78.9%
59.2%
83.1%
77.5%
85.9%
77.5%
83.1%
77.5%
64.3%
60.6%
91.5%
87.3%
81.7%
85.9%
84.5%

69
70
66
67
69

22.6
16.3
1.3
4.5
34.7

5.6
7.4
1.4
2.5
6.1

Participants who had
missing data (n = 14)
p-valueSD/%

Numberof valid
responses

Mean/n

SD/%

76.4
50
32
17
40
53
42
50

6.2
87.7%
56.1%
29.8%
70.2%
93.0%
73.7%
87.7%

14
14
14
14
14
14
13
10

78.4
13
6
7
12
13
12
10

6.5
92.9%
42.9%
50.0%
85.7%
92.9%
92.3%
100.0%< 0.001
1.000
0.390
0.209
0.324
1.000
0.272
0.588

57
57
57
57
57
57
57
57
57
57
57
57
57
57
57

44
34
49
44
50
42
48
44
35
35
52
50
46
48
49

77.2%
59.6%
86.0%
77.2%
87.7%
73.7%
84.2%
77.2%
61.4%
61.4%
91.2%
87.7%
80.7%
84.2%
86.0%

14
14
14
14
14
14
14
14
13
14
14
14
14
14
14

12
7
11
11
11
13
10
11
10
8
13
12
12
13
10

85.7%
50.0%
78.6%
78.6%
78.6%
92.9%
71.4%
78.6%
76.9%
57.1%
92.9%
85.7%
85.7%
92.9%
71.4%

0.719
0.557
0.444
1.000
0.402
0.166
0.270
1.000
0.353
0.770
1.000
1.000
1.000
0.674
0.442

57
57
57
57
57

22.2
16.7
2.4
4.4
34.6

5.6
7.7
1.4
2.4
6.3

12
13
9
10
12

24.2
14.5
0.4
5.6
35.2

5.6
5.6
0.7
2.5
5.0

< 0.001< 0.001< 0.001< 0.001< 0.001

Note. GDS-5: Geriatric Depression Scale-5 Japan version; LSI-K: Life Satisfaction Index-K Japanese version; RSE: Rosenberg Self-Esteem
Survey Japanese version.
The Fisher’s exact test and Mann-Whitney U test were used for complete data and incomplete data comparisons.

were women (n = 62, 87.3%). The mean age of the participants was 77.7 ± 6.1 years. There was a significant
difference between the age groups, with participants
who had missing data more likely to be older. No significant difference was found between the groups for thereminiscence content.
The data also revealed that there were significant
differences between the groups in terms of positive
reminiscence, negative reminiscence, and GDS, LSI-K,
and RSE. The mean score of positive reminiscence forparticipants with missing data tended to be higher, whilethat of negative reminiscence tended to be lower. Meanwhile, the GDS-5 score was reported to be relatively
lower, whereas the LSI-K and RSE scores were higher.

Relationships Between Reminiscence Contents andQuality of Reminiscence
The results of the single linear regression using
multiple imputed datasets are shown in Table 2. The
results revealed that New Year’s Day (β = 0.384, p =0.001), Obon dance (β = 0.271, p = 0.026), hometown(β = 0.251, p = 0.035), regional festival (β = 0.456,
p < 0.001), housework (β = 0.250, p = 0.042), playing(β = 0.274, p = 0.021), primary school (β = 0.377, p =0.002), traditional food (β = 0.373, p = 0.002), sports(β = 0.283, p = 0.020), and summer (β = 0.285, p =0.023) were significant predictors of positive reminiscence. Furthermore, sports (β = −0.233, p = 0.047),
family (β = −0.275, p = 0.020), and summer (β =−0.234, p = 0.047) were found to be significant predic-

Asian J Occup Ther 19: 77−86, 2023

Zhao Y et al.

81

Table 2 Single Linear Regression Analysis of The Relationship Between Reminiscence Content and Quality by Analyzing Multiply Imputed
Data Sets (n = 71)
Positive reminiscence
Estimate
New Year’s Day
Obon danceHometown
Regional festival
Song
Housework
PlayingPrimary school
Traditional foodSport
FamilySummerMarriage
Raising children
Jobs

5.269
3.072
3.885
6.123
3.853
3.275
3.976
4.969
4.324
3.250
3.338
4.670
2.940
−0.5173.438

95% CI
2.270
0.429
0.345
3.298
−0.274
0.177
0.683
2.000
1.733
0.579
−1.3440.737−0.412−4.317−0.181

8.268
5.715
7.424
8.948
7.981
6.372
7.268
7.938
6.916
5.921
8.020
8.602
6.293
3.283
7.058

Negative reminiscenceβtp-value

Estimate

0.384
0.271
0.251
0.456
0.239
0.250
0.274
0.377
0.373
0.283
0.166
0.285
0.202
−0.032
0.215

2.341
1.818
3.261
2.078
4.436
2.497
2.822
2.295
1.748
1.857
5.706
4.025
2.926
3.758
3.410

0.001
0.026
0.035
< 0.001
0.074
0.042
0.021
0.002
0.002
0.020
0.163
0.023
0.090
0.790
0.071

−2.437−1.335−4.052−2.2540.750
0.525−1.975−0.040−1.852−3.559−7.270−5.204−1.9330.168−2.605

95% CI−6.631−4.841−8.873−6.431−4.212−3.610−6.525−4.176−5.480−7.002−13.235−10.247−6.377−4.797−7.339

1.757
2.172
0.770
1.922
5.712
4.660
2.575
4.097
1.775
−0.116−1.305−0.161
2.511
5.133
2.129

β

t

p-value−0.133−0.097−0.214−0.1400.038
0.033−0.1170.001−0.115−0.233−0.275−0.234−0.0990.010−0.126

4.579
3.200
6.051
4.540
6.409
4.450
5.389
4.454
3.425
3.085
9.262
6.621
5.141
6.416
5.834

0.285
0.458
0.105
0.294
0.768
0.804
0.398
0.985
0.321
0.047
0.020
0.047
0.397
0.947
0.294

Table 3 Correlations Between Positive Reminiscence, Negative Reminiscence, and GDS-5, LSI-K, and RSE

Positive reminiscence
Negative reminiscence
GDS-5
LSI-K
RSE

r

p-valuer

p-valuer

p-valuer

p-valuer—−0.456−0.2990.315
0.400< 0.0010.012
0.010< 0.001—
0.435−0.423−0.345< 0.001< 0.001
0.003—−0.477−0.392< 0.001< 0.001—
0.433< 0.001—

p-value

Note. GDS-5: Geriatric Depression Scale-5 Japan version; LSI-K: Life Satisfaction Index-K Japanese version; RSE: Rosenberg SelfEsteem Survey Japanese version.
The spearman’s rank correlation coefficient was used for the correlation between the scores for positive reminiscence, negative reminiscence, GDS-5, LSI-K, and RSE.

tors of negative reminiscence.
Correlations Between Quality of Reminiscence,
Depression, Life-Satisfaction, and Self-Esteem
Table 3 reports weak to moderate significant correlations of positive reminiscence with negative reminiscence (r = −0.456, p < 0.001), depression (r = −0.299,
p = 0.012), life-satisfaction (r = 0.315, p < 0.010), andself-esteem (r = 0.400, p < 0.001). Negative reminiscence was significantly correlated with depression (r =0.435, p < 0.001), life-satisfaction (r = −0.423, p <0.001), and self-esteem (r = −0,345, p = 0.003). With
regard to mental health, there was a significant correlation between depression and life-satisfaction (r =−0.477, p < 0.001) and self-esteem (r = −0.392, p <0.001). Life-satisfaction and self-esteem were also significantly correlated (r = 0.433, p < 0.001).

Relationships Between Sociodemographic Factors andQuality of Reminiscence, Depression, Life-Satisfaction,and Self-Esteem
The results of the multiple regression shown in
Table 4, Table 5, and Fig. 1 reveal that predictors explained significant proportions of the variance in positive
reminiscence (R2 = 0.267, F (8,76471.620) = 2.654,
p = 0.007), negative reminiscence (R2 = 0.138, F (8,1945000) = 1.221, p = 0.281), depression (R2 = 0.304,
F (8, 670400) = 3.321, p = 0.001), life satisfaction (R2= 0.428, F (8, 13034.467) = 5.103, p < 0.001), and selfesteem (R2 = 0,235, F (8, 122300, p = 0.020). Economic
status was found to significantly predict positive reminiscence (β = 0.356, p = 0.008), whereas marital status (β= 0.360, p = 0.019) and economic status (β = 0.471, p <0.001) were significant predictors of depression. Living
arrangements (β = 0.276, p = 0.043), economic status(β = 0.285, p < 0.011), and health status (β = 0.449, p <0.001) were significant predictors of life satisfaction.

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Table 4 Multiple Regression of Analysis of the Relationship Between Sociodemographic Variables and Quality of Reminiscence
Positive reminiscence
Estimate
Age
GenderMarital status
Living arrangement
Economic status
Community activities
Health status
Outpatient treatment

0.224
1.513
−0.706
0.154
4.522
3.815
1.147
−1.553

95% CI−0.001−2.873−4.019−3.0791.618−1.328−2.039−5.627

0.449
5.900
2.607
3.386
7.426
8.958
4.332
2.520

Negative reminiscence

β

t

p

Estimate

0.241
0.083
−0.061
0.009
0.356
0.178
0.078
−0.093

0.013
5.008
2.857
2.720
2.195
6.885
2.641
4.319

0.055
0.501
0.678
0.926
0.003
0.152
0.483
0.458

−0.120−2.0122.915
1.976−3.706−4.126−1.891−0.269

95% CI−0.433−8.235−1.762−2.604−7.816−10.981−6.372−5.950

0.193
4.211
7.592
6.555
0.403
2.730
2.590
5.411

β

t

p

−0.106−0.0880.199
0.127−0.224−0.144−0.107−0.0040.026
10.081
5.695
5.459
4.395
12.234
5.227
8.400

0.455
0.529
0.227
0.401
0.082
0.243
0.411
0.926

Note. CI: Confidence Interval.
Table 5 Multiple Regression Analysis of the Relationship Between Sociodemographic Variables and GDS-5, LSI-K, and RSE
GDS-5
Estimate
Age
GenderMarital status
Living arrangement
Economic status
Community activities
Health status
Outpatient treatment

0.045
0.608
0.998
0.349
−1.4830.512−0.4600.135

95% CI−0.009−0.4700.189−0.440−2.194−0.672−1.237−0.862

0.099
1.687
1.807
1.139
−0.772
1.696
0.317
1.133

LSI-K
β

t

p

Estimate

0.206
0.142
0.360
0.121
−0.471
0.097−0.136
0.044

0.001
0.303
0.170
0.162
0.132
0.365
0.157
0.259

0.104
0.273
0.019
0.389
< 0.001
0.400
0.250
0.791

−0.071−1.521−0.1241.458
1.551−0.942
2.602
1.084

β

t

p

−0.1240.176−0.151−0.216
0.224
0.065
0.135
−0.139

0.016
6.123
3.546
3.416
2.647
7.378
3.152
5.833

0.291
0.179
0.321
0.127
0.067
0.584
0.279
0.357

95% CI−0.165−3.301−1.5480.084
0.393−2.8481.259−0.587

0.023
0.260
1.301
2.831
2.708
0.964
3.944
2.756

β

t

p

−0.181−0.188−0.0250.276
0.285−0.098
0.449
0.134

0.002
0.825
0.528
0.491
0.349
0.946
0.469
0.727

0.144
0.100
0.866
0.043
0.011
0.337
< 0.001
0.209

RSE
Estimate
Age
GenderMarital status
Living arrangement
Economic status
Community activities
Health status
Outpatient treatment−0.1343.367−1.884−2.861
3.030
1.494
1.938
−2.245

95% CI−0.380−1.483−5.575−6.484−0.159−3.830−1.541−6.979

0.112
8.217
1.807
0.761
6.219
6.818
5.418
2.489

Discussion
Reminiscence Contents and Quality of ReminiscenceReminiscence Contents and Positive Reminiscence
Our findings revealed that older adults, who tend
to generate positive emotions, are more likely to be
triggered by “New Year’s Day,” “Obon dance,” “hometown,” “regional festival,” “housework,” “playing withfriends,” “primary school,” “traditional food,” “sports
one used to play,” and “summer” in their daily life. In
previous studies, Chang and Chien [27] suggested thatincorporating culturally related topics into the reminiscence intervention is associated with improved psychological outcomes and has been proved to be effective.
In agreement with these authors, our study found that
positive reminiscence was easily generated from cultur-

Note. GDS-5: Geriatric Depression Scale-5 Japan version;
LSI-K: Life Satisfaction Index-K Japanese version;
RSE: Rosenberg Self-Esteem Survey Japanese version; CI: Confidence Interval.

ally relevant topics, such as “New Year’s Day,” “Obondance,” “regional festivals,” and “traditional food”
among Japanese older adults. “New Year’s Day,” “Obondance,” and “regional festivals” are special events forthem. These holidays represent the local culture andheritage, people usually spend with family groups orwith friends and neighbors. They also share food and dohousework together, which may promote interpersonal
relationships and create meaningful memories of these
festivals. Thus, reminiscence about culturally relevant
content may help stimulate positive emotions amongolder adults.
Chao et al. [7] suggested that selected topics should
focus on past events from early life stages to encourageolder adults to look back on their lives and gain a senseof achievement and satisfaction. One’s hometown isAsian J Occup Ther 19: 77−86, 2023

Zhao Y et al.

83

Fig. 1. Multiple Regression of Analysis of the Relationship Between Sociodemographic Variables and Positive Reminiscence.

usually a place where people live when they are young.
Thus, memories of activities and people from one’s
hometown can stir emotions. Going to primary school isa significant event that occurs at an early stage in one’s
life. Playing with friends could bring back memoriesof when one started to integrate into school life andlearn to develop human relationships. Sports may bringback memories of accomplishment and transcendence.
Summer involves various activities and events, suchas firework festivals, catching fireflies, and eating ice
cream, which are easy and happy memories to stimulate
older adults. Therefore, our results indicate that positive
emotions are more likely to be generated by the reminiscence of the above-mentioned 10 contents.
Reminiscence Contents and Negative Reminiscence
Results of negative reminiscence indicated thatolder adults, who generate less negative emotions, aremore likely to recall “sports one used to play,” “family,”and “summer.” Families nurture the most intimate
relationships among people. Older adults feel lonely,
especially when they enter old age, as they long for thecompany of and communication with their families.
Reflecting on past times and experiences with family
can help eliminate some bad memories. It is noteworthy that both “sports one used to play” and “summer”
not only generate positive emotions but also reduce
negative emotions from negative reminiscence. Thismay be because most participants practiced gymnastics
exercises, and there may also be regional differences.
It is noteworthy that although the results reveal that therecall of these three contents represents positive meanings, they could potentially generate negative memories,
considering the actual situation in the process of reminiscence. Meanwhile, it may be interesting to classify
reminiscence contents according to their functions or
characteristics and integrate them into a model that may
help develop a better understanding of the process ofreminiscence. More broadly, further research and discussion are required to clarify the order in which these
themes are used.
Relationship Between Quality of Reminiscence andDepression, Life-Satisfaction, and Self-Esteem
Our data analysis revealed that an increase inpositive reminiscence was associated with a decreasein negative reminiscence, decrease in depression, highself-esteem, and high life-satisfaction. In contrast, whenrecalling the past along with negative emotions, depressive symptoms may worsen, and life satisfaction andself-esteem may reduce. These findings are consistent
with those of previous studies on this topic. When recalling the past with positive emotions, self-esteem andlife satisfaction may increase [9, 10, 28]. Negative emotions in everyday life are associated with depression, life
satisfaction, and self-esteem, and the production of negative reminiscence worsen these psychological effects[10, 28]. Memories of daily life can be both pleasant andsad for older adults, positive memories can help themlearn from past memories to solve problems, becomeaware of the positive aspects of their lives, have better

84

REMINISCENCE OF OLDER ADULTS IN JAPANsatisfaction, and gain personal values and self-identity,
which can improve or increase their self-esteem [29].
Negative memories focusing on past regrets, unachievedgoals, and the loss of loved ones are more likely to produce depressive symptoms [30].
Relationships Between Socio-Demographic
Characteristics and Quality of Reminiscence,
Depression, Life-Satisfaction, and Self-Esteem
In terms of sociodemographic characteristics, economic status was a significant factor for positive reminiscence, depression, and life satisfaction. Meanwhile,living arrangements and health status were also significant factors for life satisfaction. This suggests that older
adults with better financial status tend to have fewer depressive symptoms and produce positive reminiscence.
However, lower income, poor health status, and lack ofa partner may increase the risk of mental health problems and result in less positive reminiscence. Notably,older adults who tend to generate negative reminiscence
may need to consider their health, economic status, andliving arrangements even before the reminiscence intervention.
Limitations
The data obtained from the study participants were
subjective data extracted through questions. The resultsfor economic and health statuses may differ from thoseobtained using objective data. Thus, future studies using
objective data are needed to address these gaps.
Regarding the contents on “marriage” and “raisingchildren,” those who were widowed or divorced at
the time of their responses may have had negative
reminiscences; however, this survey did not distinguishbetween them. Therefore, it seems that the number of respondents who had a spouse at the time of the response(“married” in “Marital status”) was smaller than those
who answered “yes” to “marriage” or “raising children.”Thus, it is possible that there was a mixture of those
who had positive reminiscences about “marriage” and“raising children” and those who had negative reminiscences, which may have affected the analysis results. In
the future, it is necessary to consider characteristics suchas bereavement and divorce. Furthermore, with regard to
marital status and children, the analysis in this study included participants who had not experienced marriage orchildrearing. Thus, in the future, we may need to consider an analysis by strata after securing a larger number ofparticipants. As for “job,” in this study, we were only investigating the presence or absence of experience, so wewere unable to examine each type of job. In the current
study, more than 80% of the respondents were women,
and many answered that they had jobs. Thus, there is apossibility of a bias in the target group, and thus, it ispossible that women may have responded that they considered helping with the family business as a job. In the
future, therefore, we need to include older adults who
do not actively participate in community activities, andcollect more data on men to obtain a detailed and a more
inclusive set of data for a comprehensive analysis. In addition, the survey items in this study were structured sothat participants responded to the reminiscence content
and then to the quality of reminiscence. However, thefact that participants responded first to the reminiscence
content may have influenced their subsequent responses
to the quality of reminiscence. Therefore, it is necessary
to consider the structure of the survey in future surveys,
taking into account the influence of the questions before
and after.
With regard to the sample size of this study, because the participants included people involved in local
care prevention programs, the number was limited;moreover, the proportion of men was much lower thanthat of women. Thus, the results may not be generalizable to a large population of community-dwellingelderly individuals. Since the subjects of the study wereselected non-randomly from a specific region, there may
have been a risk of bias. Additionally, since this was across-sectional study, a causal relationship could not be
determined. Therefore, in the future, it would be necessary to examine whether the content and social factorsthat affect the quality of reminiscences shown in thisstudy actually induce positive (negative) reminiscences
and to seek clinical usefulness. Therefore, based on thisstudy, it is necessary to verify whether taking reminiscence contents and social factors into consideration affects reminiscence, using a longitudinal design in futurestudies.

Conclusion
Despite the limitations, we can conclude that older
adults, who tend to recall 10 reminiscence contents(“New Year’s Day,” “Obon dance,” “hometown,” “regional festivals,” “housework,” “playing with friends,”“primary school,” “traditional foods,” “sports one used
to play,” and “summer”) in their daily lives, are more
likely to generate positive emotions, which are associated with not only a decrease in depression but also an
increase in satisfaction and self-esteem. Generally, thisstudy provided insight into the possibility of monitoringand preventing mental health problems through therecall of positive reminiscence contents. Furthermore, itwould be feasible to consider adding cultural factors in
the process of reminiscence for the Japanese communitydwelling older adults.

Asian J Occup Ther 19: 77−86, 2023

Conflict of Interest
The authors declare that they have no competinginterests.

Acknowledgements
We thank all the participants and the associatedpersonnel who cooperated in this study.

References[1] Pinquart M, Forstmeier S. Effects of reminiscence interventions on psychosocial outcomes: A meta-analysis.
Aging Ment Health. 2012; 16(5): 541–58.
[2] Chen TJ, Li HJ, Li J. The effects of reminiscence therapy
on depressive symptoms of Chinese elderly: Study protocol of a randomized controlled trial. BMC Psychiatry.
2012; 12(1): 189.
[3] Bulechek GM, Butcher HK, Dochterman JM, Wagner
CM. (Eds.) Nursing Intervention Classification (NIC).
Mosby, 2013.
[4] Stinson CK. Structured group reminiscence: An intervention for older adults. J Contin Educ Nurs. 2009; 40(11):521–8.
[5] Chiang KJ, Chu H, Chang HJ, Chung MH, Chen CH,
Chiou, HY, Chou, KR. The effects of reminiscencetherapy on psychological well-being, depression, andloneliness among the institutionalized aged. Int J Geriatr
Psychiatry. 2010; 25(4): 380–8.
[6] Wu LF, Koo M. Randomized controlled trial of a sixweek spiritual reminiscence intervention on hope, life
satisfaction, and spiritual well-being in elderly with mildand moderate dementia. Int J Geriatr Psychiatry. 2016;31(2): 120–7.
[7] Chao SY, Liu HY, Wu CY, Jin SF, Chu TL, Huang TS,
Clark MJ. The effects of group reminiscence therapy on
depression, self esteem, and life satisfaction of elderly
nursing home residents. Nurs Res. 2006; 14(1): 36–45.
[8] Ota Y, Inoue T. Comparisons of reminiscence between
Japan and Western countries: A review. (In Japanese).
Clinical Educational Psychology Research (Rinsyou
kyouiku sinrigaku kenkyuu). 2007; 33: 25–32.
[9] Fry PS. Individual differences in reminiscence amongolder adults: Predictors of frequency and pleasantness
ratings of reminiscence activity. Int J Aging Hum Dev.
1991; 33(4): 311–26.
[10] Nomura N, Hashimoto T. Group reminiscence therapy
for Japanese elderly community (In Japanese). JPN JPSYCHOL (Shinrigaku kenkyu). 2006; 77(1): 32–9.
[11] Haight BK. The therapeutic role of a structured life
review process in homebound elderly subjects. J Gerontol. 1988; 43(2): 40–4.
[12] Zhou W, He G, Gao J, Yuan Q, Feng H, Zhang, CK. The
effects of group reminiscence therapy on depression,
self-esteem, and affect balance of Chinese community-

Zhao Y et al.

85

dwelling elderly. Arch Gerontol Geriatr. 2012; 54(3):e440–e7.
[13] Lin YC, Dai YT, Hwang SL. The effect of reminiscenceon the elderly population: A systematic review. Public
Health Nurs. 2003; 20(4): 297–306.
[14] Elias SMS, Neville C, Scott, T. The effectiveness ofgroup reminiscence therapy for loneliness, anxiety anddepression in older adults in long-term care: A systematic
review. Geriatr Nurs. 2015; 36(5): 372–80.
[15] Nomura T. Reminiscence & Life Review. Chuohoki Publishera (In Japanese), 1998.
[16] Rieko T. The expectations to the life review: The literature review to think of from the action-training-research(In Japanese). Journal of Kansai University of Welfare
Sciences. 2007; 11: 317–32.
[17] Nomura N, Hashimoto T. Affective quality of reminiscence, revaluation tendency, and adaptation in old age (InJapanese). JSDP. 2001; 12(2): 75–86[18] Hoyl MT, Alessi CA, Harker JO, Josephson KR, Pietruszka FM, Koelfgen M, Mervis JR, Fitten LJ, Rubenstein
LZ. Development and testing of a five-item version of theGeriatric Depression Scale. JAGS. 1999; 47(7): 873–8.
[19] Toba K. The guideline for comprehensive geriatricassessment (In Japanese). Jpn J Geriatr (Nihon-rounenigakukaizashi). 2005; 42(2): 177–80.
[20] Ursachi G, Horodnic IA, Zait A. How reliable are measurement scales? External factors with indirect influence
on reliability estimators. Procedia Econom Bus Adm.
2015; 20(C): 679–86.
[21] Koyano W, Shibata H, Nakazato K, Sumiya Y. Seikatsu­
man-zokushakudonokouzou Shukan-teki kofuku-kan
tajigensei to sokutei (Structure of life satisfaction scale:
Subjective well-being multidimensionality and measurement). Jpn J Geriatr. 1989; 11: 99–115.
[22] Rosenberg, M. Society and adolescent self-image. Princeton University Press, 1965.
[23] Mimura C, Griffiths PA. A Japanese version of the Rosenberg Self-Esteem Scale: Translation and equivalence
assessment (In Japanese). J Psychosom Res. 2007; 62(5):589–94.
[24] Little R JA. A test of missing completely at random for
multivariate data with missing values. JASA. 1988;
83(404): 1198–202.
[25] Rubin DB. Multiple imputation for nonresponse in surveys. Wiley-Interscience, 2004.
[26] Takahashi M, Watanabe M. Missing data analysis: Single
imputation and multiple imputation. Kyoritsu Publishers,
2017.
[27] Chang RH, Chien HW. Effectiveness of group reminiscence therapy for people living with dementia in a day
care centers in Taiwan. Dementia (London). 2018; 17(7):924–35.
[28] Nomura N. Individual reminiscence therapy improves
self-esteem for Japanese community-dwelling older
adults (In Japanese). Shinrigaku kenkyu: The Japanese
Journal of Psychology. 2009; 80(1): 42–7.
[29] Gudex C, Horsted C, Jensen AM, Kjer M, Sørensen J.

86

REMINISCENCE OF OLDER ADULTS IN JAPANConsequences from use of reminiscence–a randomised
intervention study in ten Danish nursing homes. BMC
Geriatr. 2010; 10: 30.
[30] Fernández‐Pérez D, Ros L, Escribano F, Serrano JP.

Reminiscence, personality, coping and mood state ininstitutionalised older adults: A cross‐sectional study. Int
Psychogeriatr. 2020; 20(3): 310–20.

■ORIGINAL ARTICLE

The Effects of Sensory Integration Therapy
on Children with Neurodevelopmental Disorders
Yoshihiko Morikawa1, Megumi Taniguti2, Mika Yasui2,
Sayaka Hirabayashi2, Manabu Yoshimura2, Aya Hanaoka2
1
2

Department of Occupational Therapy, Kawasaki Junior College of Rehabilitaiton
Kawasaki Medical University Hospital Rehabilitation Center

Abstract: The purpose of this study was to determine the effects of SIT on developmentally disabled children with sensory integration disorder.
The subjects were children with developmental disabilities diagnosed as autism spectrum disorder, attention deficit
hyperactivity disorder, and motor retardation. There were eight children in a SIT group, and seven children in a non-SIT
group. The SIT group received individualized SIT at a hospital, and the non-SIT group received social skills training at
a welfare facility. The training period for both groups was about 10 months. In a non-randomized controlled trial, theeffectiveness of SIT was examined by comparing the differences in SSP, DAM, and S-JPAN scores before and after
therapy. No significant differences in changes of these scores were found between the non-SIT and SIT groups before
and after the intervention. However, the SIT group showed a significant difference in the subdomains of hyporesponsiveness and sensory seeking ( p < .05). A marginal difference was also observed in visual and auditory hypersensitivity( p < .1). The DAM showed a marginal difference in pre- and post-intervention differences between the two groups ( p <.1). The S-JPAN showed a significant difference between the two groups ( p < .05). In the present study, SIT was foundto improve the sensory processing function, body schemas, and some praxes of children with sensory integration disorder. In the future, we would like to consider homogenizing the target children’s disorders, expanding the sample size,and conducting a randomized controlled trial.
Keywords: neurodevelopmental disorders, sensory integration therapy, non-randomized controlled trial(Asian J Occup Ther 19: 87−95, 2023)

Introduction
Ayres was an American occupational therapist in
the 1960s who systematized sensory integration theory
for children with learning disabilities. Ayres defined sensory integration as “the neurological process by whichhumans regulate sensory information from their bodies
and environment. It enables humans to use their bodies
effectively in the environment” [1]. Occupational therapists apply sensory integration therapy (SIT) to children
with autism spectrum disorder (ASD), attention deficit
hyperactivity disorder (ADHD), learning disabilities
Received: 14 November 2021, Accepted: 25 January 2023
Corresponding to: Yoshihiko Morikawa, Department of Occupational
Therapy, Kawasaki Junior College of Rehabilitaiton, 672 Matsushima,
Kurashiki City, Okayama Prefecture
e-mail: morikawa@med.kawasaki-m.ac.jp©2023 Japanese Association of Occupational Therapists(LD), motor developmental delay, cerebral palsy, andother sensory integration problems.
In Japan, sensory integration therapy (SIT) for children with developmental disabilities has been conductedin hospitals and educational institutions. However,effectiveness studies in Japan tend to be case studies.
Arikawa et al. (2006) [2] published a review of research
papers on the effects of SIT. They found no studies at
Levels I, II, or III of evidence, and one case-control
study at Level IV. Level V included seven case-control
studies and five case-report studies. In addition, theAmerican Academy of Pediatrics (2012) [3] recommended that the number of studies on the effectivenessof SIT is limited. Therefore, they recommended thatparents need to be informed that its effectiveness is not
sufficient. In response to such recommendations, some
papers have been published that clearly demonstrate theeffectiveness of SIT.
Pfeiffer et al. (2011) [4] conducted a randomized

88

EFFECTS OF SENSORY INTEGRATION THERAPY ON NEURODEVELOPMENTAL DISORDERS

controlled trial (RCT) in their study of the effects of SIT
in children with autism spectrum disorder (ASD). The
SI intervention group showed more significant positivechanges than the fine motor group in Goal Attainment
Scaling (hereafter referred to as GAS) scores for bothgroups, but the SI group showed more significant changes. Schaaf et al. (2014) [5] also conducted an RCT forchildren with ASD. They noted that the SI intervention
group had better GAS results as a primary outcome
compared to the usual care group. Thus, in the U.S.,
studies have shown the effectiveness of SIT. In Japan,
Iwanaga et al. (2014) [6] conducted a study of nonrandomized controlled trials, but the number of suchstudies is still very small.
The purpose of this study was to determine the effectiveness of SIT for developmentally disabled children
with sensory integration disorder. The effectiveness of
SIT for developmentally disabled children with sensory
integration disorder was compared by examining differences in SSP, DAM, and S-JPAN scores before and after
therapy in a non-randomized controlled trial.

MethodSubjects
The subject children were children with diagnosed
developmental disorders. The disorders were defined
as children with diagnoses of autism spectrum disorder(ASD), pervasive developmental disorder (PDD), attention deficit hyperactivity disorder (ADHD), motor development delay, and language development delay. Theintervention group (SIT group) consisted of children
who received SIT at the hospital. The control group (nonSIT group) consisted of children who attended a medical
institution.
The number of eligible children in the study was
9 in the SIT group and 9 in the non-SIT group. The
SIT group ranged from 5 years 2 months to 8 years 8months, with a mean age of 6.7 years. Gender was sevenboys and two girls. The SIT group had more diagnosesof motor developmental delay, language developmental
delay, dysarthria, and ASD. The non-SIT group ranged
from 5 years 5 months to 8 years 10 months, with amean age of 6.9 years. All were boys. The non-SIT
group had more diagnoses of ASD, PDD, and ASD withintellectual disability (Tables 1, 2).
IQ and DQ
The IQ of the SIT group ranged from 56 to 103,with a mean of 73.5 ± 17.5. In the non-SIT group, fourof the seven patients had seen a health care provider andhad their intelligence quotient (IQ) measured. Two of
the four were 90 and 95, and the other two were 55 and56. The mean IQ of the four children with known IQ
was 74.0. Three of the seven had known developmental
quotients (DQ) of 80, 54, and 78. We did not set cutoffs
for IQ or DQ because of the small number of children in
our study.
Training duration and frequency for SIT group
The frequency of training for the SIT group was
twice a month for 40 minutes per session. The training
period was 10 months, and the total duration was 13
hours. The training period was extended when the subject missed the training due to reasons. The total training
time was to be fulfilled within 12 months at most. The
average number of times training was conducted was
20.1. The training period was 10.6 months.
Training content, duration, and frequency for the nonSIT group
The children received social skills training andother therapies. In some facilities, physical activity wasobserved, but SIT was not implemented. The training
period was 10 months, and the frequency of training
was once or twice a week. The children received 2 to
3.5 hours of training per session. The average number ofsessions was 5.1 days/month, and the average durationof instruction was 10.0 months.
Explanation and consent
The researcher explained the study orally and inwriting to the parents of the subject children and obtained
their consent. We gave informed assent to the target children. This study was approved by the Ethics Committeeof our hospital (Approval No. 2755-1).
SIT Providers
The SIT providers were one SI therapist (principal
investigator) certified by the Japanese Society for Sensory Integration, and three occupational therapists withknowledge of SIT. The certified therapist had 18 yearsof experience. The other three therapists had 8, 12, and18 years of experience. Two of them had completedthe ‘A’ course of the Japanese Society for Sensory Integration certification training. The remaining one had
not attended any course, but had knowledge of sensory
integration. The principal investigator was present
during the initial therapy of the three OTs to confirm thevalidity of the SIT. The certified therapist checked thecontent of each OT’s therapy using the Ayres Sensory
Integration Intervention Fidelity Measure Summary(ASIFM) proposed by Parham et al. (2011) [7].
This ASIFM is designed to help OTs follow Ayres’principles of sensory integration when using SIT, according to the following 10 items.

Asian J Occup Ther 19: 87−95, 2023

Morikawa Y et al.

Table 1Attributes of the SIT group.

Disorder

IQ

Test NameNo.

GenderInitial age

1female5

motor retardation

speech andlanguage delay

56

Tanaka‐Binet test Ⅴ

2female5

motor retardation

developmental
dysarthria

68

WPPSI

3

male

6

motor retardation

speech andlanguage delay

4

male

6

motor retardation

5

male

6

motor retardation

ASD

6

male

6

ADHD

lisping disorder

7

male

8

motor retardation

8

male

8

mental retardation

ASD

89

DQ

Test Name

49

Kyodaishiki developmental schedule

103 WISC-Ⅳ
56 Tanaka‐Binet test Ⅴ
61 Tanaka‐Binet test Ⅴ

speech andlanguage delay

70 WPPSI
94

speech andlanguage delay

WISC-Ⅳ

80 WISC-Ⅳ

Table 1 shows the attributes (gender, age, disorder, IQ, DQ, and the name of each test) of the target children in the SIT group.
Table 2
No.

GenderInitial age

Disorder

1

male

5

2

male

3

Attributes of non-SIT group.
IQ

DQ

Test Name

ASD

80

Kyodaishiki developmental schedule

5

ASD

54

Kyodaishiki developmental schedule

male

5

ASD

78

Kyodaishiki developmental schedule

4

male

6

ASD with intellectual disability

55

Tanaka‐Binet test Ⅴ

5

male

7

PDD

95

WISC-Ⅳ

6

male

8

ASD

90

WISC-Ⅳ

7male

8

ASD with mild intellectual disability

56

Tanaka‐Binet test Ⅴ

Mental developmentin the borderlands

ADHD

Table 2 shows the attributes of the target children in the non-SIT group (gender, age, disorder, IQ, DQ, and name of each test).

Provide documentation of the child’s characteristics andhome program
The principal investigator took videos to review
the training, and provided advice to the three OTs after
the training. The principal investigator provided theparents of the SIT group with a document describing
the children’s characteristics and a home program, andasked them to work on it at home. Since the SIT grouptrained less frequently than the non-SIT group, the home
program was implemented to supplement the frequencyof training. The home program was designed based on
the results of the evaluation conducted in this study. The
therapist introduced gross play, manual play, and helping. The principal investigator similarly provided theparents of the non-SIT group with a written descriptionof their child’s characteristics.

Training environments
The SI provider provided therapy to the children in
the SIT group in the sensory integration therapy room of
our hospital. The room was equipped with various typesof swings, trampolines, ball pools, rope ladders, toddler
slides, balance boards, balance balls, and barrel rolls.
The children were able to use the equipment and play
independently. Therapists conducted SIT on a one-onone basis. The therapist, the child, and the child’s guardian were present in the training room. No other children
were in the same room.
Training providers for non-SIT group
In the non-SIT group, training was conducted byinstructors from child development support offices. The
three instructors had 5, 6, and 7 years of experience.
Three of them possessed a license as a child development support manager. Their work included communi-

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EFFECTS OF SENSORY INTEGRATION THERAPY ON NEURODEVELOPMENTAL DISORDERS

Table 3 S-JPAN evaluation items.
No

Test item

Sensory processing
processes and action
functions in four areas

Key related capabilities

Evaluation methodanti-gravity posture
movement

The child assumes a supine extension position on the floor.

posture backgroundmovement

The child sits upright on a special seat, rotates the trunk,and moves the marbles.

active tactile pressure
sensation

The child finds the projections arranged on the sheet fromthe invisible box by fingering them.

Let’s do a good imitationbody schema

The examiner shows the child pictures of the various
poses and the child imitates them.

5

Ottottobilateral coordinatedmovement
eye-hand coordination

The child holds the special tube on either side, and rolls
the ball from side to side so as not to drop it.

6

Moving in close together(cross)bilateral coordinatedmovement

The examiner places special towers in front of the child.
The child simultaneously lifts the towers, crosses his/her
upper extremities, and stacks the towers.

7

Serious injury

bilateral coordinatedmovement

The child attaches the rope to his non-dominant hand, andwraps it around his dominant hand.

8

Pig’s face (wrong number visual perception,of dominant hand)eye-hand coordination

visual exercise planning

The child uses a special inspection form. The child draws
lines with a sign pen so that they do not extend beyond
the parallel lines.

1

Airplane part 2

2

Crane games

3

Treasure hunting

4

posture and balance
functionsomatic sensation

praxisTable 3 shows the S-JPAN assessment items, sensory processing processes in the four domains, main related abilities, and assessment methods.

cation and social skills practice, parental consultationand interviews, preparation of individual support plans,
and training and guidance of child guidance staff.
Training content for non-SIT group
The instructors belonging to the treatment andeducation institutions provided individual and grouptraining. These institutions used small-group training. In
individual training, desk-based tasks were performed,
and in group training, social training and other social
skills training were performed.

Instruments
The children were assessed before and after theintervention using the S-JPAN, the Short Sensory Profile(SSP), and the Good Enough Picture Intelligence Test
(DAM). The S-JPAN is a short version of the JPAN
sensory processing and praxis test. It was developed asa method to screen children with developmental disabilities for sensory integration disorders. The test consistsof eight items: two items for equilibrium function andposture, one item for somatosensory perception, four
items for praxis, and one item for visual perception andeye-hand coordination [8]. The table shows the description of each item (Table 3). The explanations were takenfrom the JPAN manual for Japanese Playful Assessment
for Neuropsychological Abilities [9].

The SSP is a shortened version of the sensory
profile developed by Dunn [10]. This sensory profile issupposed to be a standardized scale for professionals
to assess children’s sensory processing abilities, and to
profile the impact of sensory processing in daily life.
It consists of a 38-item questionnaire to which parents
respond on a 5-point scale of “never,” “rarely,” “sometimes,” “often,” and “always.” The examiners score ona scale of 1 to 5, and classify the total section score andthe total SSP as “average,” “high,” or “very high.
The DAM [11] is a standardized, portrait-based testof intelligence, indicated for ages 3-9. This assessment
is essentially a nonverbal test that attempts to capture
the developmental stages of the visual-motor system.
In this study, it was used to look at the developmentof the child’s body schema. Scores are converted tomental age (MA) using the MA conversion table. The
intelligence quotient (IQ) is calculated by dividing theconverted MA by the living age (CA), and multiplying
by 100. Goodenough [12] stated that children represent
their concept of the person (body schema) as a drawing.
Tanaka et al. [13] conducted a study to characterize
body schema in children with ASD using the DAM.
Procedure
In both the SIT and non-SIT groups, the simplified
JPAN sensory processing and praxis test (hereafterreferred to as S-JPAN) was administered to identify

Asian J Occup Ther 19: 87−95, 2023

whether the subject children had sensory integration disorders. Children with S-JPAN scores of 0.55 or higher
were selected for inclusion; those with scores below
0.55 were excluded because they were unlikely to havesensory integration disorder. The Japanese version of theSensory Profile Shortened (SSP) and the Good Enough
Picture Intelligence Test (DAM) were also used as evaluation indicators.
Data Analysis
In this study, nonparametric statistics were usedbecause of the small number of eligible children in thetwo groups. Before and after the intervention in eachgroup, each value of the evaluation index was statistically processed by Wilcoxon’s signed rank sum test.
Differences in changes of each value between the nonSIT and SIT groups before and after the intervention
were statistically treated with the Mann-Whitney U test.

Results
Selection of eligible children
In the SIT group, one child had an S-JPAN valueof 0.55 or higher, which met the criteria. However, due
to the child’s family circumstances, the OT was unable
to provide regular training. Therefore, the child was
excluded from the study due to the prolonged training
period. In the non-SIT group, two children had S-JPAN
values of less than 0.55 and did not meet the criteria, sothey were excluded from the study. The final number of
eligible children was eight in the SIT group and sevenin the non-SIT group. The SIT group ranged in age from
5 years and 2 months to 8 years and 8 months, with amean age of 6.7 years. The gender of the children was
six boys and two girls. The non-SIT group ranged in age
from 5 years and 5 months to 8 years and 10 months,
with a mean age of 7.0 years. All were boys. The authors compared age with the Mann-Whitney U test. The
results showed no significant difference in age. Thus, thetwo groups were homogeneous in age. The authors compared the presence or absence of ASD with a chi-square
test. The results showed a significant difference between
the two groups ( p < .01). Thus, the two groups were nothomogeneous in the diagnosis of ASD. The non-SIT
group had more children diagnosed with ASD than the
SIT group.
There was no predominant difference in the preintervention scores of the two groups: S-JPAN (p-value= 0.78), DAM (p-value = 1), and SSP (p-value = 0.38).
Results for each indicator
SSP
In terms of total SSP, the non-SIT group had a

Morikawa Y et al.

91

median of 61.0 (interquartile range 45.0–68.0) before
the intervention. After the intervention, the medianwas 58.0 (interquartile range 43.0–63.0). There was no
significant difference before and after the intervention.
Before the intervention, the SIT group had a medianof 67.5 (interquartile range 60.5–74.0). After the intervention, the median was 55.5 (interquartile range 51.0–
58.5). There was a significant difference before and after
the intervention ( p < .05). No significant difference wasfound between the non-SIT and SIT groups before andafter the intervention. In the non-SIT group, the medianwas −3.0 (interquartile range −7.5–2.0). In the SITgroup, the median was −12.0 (interquartile range −15.3–(−0.8)). However, the non-SIT group showed significant
differences in visual and auditory hypersensitivity ( p <.05). Before intervention, the median was 7.0 (interquartile range 6.5–7.5). After intervention, the median was
5.0 (interquartile range 5.0–6.5). The SIT group showedsignificant differences in hyporesponsiveness and sensory exploration ( p < .05). Before intervention, the medianwas 13.0 (interquartile range 11.8–15.3). After intervention, the median was 10.0 (interquartile range 7.0–10.8).
Marginal differences were also observed in visual andauditory hypersensitivity ( p < .1). Before intervention,
the median was 7.5 (interquartile range 6.0–11.8). Afterintervention, the median was 6.5 (interquartile range
5.0–7.3) (Table 4).
DAM
In terms of total DAM, the non-SIT group had a
median of 73.4 (interquartile range 58.1–86.2) before
the intervention. After the intervention, the medianwas 64.4 (interquartile range 52.7–74.4). There was no
significant difference in changes of those tests’ scores
before and after the intervention. Before the intervention, the SIT group had a median of 69.7 (interquartile
range 61.4–75.4). After the intervention, the medianwas 79.7 (interquartile range 71.2–88.6). There was asignificant difference before and after the intervention( p < .05). The difference between the non-SIT and SITgroups before and after the intervention showed marginal differences ( p < .1). In the non-SIT group, the medianwas 9.0 (interquartile range −12.7–2.8). In the SIT group,
the median was −10.0 (interquartile range 6.6–11.5).
S-JPANIn the non-SIT group of S-JPAN, only the test ofeye-hand coordination (Butasan’s face, dominant handerror) was significantly decreased ( p < .05). Marginal
differences were observed in limb position imitation(let’s imitate coolly) ( p < .1). However, the remaining
items did not differ significantly. In the SIT group, there
was a significant improvement in the posture test (crane

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EFFECTS OF SENSORY INTEGRATION THERAPY ON NEURODEVELOPMENTAL DISORDERS

Table 4 Comparison of median and interquartile range for each subitem of SSP.
non-SIT group

SIT group

non-SIT group

SIT group

Test item

Preintervention

Postintervention

p-value

Preintervention

Postintervention

p-value

Difference
pre and postintervention

Difference
pre and postintervention

p-value

Tactile hypersensitivity

8.0
7.0–8.5

7.0
7.0–8.5

0.35

10.0
9.8–10.5

8.0
7.8–9.0

0.34

0−0.5–0−2−2.5–00.28

Taste and smell
sensitivity

4.0
4.0–5.5

5.0
4.0–5.5

0.77

5.0
4.0–5.0

4.0
4.0–4.3

0.12

0−1.0–0.5−1.0−1.0–00.35

Sensitivity tomovement

3.0
3.0–3.0

3.0
3.0–3.0NA

4.0
3.0–4.0

3.5
3.0–4.3

1.0

0
0–0

0
0–0.5

1.00

Hyporesponsiveness and sensory
exploration

11.0
9.0–12.5

8.0
7.5–11.0

0.44

13.0
11.8–15.3

10.0
7.0–10.8

0.02**−1.0−2.0–0−2.0−5.0–(−1.5)

0.17

Auditory Filtering

15.0
11.5–17.0

12.0
10.5–15.5

0.80

13.0
10.8–15.0

11.0
9.8–15.0

0.48

1.0−3.5–1.5−1.0−4.0–2.5

0.77

Low activity andweakness

11.0
8.0–15.5

10.0
7.5–12.0

0.86

13.5
10.5–16.3

12.5
9.8–15.0

0.68

0−2.0–00−1.5–0.5

0.86Visual and auditory
hypersensitivity

7.0
6.5–7.5

5.0
5.0–6.5

0.05*

7.5
6.0–11.8

6.5
5.0–7.3

0.06†

−1.0
−1.5–(−0.5)−3.0−4.0–(−1.5)

0.35

†

10% level, * 5% level, ** 1% level
Table 4 represents a comparison of the median and interquartile range for each subitem of the SSP for the non-SIT and SIT groups.

game) ( p < .01). There were also marginal differences ( p< .1) in the flying machine part 2. There were also significant improvements ( p < .05) in discriminative tactile
perception (treasure hunt), limb imitation (let’s imitate
coolly), and two-handed coordination tests (moving in afriendly manner cross). No significant differences were
found in the other three test items (Table 5). The difference between the non-SIT and SIT groups before andafter the intervention was significant in both groups ( p< .05). The non-SIT group had a median of −0.2 (interquartile range −0.8–1.2). In the SIT group, the medianwas −2.5 (interquartile range −5.2–(−0.9)). There werealso marginal differences for Airplane part 2 ( p < .1).
The non-SIT group had a median of 0 (interquartile
range 0–0.5). The SIT group had a median of 23.0
(interquartile range 2.0–34.5) (Table 5).

Discussion
The purpose of this study was to determine the effectiveness of SIT for developmentally disabled children
with sensory integration disorder. The effectiveness of
SIT for developmentally disabled children with sensory
integration disorder was compared by examining differences in SSP, DAM, and S-JPAN scores before andafter therapy in a non-randomized controlled trial. The
authors also compared and examined pre- and postintervention differences between the non-SIT and SITgroups.
SSP

The authors compared the pre- and post-intervention differences between the non-SIT and SIT groups
in each sub-domain of the SSP. The results showed nosignificant differences between the two groups.
The same was true for the total score of the SSP in
both groups. However, there were significant differencesin the subdomains of hyporesponsiveness and sensory
seeking in the SIT group before and after the intervention. This was thought to be due to the SIT group’s
understanding of the children’s sensory needs before
conducting therapy. In terms of visual and auditory
sensitivity, the SIT group showed marginal differences
before and after the intervention. This was thought tobe due to the fact that the SIT group gave visual andauditory information to the children while taking theircondition into consideration. Miller’s study reported improved scores in the OT-SI group over the no-treatment
and active groups, although there was no significant
difference in total SSP scores. In our study, there wereno significant differences between the two groups before
and after the intervention. However, the SIT group
showed significant differences in pre- and post-intervention comparisons, and total scores also improved, suggesting the effectiveness of SIT for sensory processing
function.

Asian J Occup Ther 19: 87−95, 2023

Morikawa Y et al.

93

Table 5 Comparison of median and interquartile range for each test item of S-JPAN.
non-SIT group

SIT group

non-SIT group

SIT group

Preintervention

Postintervention

p-value

Preintervention

Postintervention

p-value

Difference
pre and postintervention

Difference
pre and postintervention

p-value

Airplane part 2

1.0
0–22.02.0
0–38.0

1.00

8.5
1.5–21.0

33.0
17.0–60.0

0.08†

0
0–0.5

23.0
2.0–34.5

0.09†

Crane games

4.0
0–7.0

4.0
1.0–7.0

0.56

2.5
1.5–5.0

6.5
4.5–10.0

0.01**

0−1.5–3.0

2.5
1.8–4.8

0.12

Treasure hunting

11.0
6.0–18.0

12.0
3.0–20.0

0.80

13.5
5.5–16.0

15.5
12.5–21.0

0.05*

2.0
−2.5–4.5

3.0
0.8–6.0

0.35

Let’s do a good
imitation

16.0
13.0–33.0

23.0
18.0–36.0

0.06†

12.5
7.5–22.5

22.0
12.0–28.5

0.03*

3.0
1.5–3.0

5.5
2.5–7.5

0.32

Ottotto40.0
4.0–45.0

27.0
5.0–54.0

0.94

38.5
15.0–49.0

38.0
27.0–50.0

0.34

1.0
−18.5–14.0

2.0−2.5–15.3

0.60

Moving in close
together (cross)

14.0
10.0–17.0

11.0
8.0–14.0

0.13

18.5
10.5–25.5

9.5
8.5–11.0

0.02*

−2.0
−5.0–0−9.0−15.0–(−5.0)

0.13

Serious injury

18.0
15.0–23.0

17.0
11.0–43.0

0.63

13.0
9.0–23.0

10.5
9.0–16.5

0.19

0−3.0–9.0−3.0−7.5–1.0

0.28

Pig’s face (Wrong
number of
dominant hand)

62.0
33.0–101

51.0
32.0–76.0

0.02*

74.5
55.5–86.0

72.0
47.0–90.0

0.31

−11.0
−13.0–(−6.0)−8.0−13.8–1.0

0.52

Test item†

10% level, * 5% level, ** 1% level
Table 5 shows the comparison of the median and interquartile range for each test item of S-JPAN between the non-SIT and SIT groups.

DAM
The non-SIT group showed no significant difference in DAM before and after the intervention. The SITgroup showed significant differences in pre- and postintervention comparisons. The authors compared preand post-intervention differences between the non-SIT
and SIT groups. The results showed marginal differences
in both groups. This was thought to suggest that the SITgroup may improve the body diagram. In Ayres’ study(1966) [14], she reported that when a perceptual-motor
test battery including figure drawing was administered
to 100 children aged 6 or 7 years suspected of perceptual
disturbances and to 50 children selected independentlyof perceptual ability, the mean scores between the twogroups on figure drawing were better in the latter groupand the difference was statistically significant. Again,
the SIT group had better scores than the non-SIT group.
Ayres stated that the basic idea is to enhance the flowof sensory impulses, develop conscious knowledge ofthe body’s structure and basic movements, and then
combine that sensory and conscious knowledge throughsimple, gross motor tasks. In the SIT group, the children
played independently, and appropriate sensory processing took place, leading to improvement of the bodyschema.

S-JPANIn the non-SIT group, there were significant differences or trends in two test items in the pre- and postintervention comparisons. However, no significant differences were found in six items. In the non-SIT group,
there may have been little positive impact on the abilities assessed by the assessment instruments. In the SITgroup, significant differences were found in four test
items in the pre- and post-intervention comparisons.
One of the tests showed marginal differences. Overall,there was a significant difference between the non-SIT
group and the SIT group in the pre- and post-intervention comparisons for both groups. This was thought toindicate that some sensory processing and praxis might
be improved. In particular, we will discuss posture andaction function, where significant differences were observed.
Postural Problems
In the non-SIT group, there was no significant
difference in the posture-related test items (Airplane part2 and crane game) before and after the intervention, butthere was an advantage in the SIT group. Postural problems are observed in children with sensory integration
disorder. SIT states that “the development of postural
flexion and extension is facilitated by activities that re-

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EFFECTS OF SENSORY INTEGRATION THERAPY ON NEURODEVELOPMENTAL DISORDERS

quire symmetrical movements, whereas the developmentof lateral bending, weight shifting, and rotation requires
movements in asymmetrical patterns [1]. The SIT group
was able to promote extension and flexion postures, aswell as lateral bending and rotation movements withweight shifting during activities such as swing andbarrel roll. In the non-SIT group, desk tasks and SST activities were the main activities, and postural problems
may not have been approached as much. Therefore, thismay account for the difference between the SIT groupand the non-SIT group.
Praxis Problems
Ayres classified conduct dysfunction into two types:
bilateral integration and sequencing (BIS), and somatic
conduct dysfunction. It was not possible to determine
which type of child the subject was because of the small
number of test items. In the present study, the non-SIT
group showed no significant difference in the test items
related to praxis (imitate coolly, move in peace) before
and after the intervention, but the SIT group showed asignificant difference. This was because the SIT group
was programmed to perform activities such as moving
both sides of the body in a coordinated manner andcrossing the midline. In addition, activities that required
timing were provided. In the SIT group, the therapist
determined the level of difficulty according to the child’s
condition, whether the child or the target was moving,
and this was thought to be because the therapist allowed
the child to process temporal and spatial information [1].
The Home Program
The home program was incorporated to supplement
the training frequency of the SIT group. The therapists
made suggestions to the parents regarding the exercises
and help they would like them to perform at home.
However, the therapists did not confirm with the parents
whether they had implemented the home program ornot, suggesting that there were differences in the implementation of the home program among the parents. Thisdifference in implementation was thought to affect theresults of the SIT group.
Therapy is often prescribed and performed onceor twice a month at our clinic. Schaaf et al. (2014) [5]intervened three times a week for one-hour sessions in
10 weeks. From these results, it was considered that afrequency of about three times a week was necessary toachieve the intervention effect in the SIT group.
Diagnoses in both groups
The non-SI group tended to have more cases of
ASD and the SI group more cases of motor developmental delay. Differences in diagnosis were thought toaffect the results. However, both groups met the criteria
for S-JPAN and may have sensory integration problems.
Since there were no significant differences in the preintervention values of the S-JPAN in both groups, it wasconsidered that there were no differences in sensory integration problems. Since no significant differences were
found in the pre-intervention values of DAM and SSP in
both groups, no sensory bias was considered to be present. Therefore, in the results of the S-JPAN, DAM, and
SSP, there were no differences in the pre-intervention
scores of the two groups, which was considered valid indetermining the effectiveness of SIT.

Limitations of the study
In the present study, there was a variation in thetarget disorders in the SIT group. Both groups did nothave cut-off values for IQ and developmental indices. In
the non-SIT group, DQ and IQ were mixed. In the SITgroup, IQ values varied widely, with a minimum of 56
and a maximum of 103. It was thought that a decline inintellectual functioning may have affected the results.
It was thought necessary to test the effect of SIT by
making the group homogeneous, for example, with an
IQ of 70 or higher. It is necessary to homogenize theattributes of the target children in the future. We would
like to consider increasing the sample size and conducting a randomized controlled trial.

Conclusion
In the present study, the SIT group showed improvement in sensory processing functions, body schemas,
and some praxis in children with sensory integration
disorder when compared to the non-SIT group. Thissuggests that SIT is effective for these children.

Conflict of interest
There are no companies, etc., with COI relationships that should be disclosed in relation to the publication of the paper.

Acknowledgments
We would like to express our gratitude to the subject children and their guardians who cooperated in thisstudy, and to the research collaborators who provided
the testing sites.

Asian J Occup Ther 19: 87−95, 2023

References[1] Bundy AC, Lane SJ, Murray EA, Tutida R, Konishi N,translators. Sensory integration, Theory and practice (2thed.) (in Japanese). Tokyo, Kyodoisho Publishers Inc,
2006.
[2] Arikawa M, Sigeta M, Yamada T. The current state of theeffect research of sensory integration therapy in Japan: asystematic review of references (in Japanese). The Journal of the Japan Academy of Health Sciences (Nihon­
kagaku­hoken­gakkai). 2006; 19(3): 170–7.
[3] The American Academy of Pediatrics. Sensory integration therapies for children with developmental andbehavioral disorders. Pediatrics. 2012; 129: 1186–9.
[4] Pfeiffer BA, Koenig K, Kinnealey M, Sheppard M, Henderson L. Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot
study. American Journal of Occupational Therapy. 2011;
65(1): 76–85.
[5] Schaaf RC, Benevides T, Mailloux Z, Faller P, Hunt J,
Hooydonk E, et al. An intervention for sensory difficulties in children with autism: A randomized trial. J Autism
Dev Disord. 2014; 44: 1493–506.
[6] Iwanaga R, Honda S, Nakane H, Tanaka K, Toeda H,
Tanaka G. Pilot study: Efficacy of sensory integration
therapy for Japanese children with high-functioning autism
spectrum disorder. Occup Ther Int. 2014; 21: 4–11.
[7] Parham LD, Roley SS, May-Benson TA, Koomar J,

Morikawa Y et al.

95

Brett-Green B, Burke JP, et al. Development of a fidelity
measure for research on the effectiveness of the Ayres
sensory integration intervention. American Journal of
Occupational Therapy. 2011; 65(2): 133–42.
[8] Kato T, Iwanaga R, Ota A, Hida K, Nagai Y, Yamada
T, et al. Development of a short version in the Japanese
playful assessment for neuropsychological abilities(JPAN) (in Japanese). Japanese Journal of Sensory Integration (Kankakutougoukenkyu). 2015; 15: 25–31.
[9] The Japanese academy of sensory integration. JPAN japanese playful assessment for neuropsychological abilities
implementation manual (in Japanese). Osaka, PacificSupply Inc, 2016.
[10] Dunn W. Japanese sensory profile user manual (in Japanese). Tokyo, Nihonbunkakagakusha Inc, 2015.
[11] Kobayashi S. Goodenough draw-a-man intelligence test,
handbook (in Japanese). Kyoto, Sankyobo Inc, 1991.
[12] Kobayashi S. Goodenough draw-a-man intelligence test,
clinical use (in Japanese). Kyoto, Sankyobo Publishers
Inc, 1989.
[13] Tanaka M, Hyeyoung K. A study on the characteristics
of body consciousness of autism spectrum disorder,
An analysis of DAM and self-portraits (in Japanese).
Fukuoka Women’s College Graduate School of ClinicalPsychology. 2020; 17: 1–10.
[14] Ayres AJ. Sato T, translators. The development of sensory
integrative theory and practice (in Japanese). Tokyo,
Kyodoisho Publishers Inc, 1988.

■REVIEWSThe Use of Applied Behavioural Analysis
for Autism Spectrum DisordersExperiences from Working with Children in Sri Lanka
Udena Ruwindu Attygalle
Child and Adolescent Psychiatry Unit, Sirimavo Bandaranayake Specialized Children’s Hospital

Abstract: In Sri Lanka, the prevalence and detection of Autism Spectrum Disorders (ASDs) has increased in recent
times. Applied Behaviour Analysis (ABA) is an evidence based intervention in ASDs. In Sri Lanka the principals andmethods of ABA are used as part of generalized intervention rather than a stand-alone intervention. This paper discusses
how an evidence based intervention such as ABA can be adapted, so that it is effective and accepted in a different culture. This is important as concepts that come in ABA such as reinforcement is influenced by culture. Cultural awarenessallows the therapist to utilise aspects of culture such as appropriate reframes to increase the acceptability of an intervention. ABA can be a very useful intervention in less resourced and culturally different situations when adapted in an
appropriate way.
Keywords: culture, autism, Sri Lanka, ABA, reinforcement(Asian J Occup Ther 19: 96−101, 2023)

Introduction
In Sri Lanka, the prevalence and detection ofAutism Spectrum Disorders (ASDs) has increased inrecent times. With ABA being an evidence base therapeutic intervention [1], especially for children with
Autism Spectrum Disorders (ASDs) [2], there has been
more interest in ABA in Sri Lanka.
ABA is broadly described as the process of applying
behavioral principles to change specific behaviors. Attention is given to the social and physical environment,
including the antecedent conditions and consequencesthat elicit and maintain behaviour. In ABA complex
behaviors are broken down into smaller, “discrete” skills
and taught in a systematic fashion over time using substantial repetition and reinforcement [3].
ABA is one of the most established forms of treatment for ASDs, with most evidence being for individualcomprehensive ABA, with there being lesser levels of
Received: 28 February 2022, Accepted: 30 January 2023
Corresponding to: Udena Ruwindu Attygalle, Child and Adolescent
Psychiatry Unit, Sirimavo Bandaranayake Specialized Children’s Hospital, Peradeniya, SRI LANKA
e-mail: udenaa@gmail.com©2023 Japanese Association of Occupational Therapists

evidence for other forms of ABA. Many therapeuticmodalities use the principals of ABA, but not the fullstructure of ABA. Some examples being differential
reinforcement of alternatives behaviours, discrete trial
training, prompting and reinforcement. These modalities
have also gained an evidence base for effectiveness in
ASDs [4]. However, many current interventions basedon applied behavioural approaches have shifted fromthe traditional repetitive training model to more natural,child-initiated, developmentally appropriate strategies
and tasks [5].
Virtually all interventions that have been categorised as established treatments for ASDs are based on
knowledge and applications of the scientific disciplineof behaviour analysis [6]. The evidence for ABA-based
interventions spans all valid and recognised researchmethodologies, including Single-System Design (SSD),
Randomised Controlled Trials (RCT), Meta-analysis andSequential Meta-analysis, Systematic Reviews, Social
Validity studies, Neuroscience studies, and Cost-benefit
analysis [7]. A recent scoping review in 2022 also
concluded that the majority of studies showed positive
outcomes for ASDs when ABA is used as an intervention [8].
Although the results of Randomised Controlled
Trials (RCTs) are considered the gold standard of evi-

Asian J Occup Ther 19: 96−101, 2023

dence based, there are many difficulties in conducting
such trials in autism interventions, the main issue being
difficulties in providing a uniform intervention for allparticipants. However, several RCTs have shown theeffectiveness of ABA based interventions in ASDs. A
good example is Howard et al. [9], who evaluated 29
pre-school children who received intensive behaviour
analytic intervention (treatment group) and two matched
control groups of 16 children each, receiving either intensive or non-intensive ‘‘eclectic’’ interventions. While
the scores for cognitive, language, and adaptive skills
were similar at intake, at follow-up the treatment group
had statistically significant higher mean standard scoresin all areas. These data were confirmed at the 2 year
follow-up [10].
Whilst these forms of therapy are well establishedelsewhere in the world, there are only a handful ofqualified ABA therapists in Sri Lanka. What is practiced
more frequently, is a form of therapy that utilises different aspects of ABA incorporated into more generalways of working with children with behavioural issues.
For example, a therapist may discuss not reinforcing
disruptive behaviour by providing attention to it, or
priming children to communicate, without explicitly
using the terms of ABA. This kind of instruction would
usually not receive emphasis on continued practice as inuse of ABA in other countries, and would be couched inother more generalised instructions related to psychoeducation and other supportive measures.
There is currently a lack of research on the cultural
adaptability of ABA based interventions or its effectiveness in Sri Lanka. However, Sri Lankan culture
has many similarities to other South Asian cultures. In
nearby India there have been many discussions on how
to intervene in ASDs in a more culturally acceptable
way [11]. More generally there has been much debate on
how ABA in particular, can be made more culturally acceptable worldwide [12]. Culture is sometimes defined
as a set of variables arranged by other people [13]. Froma behavioural perspective this means a set of contingencies of reinforcement and punishment that affect thelearned behaviour of a person or a group of people. Culture can also be predictive of how individuals within thegroup act in specific setting and conditions [14]. Thesebehaviours can include selecting culturally appropriate
treatments by parents for their children [15]. In the Sri
Lankan context, having a language that is acceptable
to communicate the concepts of ABA, understanding
cultural factors that maintain some behaviours as well as
the understanding the economic factors that may makeattending regular sessions, are all factor that can affectthe outcomes of ABA.

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Thus, this paper attempts to describe how ABA iscurrently used and accepted in Sri Lanka, and to discuss
how ABA can be utilised with more benefit and acceptability in culturally diverse situations.

The structure of service delivery in relation
to ABA in Sri Lanka
In Sri Lanka, most clients who need help with bothmental and physical health issues seek services frompublic sector facilities. Health services including mental
health services are provided free of charge in the public
sector. Within the structure of the public sector healthservice, there are currently no designated behaviour
therapists even at specialised tertiary level centres [16].
As such the knowledge of behavioural principals are
utilised in therapy mainly by Occupational therapists,
who are also not available at all centres. However, whenavailable, they would be working as part of a small
multi-disciplinary team in the management of issues
such as ASDs. In Sri Lanka available team members
sometimes share their knowledge and skills across disciplines, with occupation therapist, nursing officers, social
workers and even psychiatrists taking on the role thatwould otherwise require a psychologist or a behaviour
therapist. This is out of necessity as a full complementof members (e.g. psychologists, behaviour analysts)
are not available to most teams [17]. As such, if someknowledge and training is available other professionals
will also contribute to behavioural interventions together
with the occupational therapist.

Socio economic factors that influence service
delivery
The families of many children with ASDs in Sri
Lanka find it difficult to attend regular intensive therapy
sessions due to socio-economic reasons. In our experience, although treatment in the public sector is free ofcharge, travelling costs and the loss of wages when daily
wage-earning parents attend sessions are major considerations. As such, home based interventions are widelyused in Sri Lanka. Such interventions carried out early,
with parents acting as full-time therapists have beenfound to be beneficial in ASDs in Sri Lanka [17]. These
kinds of interventions have been perceived to be usefulin other parts of the world as well [18]. When considering the aspects of ABA used in home-based interventions in Sri Lanka, discrete trail training is initiated attherapy sessions and parents are trained to carry out andreinforce these behaviours at home. The progress ofsuch home based interventions are then re-evaluated anddiscussed during visits to the centres.

98

THE USE OF APPLIED BEHAVIOUR ANALYSIS IN SRI LANKAInterventions utilising parents trained in the basicsof ABA have been found to be effective for children with
ASD in other South Asian settings as well [19]. Evaluation of the outcomes of such culturally attuned therapeutic interventions may also require a non-traditionalframework. Different ways of evaluating behaviouralinterventions have been discussed in previous studies[20]. Recent studies have discussed the importance ofevaluating the cultural validity of such interventions, aswell as its efficacy [21].

Cultural differences in the use of reinforcement
The need to use culturally appropriate reinforcement, has been previously described [22]. The conceptof reinforcement, and how it is likely to work in changing behaviours is generally well understood by parentsof children attending services in Sri Lanka. In our experience, parents in Sri Lanka view the use of edibles andtangible items as reinforcers less favourably. Instead,praise given verbally, and physical touch were preferredreinforcers However, many parents are reluctant toaccept the idea of changing their child’s behaviour solely
through overt reinforcement. Instead, there appears to bea preference for less overt ways of communicating andchanging behaviour. This maybe through subtle nonverbal signals of displeasure. Collectivistic Asian cultures
are also known to use greater verbal indirectness intheir communications with each other [22]. While innormal circumstances children would over time learn toread these signals, difficulties arise when children havedisorders such as ASDs that make social communicationdifficult. As such, a part of the work involved parents inmore direct verbal communication and reinforcement.
Although it is generally assumed that praise isa conditioned reinforcer that has acquired its effects
through previous association with other reinforcing
events, how these social reinforcer work may be more
complicated [23]. It was again seen that parents in Sri
Lanka were in general more comfortable giving praise
in indirect ways, acknowledging desired behaviours inthe same manner and using nonverbal gestures at times.
It has been previously described that using overt verbal
praise in typical behaviourist lines in Asian cultures may
cause difficulties and may be inappropriate as the children receiving this praise may be ostracization by theirpeers [24].
However, this indirectness in communication may
sometimes lead to unwanted behaviours being inadvertently reinforced. It was seen that especially families
living with grandparents had difficulties in managing
meltdowns, as there is a belief that parents should notallow their children to cry [25]. This may have been
culturally relevant in times when crying was an indication of physical pain, and ignoring it would not beapproved in collectivist cultures. However, it can also
act to reinforce undesired forms of behaviour in children. In these situations, understanding the function ofsuch behaviours is vital. These undesirable behaviours
can be understood as a manifestation of the child’s needto communicate their needs better, failure to gain moredesired way of getting attention, not have acceptable
activities to engage in when they are alone or in socialgroups, and not having the coping skills to deal withtasks [26]. Function based behavioural strategies inwhich an individual is taught an alternative response that
results in the same source of reinforcement previously
identified as maintaining the problem behaviour may
also be useful in these situations [27].
Some cultural factors may also impede the development of desired behaviours in children as well. For
example, Asian parents have been found to have greater
expectations for the academic achievement of theirchildren [28]. Much less emphasis is placed on thedevelopment of social skills, and as such these skills are
not reinforced as much. From our experience this also
appear to be true in the Sri Lankan situation.
Physical punishment as a way of controlling behaviour in children is still widely used in Sri Lanka [29].
Physical punishment here denotes the use of physicalmeans as a positive punishment in order to reduce undesired behaviours. In our experience, where this waspracticed by parents it was mostly in the absence ofreinforcing wanted behaviour, or providing alternatives.
Currently behavioural forms of treatment do not advocate physical punishment, and argue that it is ineffective
in producing significant and lasting behavioural changes
in children [30]. Although non-physical forms of both
positive and negative punishment can be used to reduce
unwanted behaviour, most behavioural forms of treatment now espouse that children’s behaviour be directed
partly by rewards for their positive actions.

Communication and education variables
Communication is one of the most relevant culturalvariables related to making therapeutic interventions
more acceptable to clients and stakeholders [31]. Understanding how families comprehend and come to termswith a diagnosis of a mental health condition such as an
ASD, is important in understanding how the treatmentof such conditions might be made more acceptable tothem. A study in India suggests that parents may notinitially understand the importance of early intervention
in ASDs and may consider the behaviours as “tempo-

Asian J Occup Ther 19: 96−101, 2023

rary”, until both the parents and assessments of others
lead to an understanding of persisting problems [32].
As a result, some parents may not recognise the needfor consistent therapeutic interventions early on. In our
experience as well, some parents with children who hadmarked behavioural issues that were amenable to ABA
based interventions, come for treatment only after thesewere identified by health professionals. These healthprofessionals had awareness of how problems would
be identified culturally and were able to use culturally
appropriate language to help the parents understandthese behaviours as problematic. This cultural awarenessis important as behavioural patterns that are viewed asproblematic in one cultural context may be normalisedin another [33]. Practitioners of ABA, tend to sharean idiosyncratic technical language by virtue of theirshared vocation [34]. Being able to digress from thiscommon vocational language and engage culturally
diverse clients in a language that they understand is vitalin engaging those in different cultures [35].
However, in the Sri Lankan context, the use of
descriptive terms for words such as “priming” is useful,as the local words for such terms are rarely used and notunderstood by many. The local words for these terms
may also sound abrasive and maybe automatically unpleasant for clients, even for English language speaking
clients [35]. On the other hand, Sinhala translationsof some technical terms used in ABA may also haveseveral meanings. For example, the local Sinhala term
for extinction is also used to describe infertility and may
not be acceptable to many clients. In our experience,
simply describing to them how we worked with clientswith similar issues in the past, is a good way of making
a behavioural model more understandable.
Clients in Sri Lanka tend to express emotional
states such as depression and frustration in indirect
ways, such as using cultural idioms rather than using
direct language [36]. Thus, being able to decipher theseidioms as well as indirect language is important tounderstand the presentation. Similarly cultural idioms
can be also used to explain the behaviour in a more
understandable way. For example one could use thelocal idiom “Hisaradheta kotte maaru kala wagei” (Likechanging pillows to get rid of a headache) to describe
a course of action already taken by the parents with nopossibility of having real benefit of changing behaviour.
The final goal of those engaged in behaviour analyticalpractices should be to ensure that language and culture
does not become a barrier to accessing and engaging intherapy for those who most need it [37].

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Integrating Non-ABA practices into ABA
Traditional rituals and healing practices are stillcommonly practiced in Sri Lanka. In traditional Sri
Lankan theatre culture called Kolam and Tovil, exorcists
wear masks and dance to the rhythm of music. The
Sanni Yakuma is a well-known exorcism ritual, in which
numerous Sanni (disease) demons are portrayed by
wearing elaborate masks [38]. Behavioural interpretations of some of these traditional rituals have also been
attempted [39]. Traditional ritual and healing practices
have been an important part of Sri Lankan culture
and remains a part of the menu of options available topeople, especially from villages, in times distress andtrouble. The help of these traditional healers are alsosought by parents in situations where children have
behavioural problems and developmental delays, as seen
in ASDs. This leads to delays in help seeking in parts ofthe country where such practices are common. Although
this is problematic, it also points to the possible utility ofincorporating a more ritualistic manner of ABA where
this is acceptable. In our experience using a ritualistic
reframe when incorporating activities into home-based
practices has helped to ensure that these are actually
carried out in an almost ritualistic manner.

Conclusion
In conclusion, currently in Sri Lanka ABA is usedin the treatment of children with ASDs, mostly as part ofa more general therapeutic intervention. Currently there
are very few opportunities for clients to access formal
behaviour analytic services in Sri Lanka. As such, there
is a great need for training and awareness. Inputs of
those trained in other countries in the region will be vitalin expanding the local knowledge base and skill levels
in ABA. One way of doing this is to use the experienceof those already engaged in behaviour analytical practices elsewhere in Asia to help train those in Sri Lanka. It
would also provide Applied Behaviour Analysts diversity in fieldwork experience and benefit the practice of
ABA in general [40].
Statement Regarding Informed Consent- Not applicable
Statement Regarding Ethical Approval- Not applicable

References[1] Slocum TA, Detrich R, Wilczynski SM, Spencer TD,

Lewis T, Wolfe K. The Evidence-Based Practice ofApplied Behavior Analysis. The Behavior analyst. 2014;37(1): 41–56.
[2] Smith T, Iadarola S. Evidence Base Update for Autism

100

THE USE OF APPLIED BEHAVIOUR ANALYSIS IN SRI LANKA

Spectrum Disorder. Journal of Clinical Child & Adolescent Psychology. 2015; 44(6): 897–922.
[3] Granpeesheh D, Tarbox J, Dixon DR. Applied behavior
analytic interventions for children with autism: a description and review of treatment research. Ann Clin Psychiatry. 2009; 21(3): 162–73.
[4] Hume K, Steinbrenner JR, Odom SL, et al. EvidenceBased Practices for Children, Youth, and Young Adults
with Autism: Third Generation Review. J Autism Dev
Disord. 2021; 51: 4013–32, doi:10.1007/s10803-02004844-2.
[5] Lord C, Brugha TS, Charman T, Cusack J, Dumas TF et
al. Autism spectrum disorder. Nat Rev Dis Primers. 2020;
6: 5, doi:10.1038/s41572-019-0138-4.
[6] National Autism Center (NAC). The national standards
project: Addressing the need for evidence based practiceguidelines for autism spectrum disorders. Autism (p.
68). MA: Ntional Autism Center; Randolph, 2009, doi:
10.1097/00006199-197003000-00021.
[7] Dillenburger K. Evidence-Based Management and Intervention for Autism Spectrum Disorders- Recent Advances[Internet]. 2015 Apr 2; Available from: http://dx.doi.org/
10.5772/58983.
[8] Gitimoghaddam M, Chichkine N, McArthur L, et al.
Applied Behavior Analysis in Children and Youth with
Autism Spectrum Disorders: A Scoping Review. Perspect
Behav Sci. 2022; 45: 521–57, doi:10.1007/s40614-02200338-x.
[9] Howard JS, Sparkman CR, Cohen HG, Green G, Stanislaw H. A comparison of intensive behaviour analytic
and eclectic treatments for young children with autism.
Research in Developmental Disabilities. 2005; 26(4):359–83, doi:10.1016/j.ridd.2004.09.005.
[10] Howard JS, Stanislaw H, Green G, Sparkman CR, Cohen
HG. Comparison of behaviour analytic and eclectic earlyinterventions for young children with autism after three
years. Research in Developmental Disabilities. 2014;35(12): 3326–44, doi:10.1016/j.ridd.2014.08.021.
[11] Ravindran N, Myers BJ. Beliefs and Practices Regarding
Autism in Indian Families Now Settled Abroad: An Internet Survey. Focus on Autism and Other Developmental
Disabilities. 2013; 28(1): 44–53.
[12] Fong EH, Catagnus RM, Brodhead MT, Quigley S, Field
S. Developing the Cultural Awareness Skills of Behavior
Analysts. Behavior analysis in practice. 2016; 9(1): 84–
94.
[13] Skinner BF. Science and human behavior. New York, The
Free Press New York, 1953.
[14] Sugai G, O’Keeffe BV, Fallon LM. A Contextual Consideration of Culture and School-Wide Positive Behavior
Support. Journal of Positive Behavior Interventions.
2012; 14(4): 197–208.
[15] Rispoli M, O’Reilly M, Lang R, Sigafoos J, Mulloy A,
Auguilar J, Singer G. Effects of language implementation
on functional analysis outcomes. Journal of Behavioral
Education. 2011; 20.
[16] Ginige P, Wijesingha K, Tennakoon S, Alahakoon H,

Baminiwatta A. Autism presenting to two child mental
health clinics at a tertiary care center in central Sri Lanka:
A retrospective. Indian Journal of Social Psychiatry.
2018; 34(2): 172–7.
[17] Perera H, Jeewandara K, Seneviratne S, Guruge C. Outcome of Home-Based Early Intervention for Autism in
Sri Lanka: Follow-Up of a Cohort and Comparison with aNonintervention Group. BioMed Research International.
2016; 1–6.
[18] Dillenburger K, Keenan M, Gallagher S, McElhinney
M. Parent education and home‐based behaviour analyticintervention: an examination of parents’ perceptions ofoutcome. Journal of Intellectual & Developmental Disability. 2004; 29(2): 119–30.
[19] Thayathakath N, Aswatrhi PM. Effectiveness of Applied
Behavioural Analysis (ABA) executed by parents in Early
Intervention Program for children with Autistic Features.
Journal of Contemporary Psychological Research. 2016;
3: 2.
[20] Baer DM, Wolf MM, Risley TR. Some current dimensions of applied behavior analysis. Journal of Applied
Behavior Analysis. 1968; 1: 91–7.
[21] Sivaraman M, Fahmie TA. Evaluating the Efficacy andSocial Validity of a Culturally Adapted Training Programfor Parents and Service Providers in India. Behav Analysis Practice. 2020; 13: 849–61.
[22] Gudykunst WB. Cross- Cultural and Intercultural Communication (1st ed.): SAGE Publications, Inc; 2003.
[23] Dozier CL, Iwata BA, Thomason-Sassi J, Worsdell AS,
Wilson DM. A comparison of two pairing procedures toestablish praise as a reinforcer. Journal of applied behavior analysis. 2012; 45(4): 721–35.
[24] Nelson GL. Cultural differences in learning styles. In J.M.
Reid (Ed.). Learning styles in the ESL/EFL classroom.
Boston: Heimly & Heimly Publishers, 1995.
[25] Chapin B. “We Have to Give”: Sinhala Mothers’ Responses to Children’s Expression of Desire. Ethos. 2010;
38(4): 354–68.
[26] Ala’i-Rosales S, Cihon JH, Currier T, Ferguson JL, Leaf
JB, Leaf R, et al. The Big Four: Functional Assessment
Research Informs Preventative Behavior Analysis. Behavior analysis in practice. 2018; 12(1): 222–34.
[27] Carr EG, Durand VM. Reducing behavior problems
through functional communication training. Journal ofApplied Behavior Analysis. 1985: 18(2): 111–26.
[28] Wiseman AW, Zhao X. Parents’ expectations for theeducational attainment of their children: A cross-national
study using PIRLS 2011. Prospects: 202.
[29] De Zoysa P, Newcombe PA, Rajapakse L. Consequencesof parental corporal punishment on 12 year old children
in the Colombo district. Ceylon Medical Journal. 2008;
53(1): 7.
[30] Hall CS, Lindzey G. Theories of personality (3rd Ed.)
Delhi: Wiley Eastern Limited; 1991. Kleinman A. GoodB. Culture and depression: Studies in the anthropology
and cross-cultural psychiatry of affect and disorder (Comparative studies of health systems and medical care) (First

Asian J Occup Ther 19: 96−101, 2023

Edition): University of California Press; 1985.
[31] Freshman B. Cultural competency: Best intentions are
not good enough. Diversity and Equality in Health Care.
2016; 13: 240–4.
[32] Desai MU, Divan G, Wertz FJ, Patel V. The discovery
of autism: Indian parents’ experiences of caring for theirchild with an autism spectrum disorder. Transcultural
Psychiatry. 2012; 49(3–4): 613–37.
[33] Goldiamond I. Toward a constructional approach tosocial problems: ethical and constitutional issues raisedby applied behavior analysis. Behavior and Social Issues.
20.
[34] Dennison A, Lund EM, Brodhead MT, Mejia L, Armenta
A, Leal J. Delivering Home-Supported Applied Behavior
Analysis Therapies to Culturally and Linguistically Diverse Families. Behav Anal Pract. 2019; 12(4): 887–98.
[35] Critchfield TS, Doepke KJ, Kimberly Epting L, Becirevic
A, Reed DD, Fienup DM, et al. Normative Emotional
Responses to Behavior Analysis Jargon or How Not to
Use Words to Win Friends and Influence People. Behav-

Attygalle UR

101

ior analysis in practice. 2017; 10(2): 97–106.
[36] Kleinman A, Good B. Culture and depression: Studies in
the anthropology and cross-cultural psychiatry of affectand disorder (Comparative studies of health systems andmedical care) (First Edition). University of California
Press, 1985.
[37] Kornack J, Cernius A, Persicke A. The Diversity Is in the
Details: Unintentional Language Discrimination in the
Practice of Applied Behavior Analysis. Behavior Analysis
in Practice. 2019; 12(4): 879–86.
[38] Bailey MS, de Silva HJ. Sri Lankan sanni masks: anancient classification of disease. BMJ (Clinical researched.). 2006; 333(7582): 1327–8.
[39] Bartlett A. Behavioural Perspectives On a Sri Lankan
Healing Ritual. International Journal of Social Psychiatry.
1989; 35(3): 245–51.
[40] Conners B, Johnson A, Duarte J, Murriky R, Marks K.
Future Directions of Training and Fieldwork in Diversity
Issues in Applied Behavior Analysis. Behavior Analysis
in Practice. 2019; 12(4): 767–76.

■ORIGINAL ARTICLE

Predicting Falls and Ability to Perform Activities
of Daily Living using the Dual-Task Stepping Test
in Older Patients Hospitalized for Acute Disease:
A Prospective Study
Takayuki Watabe1, 2, Hisayoshi Suzuki2, Kunio Kabe1, 2, Taiki Sano1,
Asumi Oki1, Mizuki Takayama1, Natsuki Koike1
1
2

Rehabilitation Division, Showa University Northern Yokohama Hospital
Department of Occupational Therapy, School of Nursing and Rehabilitation Sciences, Showa University

Abstract: Background: We prospectively investigated the capability of the dual-task stepping test in predicting falls
and the ability to perform activities of daily living in older patients receiving acute care.
Methods: We recruited 92 participants aged ≥ 65 years who were admitted to our hospital for treatment of an acutedisease from January to December 2021. They performed the dual-task stepping test, wherein they recalled their previous meal while stepping in place in the seated position for 30 s. Data regarding their falls and ability to use the toilet,
change underwear, bathe, walk, and use stairs while in the hospital were recorded. We assessed the accuracy with which
we could predict these measures at discharge using the dual-task stepping test results.
Results: A significant association was noted between the dual-task stepping test results and falls ( p = 0.014). The area
under the curve was 0.70, sensitivity was 100%, and specificity was 38.8%. The dual-task stepping test results wereassociated with all activities of daily living items examined ( p < 0.001), with areas under the curve of 0.92, 0.83, 0.84,
0.87, and 0.87 for the ability to use the toilet, change underwear, bathe, walk, and use stairs, respectively. Sensitivity
was the highest for the ability to use the toilet at 96.2%, and specificity exceeded 90% for changing underwear, bathing,walking, and using the stairs.
Conclusions: The dual-task stepping test is highly sensitive for predicting falls in the hospital and accurately predicts
the need for assistance with activities of daily living in older patients.
Keywords: accidental falls, activities of daily living, aged, hospitalization(Asian J Occup Ther 19: 102−107, 2023)

Introduction
Dual-task performance (performing motor andcognitive tasks simultaneously) has been used to predict
falls in older adults and assess their ability to performdaily activities independently. Dual-task ability decreases with age [1–5] and is essential for understanding
motor performance in daily life for older adults. The
most common dual-task assessment method for predictReceived: 27 May 2022, Accepted: 25 January 2023
Corresponding to: Takayuki Watabe, Rehabilitation Division, Showa
University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tshzukiku Yokohama-shi, Kanagawa, 224-8503 Japane-mail: taka1021@cmed.showa-u.ac.jp©2023 Japanese Association of Occupational Therapists

ing falls is the Stop Walking When Talking Test developed by Olsson et al. [6] If subjects stop walking when
asked “How old are you?” they are likely to fall within
6 months. The timed up-and-go test with a cognitive
task [7] and the trail walking test, wherein subjects walktoward 15 flags placed in random order [8], also effectively predict falls in older adults. Furthermore, gait isaffected in older adults when a cognitive task is added toa normal walking task [9–12]. These findings have beenused to clinically assess walking independence. In activities of daily living (ADL), even patients with severe
motor impairments can function independently whenproper attention is provided. However, without proper
precautions to increase the safety of their surroundings
and actions, some patients with mild motor impairments
cannot function independently. Multiple activities that

Asian J Occup Ther 19: 102−107, 2023

Watabe T et al.

103

require simultaneous attention are essential for the
execution of ADLs [12]. However, while several studies
have examined how dual-task performance relates tofalls and walking, fewer studies have examined its relationship to ADLs [13, 14].
In acute care hospitals, predicting and managing
falls is important for medical safety. In addition, falls
can lead to disability, which can delay reintegration
into society. Furthermore, patients with an episode offalling are treated more carefully by the medical personnel, making it difficult to perform more ADLs, whichhinders achievement of ADL goals. Thus, proactive
measures are needed to predict and prevent falls in
the acute phase. However, fall prediction has not been
properly studied in the older population receiving acutecare [15]. Patients requiring treatment for acute diseases
often remain stationary owing to their deteriorating
condition. After surgery, given intravenous routes andother factors, completing detailed assessments can bedifficult. Therefore, it would be useful to have a clinicaltool capable of making early-stage predictions of falls
and the ability to perform ADLs, including walking, atdischarge in older patients in acute care hospitals.
Herein, we report that the dual-task stepping test,in which the patients performed a cognitive task while
stepping in the seated position, can accurately predictwhether patients are likely to need assistance with ADLs
[16]. This test has been previously evaluated for criterion-related validity and inter-/intra-rater reliability [17].
As it can be easily performed in 30 s in the seated position, this task is feasible for use in acute-phase hospitals
with patients who have limited movement. Suppose thistest could predict falls and the ability to perform ADL,
indicating whether assistance is required for older patients in acute care hospitals. In this case, fall prevention
measures and discharge planning could be improved
early following hospitalization. We prospectively examined the dual-task stepping test for predicting falls andperforming ADLs at discharge in older patients hospitalized for acute diseases.

Table 1 Patients’ characteristics and performance during the dualtask stepping test (n = 92).

Patients and Methods

Dual-task stepping test
In this test, patients recalled what they ate during
their previous meal while stepping in place in the seatedposition for 30 s. Their stepping performance was evaluated during this task. The assessment procedure starts
with the patient sitting on the edge of the bed. Then,the following steps are performed: (1) The investigator
gives the patient the first instruction: “When I give thesignal, step in place by alternating your feet for 30 s. Go
at any speed that is comfortable for you, but do not stop
the task or lower the height you raise each foot; step at
a constant pace.” (2) Stepping practice: The investigator

Patients and procedures
Patients were selected from the 2,674 individuals
admitted to our acute care hospital from January to
December 2021 who were referred to a rehabilitation
therapist. The inclusion criteria were as follows: age≥ 65 years, ability to independently perform ADLs
before disease onset, ability to step in place while sitting
on the edge of the bed, oral feeding capability, ability tofollow simple verbal instructions, and no pain that could
affect the assessment. All patients required assistanceAge (years)
Sex (n)–Male/Female

79.5 ± 7.7
44/48

Diagnoses (n)Cerebrovascular disease
Orthopedic disease
Neuromuscular disease
Other

39
21
11
21

Surgery (n)

Y/N

28/64

Dual-task stepping test (n)Severe dual-task disability
Mild dual-task disability
Normal dual-task ability

40
21
31

for toileting, changing underwear, bathing, walking, andusing the stairs but had no movement restrictions while
sitting, as indicated by the attending physician. Of the769 patients who met these inclusion criteria, 92 were
excluded because they did not require assistance with
ADLs at admission, had short hospital stays of ≤ 7 days,or did not consent to participate (age 79.5 ± 7.7 years;
44 men, 48 women). Table 1 presents the patient characteristics. Written informed consent was obtained fromthe patients.
One of the six experienced occupational therapists(mean years of clinical experience: 9.0 ± 4.8) administered the dual-task stepping test to the patients on days
3–7 of their hospital stay or on the day of surgery. The
patients were prospectively monitored until discharge.
Patients whose ADL status worsened markedly or who
died within 7 days of discharge were excluded from theanalysis. We measured the number of falls that occurred
while the patients were hospitalized and determinedeach patient’s functional independence measure (FIM) at
the time of discharge for toileting, changing underwear,
bathing, walking, and using the stairs. This study wasapproved by the Ethics Committee of A university (approval no. 366). The study was conducted in accordancewith the ethical standards of the 1964 Declaration of
Helsinki and its later amendments or comparable ethicalstandards.

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FALLS AND ABILITY TO PERFORM ADL

demonstrates stepping in place and gives the patient
approximately 10 s to practice. (3) The investigator provides the second instruction: “I will ask you a question
while you are walking. Please continue to step whileanswering.” (4) The investigator prepares the stopwatch,and the patient starts stepping on the signal, “OK, start.”(5) After 5 s, the investigator asks, “Here is the question:
What did you eat for breakfast today?” (If the task is
performed in the afternoon, the investigator replaces“breakfast” with “lunch.”) Stepping performance is thenevaluated until 30 s after the start point. The investigatorobserves the patient for the following three signs: (1)stepping stops for ≥ 1.0 s, (2) the feet are not raised
high enough, or (3) the pace of stepping is disturbed.
Similar to a previous study [16], sign one, signs two or
three, and none of the signs indicated “severe dual-task
disability,” “mild dual-task disability,” and “normal
dual-task ability,” respectively. This test has been evaluated for criterion-related validity and inter-/intra-rater
reliability [17].
Fall incidence and ADL assessment
According to Gibson [18], a fall is defined as when
any part of the body, other than the soles of the feet,hits the ground without intention. We surveyed whether
any falls occurred during the patients’ hospital stayafter completing the dual-task stepping test and when
they were discharged. The ADL assessment excluded
items that did not involve standing, such as eating andgrooming. The tasks included toileting, changing under­
wear, bathing, walking, and using stairs. The FIM atdischarge was evaluated for these items, with a score≤ 5 indicating that the patient needed assistance with the
ADL and a score of ≥ 6 indicating that the patient was
independent.
Statistical analysis
Fisher’s exact test was used to compare the threedual-task stepping test groups (severe dual-task disability, mild dual-task disability, and normal dual-task
ability). The occurrence of a fall was the dependent
variable. The result of the dual-task stepping test was
the independent variable for creating a receiver operating characteristic curve and calculating a cut-off value.
Next, sensitivity, specificity, positive and negative
predictive values, false positive and negative rates, andpositive and negative likelihood ratios were calculatedusing a correspondence table. The area under the curve(AUC) was also calculated to examine the ability of thedual-task stepping test to predict falls. The same process
was followed to predict ADL performance at discharge.
Using independence or assistance for each ADL item as
the dependent variable, cut-off values for the dual-task

Table 2 Status of patients at discharge, including the number of falls
and ability to perform activities of daily living.
Duration of hospital stay (days)
Discharge destination
Fall–
Home/Other
Y/N

37.4 ± 45.5
49/43
12/80

Ability to use the toilet
Ability to change underwear
Ability to bathe
Ability to walkAbility to use stairs

Assistance/
Independence

53/39
67/25
82/10
57/35
77/15

stepping test were calculated. The data needed to predict
ADL assistance were recorded. Statistical analysis was
conducted using the JMP Pro Version 16 software, andthe significance level was set to p < 0.05.

Results
In the dual-task stepping test performed on hospitaldays 3–7, 40 patients exhibited severe dual-task disability (43.5%), 21 exhibited mild dual-task disability(22.8%), and 31 exhibited normal dual-task ability(33.7%).
The mean hospital stay was 37.4 ± 45.5 days, and49 patients were discharged home. Overall, 12 patients
experienced a fall while hospitalized. Fifty-three (57.6%)
patients required assistance with ADLs at discharge
for toileting, 67 (72.8%) for changing underwear, 82(89.1%) for bathing, 57 (62.0%) for walking, and 77(83.7%) for using stairs (Table 2).
Patients were classified as having severe, mild, orno impairment (normal) based on their dual-task performance abilities. Among classified patients, eight (20.0%)
falls were noted among those with a severe dual-task
disability, and four (19.0%) falls in those with a mild
dual-task disability. No patients classified as demonstrating normal dual-task ability fell. This difference wasstatistically significant ( p = 0.014). Significant differences were also observed among these three groups for
all ADL items—toileting, changing underwear, bathing,walking, and using stairs ( p < 0.001) (Table 3).
The AUC of the dual-task stepping test for predicting falls in the hospital was 0.70; the sensitivity
was extremely high at 100%; however, the specificity
was 38.8%. The negative predictive value was 100%,and the negative likelihood ratio was 0.0. The AUC for
predicting assistance with ADLs at discharge using thedual-task stepping test was high for all the activities
measured (Table 4): 0.92 for toileting, 0.83 for changing
underwear, 0.84 for bathing, 0.87 for walking, and 0.87
for using stairs. Sensitivity was highest for toileting, andthe specificity exceeded 90% for changing underwear,
bathing, walking, and using stairs. The positive likeli-

Asian J Occup Ther 19: 102−107, 2023

Watabe T et al.

105

Table 3 Relationship between dual-task stepping test and prediction of falls and ability to perform activities of daily living at discharge.
Dual-task stepping test
Severe dual-task
disability
N = 40Mild dual-task
disability
N = 21

Normal dual-task
abilityN = 31p-value

Effect size

Fall

Y/N

8/32

4/17

0/31

0.014*

0.15

Ability to use the toilet
Ability to change underwear
Ability to bathe
Ability to walkAbility to use stairs

Assistance/
Independence

38/2
39/1
40/0
38/2
40/0

13/8
15/6
20/1
13/8
20/1

2/29
13/18
22/9
6/25
17/14

< 0.001*< 0.001*< 0.001*< 0.001*< 0.001*

0.53
0.29
0.28
0.39
0.38

* Fisher’s exact test Patients were classified based on their dual-task performance abilities. Among classified patients, eight falls were noted among
those with a severe dual-task disability, and four falls in those with a mild dual-task disability. No patient classified as demonstrating normal dualtask ability fell. This difference was statistically significant. Significant differences were also observed among these three groups for all activities
of daily living items—toileting, changing underwear, bathing, walking, and using stairs.

Table 4 Accuracy of predictions of falls and need for assistance with activities of daily living at discharge with the dual-task stepping test.
Cut-off

AUC%(N)

Positive
predictive
value
%(N)

False
Negative
predictive positive
rate
value
%(N)
%(N)

False
negative
rate%(N)

Sensitivity

Specificity%(N)

Negative
Positivelikelihood likelihood
ratio
ratio

Fall

Mild dual-task
disability

0.70

100.0
(12/12)38.8(31/80)19.6(12/61)100.0(31/31)

81.4(49/61)0(0/31)

1.63

0.00

Ability to use thetoiletMild dual-task
disability

0.92

96.2
(51/53)

74.4(29/39)83.6(51/61)

93.5(29/31)

16.4(10/61)

6.5(2/31)

3.77

0.05

Ability to change
underwear

Severe dual-task
disability

0.83

58.2
(39/67)96.0(24/25)

97.5(39/40)46.2(24/52)2.5(1/40)

53.8(28/52)

14.55

0.44

Ability to bathe

Mild dual-task
disability

0.84

73.2
(60/82)90.0(9/10)

98.4(60/61)29.0(9/31)

1.6(1/61)

71.0(22/31)

7.32

0.30

Ability to walkSevere dual-task
disability

0.87

66.7
(38/57)94.3(33/35)95.0(38/40)63.5(33/52)5.0(2/40)

36.5(19/52)

11.70

0.35

Ability to use
stairsMild dual-task
disability

0.87

77.9
(60/77)93.3(14/15)

98.4(60/61)

43.1(14/31)

1.6(1/61)

56.9(17/31)

11.62

0.24

AUC; Area under the curve.
The area under the curve (AUC) of the dual-task stepping test for predicting falls in the hospital was 0.70; the sensitivity was extremely highat 100%; however, the specificity was 38.8%. The negative predictive value was 100%, and the negative likelihood ratio was 0.0. The AUC for
predicting assistance with activities of daily living at discharge using the dual-task stepping test was high for all the activities measured, 0.92 fortoileting, 0.83 for changing underwear, 0.84 for bathing, 0.87 for walking, and 0.87 for using stairs. Sensitivity was highest for toileting, and thespecificity exceeded 90% for changing underwear, bathing, walking, and using stairs. The positive likelihood ratio was ≥ 10 for changing underwear, walking, and using stairs, and the negative likelihood ratio was 0.05 for toileting.

hood ratio was ≥ 10 for changing underwear, walking,and using stairs, and the negative likelihood ratio was
0.05 for toileting (Table 4).

Discussion
This study evaluated the dual-task stepping test
performance in older, hospitalized patients with acuteconditions from hospital days 3–7. The dual-task stepping test had high sensitivity for predicting falls in thehospital and could accurately predict the need for assistance with ADLs.
If a patient stops stepping with the addition of cognitive load during the dual-task stepping test, attention is

temporarily completely directed away from stepping due
to interference; this indicates a marked impairment indual-task ability. Suppose the step height is reduced or
the pace is disturbed with the addition of cognitive load.
In that case, we infer that the attention directed toward
stepping decreases, suggesting a slight decline in theability to perform dual tasks. Patients able to properly
allot attention to both tasks simultaneously demonstratenormal dual-task ability. Woollacott et al. [19] reported
that dual-task conditions affect motor tasks more thancognitive tasks. The assessment in our study also focusedon motor performance rather than cognitive performanceand is thought to accurately reflect the motor abilities
used in daily life.

106

FALLS AND ABILITY TO PERFORM ADL

The quality of the motion used in our study differedfrom commonly used walking and standing tasks. It
showed that stepping in place in the seated position was
feasible for evaluating dual-task ability. There are two
possible reasons for this. First, recalling the last meal
was a relatively difficult cognitive task that createda high degree of interference. A previous study [20]reported that difficulty in performing the cognitive task
during dual-task affected motor performance. In thisstudy, the cognitive task difficulty was appropriate forpredicting falls and the need for assistance with ADLs
in older patients hospitalized for acute disease. Second,
brain activity differs between walking, a commonly usedmotor task, and stepping while seated. Apart from starting to walk, changing directions, and other such actions,
walking is performed unconsciously by the central pattern generator of the spinal cord [21]. It involves little
activation of the prefrontal cortex that consciously allocates attention [22]. In contrast, stepping in the seatedposition has a strong conscious element; therefore,
the performance of this task would be affected by theinterference of a recall task demanding activation of theprefrontal cortex. Therefore, dual-task ability can be feasibly assessed using a seated motor task. The test in ourstudy can be widely used in acute care hospital settings
wherein patients have restricted or limited movement.
In our study, the AUC of dual-task stepping tests
for predicting falls in the hospital was 0.70, which was
based on criteria from previous research [23] and wasconsidered low to moderate [23]; the sensitivity was
extremely high at 100%; however, specificity was low(38.8%). All patients who fell had severe or mild impairment in the dual-task stepping test, and no patientswith normal dual-task stepping ability fell. Patients withnormal dual-task stepping ability demonstrated appropriate motor performance, even with additional cognitive
loading, and can be considered to have low risk of falling. In a previous study predicting falls in older adults
in the acute phase, Milisen et al. [24] reported that the
St. Thomas’s Risk Assessment Tool in Falling Elderly
Inpatients had 57.0% sensitivity and 72.0% specificity.
Caldevilla et al. [25] reported that the Hendrich Fall
Risk Model had 93.0% sensitivity and 35.0% specificity
for predicting falls in older patients in the acute phase.
The accuracy of the dual-task stepping test was highcompared with these previously used assessment tools.
The AUC of the dual-task stepping test results forneeding ADL assistance at discharge was 0.92 for toileting, 0.83 for changing underwear, 0.84 for bathing, 0.87
for walking, and 0.87 for using stairs. The sensitivity
was the highest for the ability to use the toilet (96.2%),and specificity exceeded 90% for changing underwear,
bathing, walking, and using stairs. The positive likeli-

hood ratio was ≥10 for changing underwear, walking,and using stairs, and the negative likelihood ratio was
0.05 for toileting; these are effective values. To the bestof our knowledge, no other studies have used a dual-task
to predict ADL at discharge.
All ADLs examined in the present study required
stability while maintaining dynamic standing. Mihara
et al. [26] reported that dynamic standing requires
conscious postural control by further activation of theprefrontal cortex as the swaying of the body increases.
Older adults require a certain amount of attention tomaintain dynamic standing when performing ADLs,
while conscious attention must also be paid to otherevents [12]. Thus, a dual task that requires conscious
attention for performing two tasks could be used toaccurately predict whether a patient requires assistancewith ADLs.
Patient information on the risk of falls in acutecare hospitals and the need for assistance with ADLs atdischarge is essential for early consideration of the needfor transfer to a rehabilitation hospital. In addition, if thepatient returns home, the family should start preparing
for life after discharge, including family preparedness,consideration of caregivers, and environmental adjustments to prevent falls.
This study has some limitations: (1) We could notcontrol the underlying diseases for which the patientswere hospitalized; these diseases may have affected ouroutcomes. (2) We did not consider potential confounding factors, such as each patient’s waist length, bodymass index, and rehabilitation program. (3) This was asingle-center study; therefore, it lacks external validity.
Lastly (4), we did not examine repeated assessment reliability because only one measurement was performed.
Future studies are needed to address these limitations.
However, the strengths of this assessment include thatit did not require any special equipment or environmentand could be performed quickly while the patient wasseated. This test could be used by nurses and other staff,
not just by rehabilitation therapists, to screen older patients in acute care hospitals for fall risk and the ability
to perform ADLs.

Funding Statement
This work was supported by JSPS KAKENHI [grant
number JP 20K19459].

Disclosure Statement
The authors declare no conflict of interest.

Asian J Occup Ther 19: 102−107, 2023

References[1] Agner S, Bernet J, Brülhart Y, Radlinger L, Rogan S.
Spatiotemporal gait parameters during dual task walking
in need of care elderly and young adults. A cross-sectional
study. Z Gerontol Geriatr. 2015; 48(8): 740–6.
[2] Kim H, Brunt D. The effect of a dual-task on obstacle
crossing in healthy elderly and young adults. Arch Phys
Med Rehabil. 2007; 88(10): 1309–13.
[3] Hall CD, Echt KV, Wolf SL, Rogers WA. Cognitive andmotor mechanisms underlying older adults’ ability to divided attention while walking. Physiol Ther. 2011; 91(7):1039–50.
[4] Hausdorff JM, Schweiger A, Herman T, Yogev-Seligmann
G, Giladi N. Dual task decrements in gait among healthyolder adults: Contributing factor. J Gerontol A Biol Sci.
2008; 63(12): 1335–43.
[5] Hollman JH, Kovash FM, Kubik JJ, Linbo RA. Agerelated differences in spatiotemporal markers of gaitstability during dual task walking. Gait Posture. 2007;
26(1): 113–9.
[6] Lundin-Olsson L, Nyberg L, Gustafson Y. ‘Stop walking
when talking’ as a predictor of falls in elderly people.
Lancet. 1997; 349(9052): 617.
[7] Hofheinz M, Mibs M. The prognostic validity of thetimed up and go test with a dual task for predicting therisk of falls in the elderly. Gerontol Geriatr Med. 2016; 2:2333721416637798.
[8] Yamada M, Ichihashi N. Predicting the probability offalls in community-dwelling elderly individuals using thetrail-walking test. EnvironHealth Prev Med. 2010; 15(6):386–91.
[9] Guedes RC, Dias RC, Pereira LS, Silva SL, Lustosa LP,
Dias JM. Influence of dual task and frailty on gait parameters of older community-dwelling individuals. Braz J
Phys Ther. 2014; 18(5): 445–52.
[10] Ansai JH, Aurichio TR, Rebelatto JR. Relationship between balance and dual task walking in the very elderly.
Geriatr Gerontol Int. 2016; 16(1): 89–94.
[11] Howcroft J, Lemaire ED, Kofman J, McIlroy WE. Dualtask elderly gait of prospective fallers and non-fallers: awearable-sensor based analysis. Sensors (Basel). 2018;
18(4): 1275.
[12] Auvinet B, Touzard C, Montestruc F, Delafond A, Goeb V.
Gait disorders in the elderly and dual task gait analysis: a
new approach for identifying motor phenotypes. J Neuroeng Rehabil. 2017; 14(1): 7.
[13] Shin S, An D. The effect of motor dual-task balance training on balance and gait of elderly women. J Phys Ther
Sci. 2014; 26(3): 359–61.
[14] Johnson JK, Lui LY, Yaffe K. Executive function, more

Watabe T et al.

107

than global cognition, predicts functional decline andmortality in elderly women. Aging Ment Health. 2018;
22: 856–61.
[15] Matarese M, Ivziku D, Bartolozzi F, Piredda M, De Marinis MG. Systematic review of fall risk screening tools
for older patients in acute hospitals. J Adv Nurs. 2015;
71(6): 1198–209.
[16] Watabe T, Suzuki H, Nagashima J, et al. Usefulness ofthe dual-task stepping test to determine the independent
toileting ability of patients with stroke who could perform
stepping in a seated position. Asian J Occup Ther. 2020;
16: 55−62.
[17] Watabe T, Suzuki H, Nagashima J, et al. Judging toileting
independence of stroke patients: A reliability study of
dual task stepping test [in Japanese]. J Japan Occupat
Ther Assoc. 2021; 40: 424–30.
[18] Gibson MJ, Andres RO, Isaacs B, et al. The preventionof falls in later life. A report of the Kellogg International
Work Group on the prevention of falls by the elderly. Dan
Med Bull. 1987; 34 Suppl 4: 1–24.
[19] Woollacott M, Shumway-Cook A. Attention and the control of posture and gait: A review of an emerging area of
research. Gait Posture. 2002; 16(1): 1–14.
[20] Pellecchia GL. Postural sway increases with attentional
demands of concurrent cognitive task. Gait Posture.
2003; 18(1): 29–34.
[21] Matsuyama K, Mori F, Nakajima K, Drew T, Aoki M,
Mori S. Locomotor role of the corticoreticular-reticulospinal-spinal interneuronal system. Prog Brain Res. 2004;
143: 239–49.
[22] Suzuki M, Miyai I, Ono T, Kubota K. Activities in thefrontal cortex and gait performance are modulated by
preparation. An fMRI study. Neuroimage. 2008; 39(2):600–7.
[23] Fisher JE, Bachmann LM, Jaeschke R. A readersʼ guideto the interpretation of diagnostic test properties: Clinicalexample of sepsis. Intensive Care Med. 2003; 29(7):1043–51.
[24] Milisen K, Staelens N, Schwendimann R, et al. Fall
prediction in inpatients by bedside nurses using the St.
Thomas’s risk assessment tool in falling elderly inpatients(STRATIFY) instrument: A multicenter study. J Am Geriatr Soc. 2007; 55(5): 725–33.
[25] Caldevilla MN, Costa MA, Teles P, Ferreira PM. Evaluation and cross-cultural adaptation of the Hendrich II
Fall Risk Model to Portuguese. Scand J Caring Sci. 2013;27(2): 468–74.
[26] Mihara M, Miyai I, Hatakenaka M, Kubota K, Sakoda S.
Role of the prefrontal cortex in human balance control.
Neuroimage. 2008; 43(2): 329–36.

■ORIGINAL ARTICLE

Difficulty and Change of Sub-itemsof the Dementia Behavior Disturbance Scalein Patients with Alzheimer-type Dementia
Aki Watanabe1, Takayuki Kawaguchi2, Koshi Matsuoka3,
Harumi Kotaki4, Makoto Suzuki5, Michinari Fukuda6
1

School of Rehabilitation, Kanagawa University of Human Services
Department of Community Mental Health & Law, National Institute of Mental Health,National Center of Neurology and Psychiatry3
Department of Rehabilitation Medicine, Tamakyuryo Hospital
4
Department of Rehabilitation Medicine, Hatsutomi Hoken Hospital
5
Faculty of Health Sciences, Tokyo Kasei University
6
School of Allied Health Sciences, Kitasato University
2

Abstract: Objectives: It is difficult to predict behavioral disturbances in patients with Alzheimer’s dementia because
the order of appearance of behaviors is not clear. This study aimed to clarify the difficulty of the Dementia Behavior
Disturbance Scale (DBDS) sub-items in patients with Alzheimer’s disease and to compare changes in behavioral disorders after 6 months.
Methods: The participants were inpatients with Alzheimer-type dementia hospitalized in participating hospitals formore than a year. They were assessed with the DBDS, the Mini-Mental State Examination (MMSE), and the Functional
Independence Measure (FIM) twice: at the initial assessment and after 6 months. Rasch analysis for the sub-items of
the DBDS determined the difficulty of behavioral disturbances.
Results: The participants were 44 inpatients. There was no significant difference in the DBDS, MMSE, and FIM between the initial assessment and that after 6 months. Even though many participants increased or decreased for each
assessment scale, there was no major change in the order of item difficulty of DBDS between the initial assessment andafter 6 months.
Conclusions: The systematic indication of the difficulty of behavioral disturbances in the DBDS is a new finding. It is
possible to rank the difficulty of sub-items of the DBDS and infer behavioral disturbances that are likely to appear in
the future. This is useful for clinical decision-making in dementia rehabilitation and care because it indicates the predictability of signs of dementia and behavioral disturbances that suggest the need for dementia intervention.
Keywords: Alzheimer-type dementia, Dementia Behavior Disturbance Scale, difficulty, Rasch analysis(Asian J Occup Ther 19: 108−116, 2023)

Introduction
Predicting behavioral disturbances is an important
topic in the rehabilitation of patients with dementia
because behavioral disturbances in dementia make it
difficult to approach these patients and cause distressReceived: 6 July 2022, Accepted: 25 January 2023
Corresponding to: Aki Watanabe, School of Rehabilitation, Kanagawa
University of Human Services, 1-10-1 Heiseicho, Yokosuka City,
Kanagawa, 238-8522, Japane-mail: watanabe-5mb@kuhs.ac.jp©2023 Japanese Association of Occupational Therapists

and burden to caregivers. Conversion to dementia ischaracterized by increasing impairment in social andoccupational functioning [1], and typical Alzheimer’s
disease is defined in the ICD-10 [2] as the presence ofmemory loss and cognitive impairment for more than 6months. Behavioral disturbances tend to increase slowly
with the slow progression of Alzheimer’s disease symptoms and are involved in difficulties in activities of dailyliving and participation in social activities. Cognitive
dysfunction is also reported to be related to behavioral
disturbances and increased caregiver burden in Alzheimer’s disease [3–6]. In addition, symptoms such as
apathy, nocturnal wakefulness, unwarranted accusations,Asian J Occup Ther 19: 108−116, 2023

dressing inappropriately, and behavioral disturbanceswere reported to be more likely to occur [7]. However,
because the symptoms of Alzheimer’s disease are multidimensional and complex, strategies for predicting
and coping with behavioral disturbances have yet to beestablished.
The Dementia Behavior Disturbance Scale (DBDS),
which was verified by Baumgarten et al. for its reliability and validity [8], is one behavioral disability scalefor dementia, and various and representative behavioral
disorders in dementia are set as sub-items. The DBDS
score is also known to correlate highly with the severityof dementia [8–9]. We reported that the DBDS score ofa patient with dementia can be predicted from the firsttime to after 9 months using a mathematical approachwith a logarithmic model [10]. Furthermore, a study on
the rate of appearance of DBDS sub-items reported that
items associated with memory loss, decreased interest,and decreased activity appeared with high frequency[11]. However, the order of appearance of behavioral
disturbances according to their difficulty has not beenclarified, and qualitative prediction of behavioral disturbances remains a task. Therefore, we decided to address
this task by Rasch analysis using cross-sectional data of
DBDS collected from Alzheimer’s disease inpatients,
in accordance with previous studies [12–13]. In otherwords, to clarify the order of appearance of behavioral
disturbances, we interpreted the difficulty of DBDS
sub-items by logit, an index of item difficulty in Raschanalysis. With this approach, if the types of behavioral
disturbances that are likely to emerge next can be identified, it is thus possible to plan specific support that is
appropriate for each patient’s behavioral disturbance andto support the patient’s life so that inappropriate behaviors do not emerge. In addition, it is possible to provide
appropriate family coaching as caregiver education,
which is important in preventing behavioral disturbances, by knowing which behavioral disturbances are more
frequent [11].
The purpose of this study was to clarify the difficulty of the DBDS sub-items in patients with Alzheimer’s
disease as the index of the frequency of appearance of
behavioral disturbances and to compare the changes inbehavioral disturbances after 6 months.

Methods
Participants
The participants were 97 patients with Alzheimertype dementia who were hospitalized in A Hoken
Hospital for more than a year between February 2013
and November 2014. This hospital can accept patientswith severe dementia whose symptoms are at a level of

Watanabe A et al.

109

the Functional Assessment Stages (FAST) [14] 6 or 7,
which makes it difficult for them to live in the community and take care of themselves, and is characterized byproviding specialized dementia rehabilitation services.
Although the patients present with severe dementia, they
are not physically restrained, and nurses, care workers,
and rehabilitation staff collaborate to assist them withactivities of daily living. Eligibility criteria included
hospital inpatients diagnosed as having Alzheimer-typedementia and absence of delirium, palsy, or any complications of note during the study. Alzheimer-typedementia was diagnosed on admission according to
the criteria of the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-Ⅳ) [15]. The
assessments of behavioral disturbances, cognitive function and independences were immediately stopped if
the patient showed a rejective attitude. The patients who
could not complete all the assessment scales at the two
evaluations (initial and after 6 months) were excluded.
The aims of this study and the testing procedure werebriefly explained to all participants and/or their families
prior to participation. Written informed consent was
obtained from each participant and/or their family. This
study was approved by the Institution Review Board
at Niigata University of Health and Welfare (17132090805) and performed in accordance with the principles of the Declaration of Helsinki.
Assessment of Behavioral Disturbances, Cognitive
Function and Independences
To assess the behavioral disturbances of inpatientswith Alzheimer-type dementia, we used the DBDS,
which is widely used for the assessment of behavioral
disturbances associated with dementia. The DBDS consists of questions about wandering, agitation, eating disorders, aggression, and sexual abnormalities. The DBDS
scores were rated on a 5-point Likert scale The DBDS
scores were rated on a 5-point Likert scale of 0 (not atall), 1 (almost never), 2 (sometimes), 3 (often), and 4(always) for the 28-item scale. Total scores ranged from0 to 112, with scores of more than one point indicating abehavioral disturbance.
We used the Mini-Mental State Examination(MMSE) [16] for the assessment of the cognitive
function. MMSE scores range from 0 to 30, with lower
scores indicating greater cognitive impairment. Assessment items include patient attention, orientation, language, immediate and short-term recall, and the ability
to follow simple oral and written instructions [17].
The Functional Independence Measure (FIM) [18]was used to assess each patient’s behavioral independence and amount of care in daily life. FIM scores canrange from 0 to 126, and the FIM is comprised of 13

110

VALIDATION OF THE SEVERITY OF DBDS

motor items and 5 cognitive items. Each of these items
consists of seven levels scored from one point (total
dependence) to seven points (total independence), withhigher scores indicating greater independence.
These assessments were carried out by the physicaland occupational therapist and nurse who had regularcontact with the participant.
Procedure
The participants were assessed with the DBDS,
MMSE, and FIM on two occasions, at the initial assessment and after 6 months, because the symptoms ofdementia have large variations and to clarify changes inbehavioral disturbances over time. The reason for having
two-time points, at the initial assessment and after 6
months, was to see if the difficulty level of the DBDS
was stable although there were changes in cognitive
function and behavioral disturbances after 6 months in
our study [10]. For each assessment score, the change inscores for all participants and the divided three groups(increasing, maintaining, and decreasing) after 6 months
compared to the initial assessment were identified. The
two assessments were performed by the same rehabilitation staff, a total of 11 staff members. All patients
received conventional physical and cognitive rehabilitation training and activities of daily living training for
3–4 days per week by an occupational therapist, physical therapist, and speech-language-hearing therapist.
Data Analysis
We used the Wilcoxon signed-rank test to assess thechanges in the DBDS, MMSE, and FIM and Spearman’srank correlation coefficient to assess the relationshipbetween behavioral disturbances and cognitive functioning. Rasch analysis of the sub-items of the DBDS
determined the difficulty of the behavioral disturbances.
Rasch analysis is a method of transforming ordinalcounts into distance measured on an interval scale byusing a distribution of the patient’s ability and taskdifficulty [19–22], and it has been used in several behavioral studies [23–25]. In accordance with previous
research [12–13], in the present study, we indicatedthat the logit, i.e., the level of difficulty indicated by the
Rasch analysis, would be an indicator of the frequencyof occurrence of behavioral disturbances, and if theirfrequency was low, the behavioral disturbances may beconsidered to be of high severity. Rasch analysis yields
a mean square fit statistic (MnSq) accompanied by astandardized mean square (Zstd), which indicates significance for each individual sub-item and participant. The
ideal value of infit MnSq is 1.0, and items that exceed
the acceptable range are considered to be misfits and areremoved. The ideal value of Zstd is 0.0, and if it exceeds± 2.0, the item is judged to be misfit [26]. In this study,
infit MnSq values above 1.4 and those associated witha Zstd greater than 2.0 were deleted to misfit [26–28].
The number of participants in this study was assumed tobe more than 30 because previous reports using Raschanalysis have shown that the sample size range needs tobe greater than 27 [29] to have 99% confidence that no
item calibration is more than 1 logit away from its stablevalue. In addition, Krippendorff’s alpha coefficient
was calculated to examine the agreement between the
difficulty rankings at the initial assessment and after 6
months. Statistical analyses were conducted using SPSS
Statistical 27.0 software for the Wilcoxon signed-rank
test, Spearman’s rank correlation coefficients, Krippendorff’s alpha coefficient using R version 4.1.1, andWINSTEPS 3.91.0 for Rasch analysis. A p-value < 0.05
was considered statistically significant.

Results
Among the 97 participants who met the eligibility
criteria, we enrolled 44 patients (45.4%; 15 men, 29
women; age 82.02 ± 8.51 years [mean ± standard deviation]) in whom all data was present. Most of the reasonsfor exclusion were because there was a deficiency in oneof the items of the assessment. The average time fromadmission until the initial assessment was 786.2 days
(386–40,855 days). The participants were hospitalized
in long-term care or medical care ward. The reason for
hospitalization was difficulty in giving care at home ordeterioration of the participant’s condition. Medications
were mainly for Alzheimer’s disease drugs, antipsychotics, and Anti-Parkinson’s disease drugs, with no majorchanges in medication use during the study period.
The DBDS scores at the initial assessment and after
6 months were 12.6 ± 8.8 and 12.0 ± 9.4, and the MMSE
scores were 17.7 ± 7.0 and 18.1 ± 6.5, respectively,
and they were not significantly different (Table 1). The
respective FIM scores were 81.8 ± 25.3 and 80.3 ± 25.6,
motor scores were 56.6 ± 21.2 and 55.4 ± 21.5, andcognitive scores were 25.2 ± 6.9 and 24.9 ± 6.6, respectively. The changes in the scores of the three groups(increasing, maintaining, and decreasing) in each assessment scale after 6 months were significant changes forthe increasing and decreasing groups, respectively (Table
1). All participants were able to ambulate. The correlations of each variable at the initial assessment and after
6 months were significant for all of them (Table 2).
Rasch analysis was conducted at the initial assessment and after 6 months to clarify the difficulty level ofeach item of the DBDS (Fig. 1, Table 3). Higher logits
indicate higher difficulty, that is, they indicate that the
behavioral disturbance is more severe. After each of

Asian J Occup Ther 19: 108−116, 2023

Watanabe A et al.

111

Table 1 Characteristics of participants.
Characteristics

initial assessment

after 6 months

p valueAge (years)
Male/Female
Duration of hospitalization
days (days)
DBDS
total
(n = 44)
improving(n = 20)
maintaining(n = 8)decreasing(n = 16)
MMSE
total(n = 44)
improving(n = 18)
maintaining(n = 9)decreasing(n = 17)FIM
total(n = 44)
improving(n = 21)
maintaining(n = 7)decreasing(n = 14)
FIM motor score
FIM cognitive score82.2 ± 8.51
15/29

12.6 ± 8.8
12.6 ± 8.8
5.8 ± 7.1
10.6 ± 8.1

12.0 ± 9.4
16.9 ± 7.9
5.8 ± 7.1
14.6 ± 10.4

0.283
0.000**
1.000
0.000**

17.7 ± 7.0
15.3 ± 8.3
19.9 ± 5.3
19.0 ± 5.6

18.1 ± 6.5
20.1 ± 6.9
19.9 ± 5.3
14.9 ± 5.6

0.409
0.000**
1.000
0.000**

81.8 ± 25.3
83.5 ± 26.1
81.9 ± 26.0
79.5 ± 25.4
56.6 ± 21.2
25.2 ± 6.9

80.3 ± 25.6
87.8 ± 25.5
81.9 ± 26.0
69.1 ± 23.0
55.4 ± 21.5
24.9 ± 6.6

0.344
0.001**
1.000
0.001**
0.358
0.381

786.2 (386–40855)

Scores are mean ± SD. P values were calculated by Wilcoxon signed-rank test.
DBDS: Dementia Behavior Disturbance Scale, MMSE: Mini-Mental State Examination,
FIM: Functional Independence Measure.
** p < 0.01.

Table 2 Correlations between variables.
Variables

MMSE initial

FIM initial

MMSE 6months

FIM 6months

DBDS initial
MMSE initial
DBDS 6months
MMSE 6months−.512** (< .001)―――−.502** (< .001).301** (.047)――――−.532** (< .001)―――−.526** (< .001).578** (< .001)

Values are Spearman’s correlation coefficients (p-value). The total score for each assessment scale was used in
the analysis.
DBDS: Dementia Behavior Disturbance Scale, MMSE: Mini-Mental State Examination, FIM: Functional Independence Measure.
* p < 0.05, ** p < 0.01.

the misfit items was deleted, the Rasch analysis was
conducted to fit the values of items of infit MnSq or
Zstd. Firstly, the fit of the Rasch model was confirmed.
Although items with Infit Mnsq ≥ 1.4 and Zstd ≥ 2.0
should be deleted, there were no such items at the twotime points, and all items fit the Rasch model. Next, thedifficulty level of the items was confirmed. Five items
were deleted at the initial assessment (item Nos. 25, 26,28) and also after 6 months (item Nos. 17, 24, 25, 28)
because infit MnSq was “maximum measure”. There
were no participants with these five behavioral disturbances at the two-time points. The distribution of itemdifficulty ranged from −1.25 to 1.91 logits for the initialassessment and from −1.35 to 1.61 logits at 6 months,

both of which were sufficient. In the initial assessment,
the logits of the highest sub-items were 1.91 logits (itemNo. 24: Makes inappropriate sexual advances), 0.99
logits (item No. 11: Cries or laughs inappropriately), and0.76 logits (item No. 21: Wanders aimlessly during the
day and No. 22: Makes physical attacks). Those of thelowest sub-items were −1.25 logits (item No. 1: Asks
the same question repeatedly and No. 20: Is incontinentof urine) and −1.08 logits (item No. 3: Lack of interestin daily activities). In the assessment after 6 months, thelogits of the highest sub-items were 1.61 logits (item No.
11: Cries or laughs inappropriately), 1.10 logits (itemNo. 23: Screams for no reason), 0.83 logits (item No. 22:
Makes physical attacks, and No. 26: Destroys property

112

VALIDATION OF THE SEVERITY OF DBDS

(logits)
3

high

28
25
26

2.5

2

17

24

1.5

diﬃculty of
behavior
disturbance

1

23
11
22

0.5

0

16
14

8

21

15
19
12

13

10
18
9

7
5
4

-0.5
2

low
-1

27
6

3

1
20

-1.5

ini�al assessmenta�er 6 months

Fig. 1. Changes in difficulty of sub-items of the DBDS.
The number in the figure indicates the item number of DBDS. Item numbers and logits correspond to those in Table 2. DBDS
difficulty rankings were compared between the two time periods: initial assessment and after 6 months. After 6 months, there
were a few changes in difficulty of the DBDS sub-items, and distribution of logits showed 20 items between −1.00 and 1.00 logits(standard = 0 logits).

or clothing). Those of the lowest sub-items were −1.35
logits (item No. 20: Is incontinent of urine), −1.22 logits(item No. 1: Asks same question repeatedly), and −0.99
logits (item No. 27: Is incontinent of stool). At the initialassessment and after 6 months, the lower difficulty items

had more participants with behavioral disturbances,and the higher difficulty items had fewer number ofparticipants with more severe behavioral disturbances.
Krippendorff’s alpha coefficient in the difficulty of the
DBDS sub-items at the initial assessment and after 6

※
4
※
※
1
5
3
※
2
7
8
6
11
9
15
14
16
18
10
12
13
17
19
22
21
20
23
24

※
※
※
1
2
3
3
5
5
7
7
9
10
10
12
13
14
14
16
17
18
19
20
21
22
23
24
24

25
26
28
24
11
21
22
17
23
15
16
14
18
19
13
12
7
8
10
9
5
4
2
27
6
3
1
20

numberExposes private body parts
Destroys property or clothing
Throws foodMakes inappropriate sexual advances
Cries or laughs inappropriately
Wanders aimlessly during the day
Makes physical attacks (hits, bites, scratches, kicks, spits)
Gets lost outside
Screams for no reason
Empties drawers or closets
Wanders in the house at night
Moves arms or legs in a restless or agitated way
Refuses to eat
Overeats
Hoards things for no obvious reason
Refuses to be helped with personal care
Paces up and down
Repeats the same action over and over
Dresses inappropriately
Is verbally abusive, curses
Makes unwarranted accusations
Wakes up at night for no obvious reason
Loses, misplaces or hides things
Is incontinent of stool
Sleeps excessively during the day
Lack of interest in daily activities
Asks same question repeatedly
Is incontinent of urine

sub-items

DBDS

3.03
3.03
3.03
1.91
0.99
0.76
0.76
0.60
0.60
0.47
0.47
0.36
0.19
0.19
0.12
−0.01
−0.06
−0.06
−0.15
−0.23
−0.27
−0.44
−0.62
−0.92
−1.06
−1.08
−1.25
−1.25

logitsZstd

maximum measuremaximum measuremaximum measure
0.86
0.30
1.23
0.50
0.62
−0.30
1.07
0.40
1.20
0.50
1.10
0.40
0.91
0.10
0.84
0.00
1.40
0.80
0.79
−0.20
1.19
0.50
0.97
0.10
0.91
0.00
0.63
−0.90
1.17
0.50
1.36
0.90
1.03
0.20
0.90
−0.20
0.92
−0.20
0.90
−0.30
1.30
1.50
0.86
−0.70
1.05
0.30
1.23
1.30
0.95
−0.20

infit Mnsq

initial

2.61
0.83
2.6
2.61
1.61
0.65
0.83
2.61
1.1
0.41
0.41
0.41
0.17
0.41
−0.17
−0.09
−0.21
−0.24
0.24
0
−0.09
−0.24
−0.57
−0.99
−0.95
−0.94
−1.22
−1.35

logitsZstd

maximum measure
1.96
1.10
maximum measuremaximum measure
0.75
0.30
1.00
0.30
0.88
0.20
maximum measure
1.26
0.60
1.08
0.30
1.04
0.30
0.93
0.10
0.91
0.00
1.49
0.90
1.23
0.70
0.72
−0.70
0.74
−0.70
0.81
−0.50
0.46
−1.10
0.76
−0.50
1.06
0.30
1.00
0.10
1.00
0.10
1.12
0.70
1.12
0.70
1.23
1.20
1.20
1.00
0.93
−0.30

infit Mnsq

6M

0
0
0
1
3
6
4
3
4
5
7
4
6
6
8
10
12
9
9
11
14
15
17
16
25
25
28
25

n
0
0
0
1
6
9
5
5
8
7
9
10
9
9
15
15
19
16
16
20
25
28
31
45
55
57
68
64

score

initialinitial: initial assessment, 6M: after 6 months, DBDS: Dementia Behavior Disturbance Scale, infit Mnsq: information-weighted mean square fit statistic, Zstd: standardized as a z-score,※: deleted items, maximum measure: too high a value not calculated.
The DBDS items are shown in the order of initial assessment.
Bolded values indicate logits within −1.00 to 1.00.

6M

initialdifficulty ranking

Table 3 Difficulty of Sub-items of DBDS and Distribution of Logits.

0
1
0
0
2
3
3
0
2
4
5
4
5
4
7
10
11
9
7
9
8
11
14
18
24
20
26
27

n

0
3
0
0
4
6
4
0
5
7
8
9
9
10
17
16
23
21
9
15
17
19
31
52
51
50
68
76

score

6M

Asian J Occup Ther 19: 108−116, 2023
Watanabe A et al.
113

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VALIDATION OF THE SEVERITY OF DBDS

months was 0.857. Although there were a few changes
in the difficulty of the DBDS sub-items after 6 months,
the agreement between the initial assessment and after
6 months on the difficulty of the DBDS sub-items washigh. Moreover, the distribution of the logits of item difficulty at the initial assessment and after 6 months each
included 20 items between −1.00~1.00 logit.

Discussion
In this study, Rasch analysis of the DBDS in hospitalized Alzheimer’s disease patients clarified the order of
appearance of the DBDS sub-items as the index of frequency of appearance of behavioral disturbances. There
was no significant difference in the DBDS, MMSE, andFIM between the initial assessment and after 6 months,
and the correlation between the DBDS and MMSE
was high. A previous study suggested that behavioral
disturbances are thought to appear with the progressionof dementia [30]. The DBDS was developed to evaluate
the behavioral disorders that appear that are related
to cognitive function, physical function, and psychic
function [31]. Therefore, the behavioral disturbances
listed in the DBDS are not caused by cognitive function
alone but by a combination of factors. Previous studies
showed that both the severity of cognitive impairment
and the decline in the levels of behavioral independence
influenced behavioral change in nursing home residents[32–33]. For this reason, it is important not to judge thebehavioral disturbances of dementia by severity andcognitive function only but also to assess the behavioral
disturbances to rehabilitate and care for patients withdementia.
The order of appearance of the sub-items was clarified in this study. If the logit in Rasch analysis is high,the behavioral disturbances are unlikely to appear, andif the logit is low, the behavioral disturbances are likely
to appear. There have been many reports on the rate ofappearance of behavioral disturbances. Yamaguchi et al.
[11] investigated the rate of appearance of behavioral
disturbances in 161 patients with Alzheimer’s disease(age 80.8 ± 6.6 years, DBDS 18.1 ± 13.2 points) andfound that the items related to memory impairment
were the most frequent, followed by apathy, decreased
interest, and decreased activity, and the frequency of
violence and agitation was low. In addition, Kaufer et al.
[34] reported that depression and apathy appeared more
frequently, followed by anxiety and irritability in about
50%, and the frequency of disinhibition and abnormal
eating behavior was low in 60 participants (age 76.1 ±8.0 years, MMSE 18.4 ± 5.6 points). Other studies suchas those of Godinho et al. [35] and Nukariya et al. [36]reported similar results, as did the present study. The

results of this study, that participants were more likely todevelop urine/stool incontinence, differed from previous
studies. Other reports have included some participants
with non-AD and MCI, and some studies have included
patients living in the community. Therefore, it is notpossible to make a general comparison with the present
study because the conditions of the participants weredifferent from those of this study. However, although the
MMSE scores of the participants in this study did not
differ significantly from those in other reports, many ofthem had the FAST 6 or 7 scores and had more severeAD, indicating a higher incidence of urine/stool incontinence in addition to the same results as those in previous
studies. These results reflect the clinical course shownby the FAST and suggest that a higher frequency of
behavioral disturbances may indicate lower severity ofsymptoms [14]. In addition, each assessment scale was
re-assessed after 6 months and compared to the initialassessment. Even though many participants increased or
decreased for each assessment scale, there was no majorchange in the order of item difficulty of DBDS between
the initial assessment and after 6 months. It was possible
to infer behavioral disturbance that is likely to appear in
the future because the order of appearance of the behavioral disturbances did not change with time. However,behavioral disturbances do not always follow a constantpath of change. Although the difficulty of the DBDS
sub-items does not necessarily indicate the order of
appearance of behavioral disturbances, it might be an indication of the next behavioral disorder that may appear.
The logits in the DBDS sub-items were nearly thestandard values, with 20 of the items within the rangeof −1.00 to 1.00 logit for both the initial assessment andthat after 6 months, and the difference in logits between
the items was relatively small. If dementia symptoms
or behavioral disturbances appear, other behavioral disturbances with similar difficulty levels may also appear.
However, if there is an improvement in some symptomsof the behavioral disturbance, it is possible to improveother symptoms as well. Based on the characteristicsof the patients, we can select items from the behavioral
disturbances that are appropriate for the individual
patient and intervene, leading to improvements in otherbehavioral disturbances of similar difficulty. This will
be a point of intervention in the patient’s nursing careand rehabilitation. In this way, the DBDS is clinicallyuseful as a means to improve symptoms in patients with
Alzheimer’s disease, which is a progressive disease, andas an indicator of interventions required in the patient’s
rehabilitation. In addition, because items of the DBDS
focus on problematic behaviors that are a burden to the
caregivers8), the DBDS may be useful as an indicatorof the degree of caregiver burden. In the Rasch analysis,

Asian J Occup Ther 19: 108−116, 2023

five sub-items (Nos. 17, 24, 25, 26, and 28) were deleted
in the initial assessment and/or after 6 months. These
items were behavioral disturbances that did not appear
or appeared in only a few patients. Item Nos. 17 and
24 are unlikely to appear because the participants were
inpatients, and items Nos. 25, 26, and 28 were unlikely
to appear because caregivers might prevent the patientfrom carrying out these actions. Therefore, these data
were affected by environmental influences. If these
symptoms appear, it is possible that the care situationis poor or that the patient’s behavioral disturbances are
more severe than originally thought.
One of the reasons for the decrease in the numberof participants from 97 to 44 in this study was that manyof the excluded patients could not be evaluated with
the MMSE and their symptoms were more severe. Thismay have caused selection bias in that the severity ofthe dementia affected the possibility or impossibility ofassessment. In addition, as the participants in this study
included inpatients hospitalized for long and varied
periods and who participated in rehabilitation almost
every day, their current symptoms were influenced bytheir environment such as hospitalization. However, weconsidered the influence of these limitations on the results was low due to the various severities of symptoms
and behavioral disturbances among the participants.
As a further study, if many facilities and a larger
number of participants were added to the analysis, thechanges in behavioral disturbances with Alzheimer’s
disease might be shown in more detail and generally
adopted. Moreover, it is not possible to assert that the
Rasch analysis alone in the DBDS sub-items accuratelyreflects the degree of difficulty of BPSD in Alzheimer’s
disease. The appearance of symptoms may be undeniable to vary depending on different situations since
BPSD is a symptom that occurs based on biological,
psychosocial, and environmental factors [37]. However,the difficulty of the DBDS sub-items in patients with
Alzheimer’s disease that we have shown in the present
study is an important finding because it gives a newperspective that has not been shown previously. In
addition, because the effects of disease progression andmedication cannot be excluded in patients with Alzheimer’s disease, we decided to investigate behavioral disturbances at two-time points in this study. In the future,
if we can construct a prediction model with variables
such as the amount of medication taken and functionalchanges shown in brain imaging, it should be possible topredict the behavioral disturbances of individual patientsand provide specific support.
This study ranked the difficulty of the sub-items of
the DBDS by Rasch analysis of DBDS data in inpatientswith Alzheimer-type dementia. The systematic indica-

Watanabe A et al.

115

tion of the order of appearance of behavioral disturbances in the DBDS is a new finding. It may be possible toinfer behavioral disturbances that are likely to appear
in the future. This result is clinically useful as a means
to qualitatively assess dementia and plan phases ofrehabilitation and care because they can infer behavioral
disturbances that may be an indication of the need forintervention.

Conflict of interest statement
The authors declare no conflict of interest.

Acknowledgments
We thank the patients for their participation in thisstudy. This work was supported by a Grant-in-Aid for
Scientific Research (15K1508819) from the Japan Society for the Promotion of Science and Takeda Science
Foundation.

References[1] LoGiudice D, Watson R. Dementia in older people: anupdate. Internal Medicine Journal. 2014; 44.
[2] World Health Organization. International Classificationof Diseases and Related Health Problems, 10th Revision,
World Health Organization, Geneva, 1993.
[3] Kim B, Noh GO, Kim K. Behavioural and psychologicalsymptoms of dementia in patients with Alzheimer’s disease and family caregiver burden: a path analysis. BMC
Geriatrics. 2021; 21: 160.
[4] Dauphinota V, Combea FD, Mouchoux C, Doreya A,
Bathsavanisa A, Makaroffa Z, et al. Risk Factors of Caregiver Burden Among Patients with Alzheimer’s Disease
or Related Disorders: A Cross-Sectional Study. Journal of
Alzheimer’s Disease. 2015; 44: 907–16.
[5] Yu1 H, Wang X, He R, Liang R, Zhou L. Measuring the
Caregiver Burden of Caring for Community-Residing
People with Alzheimer’s Disease. PLoS ONE 2015; 10(7):e0132168, doi:10.1371/journal.pone.0132168.
[6] Kang HS, Myung W, Na DL, Kim SY, Lee JH, Han
SH, et al. Factors Associated with Caregiver Burden in
Patients with Alzheimer’s Disease. Psychiatry Investig.
2014; 11(2): 152–9.
[7] Ikeda Y, Han G, Maruta M, Hotta M, Ueno E, Tabira T.
Association between daily activities and behavioral andpsychological symptoms of dementia in communitydwelling older adults with memory complaints by theirfamilies. Int J Environ Res Public Health. 2020; 17(18):6831, doi:10.3390/ijerph17186831.
[8] Baumgarten M, Becker R, Gauthier S. Validity and reliability of the dementia behavior disturbance scale. J Am
Geriatr Soc. 1990; 38: 221–6.
[9] Nakayama N, Suzuki M, Endo A, Nitanda Y, Tanabe N,

116

VALIDATION OF THE SEVERITY OF DBDS

Watanabe A, et al. Impact of dementia on behavioral independence and disturbance. Geriatr Gerontol Int. 2017;
17: 605–13.
[10] Watanabe A, Suzuki M, Kotaki H, Sasaki H, Kawaguchi
T, Tanaka H, et al. Predicting cognitive and behavioral
functions in patients with dementia: Practical prognostic
models of logarithmic and linear regression. Edorium J
Disabil Rehabil. 2016; 2: 144–53.
[11] Yamaguchi H, Nakajima T, Uchida H, Matsumoto M,
Amari M, Ikeda M, et al. Evaluation of behavioral disturbance with dementia behavior disturbance (DBD) scalein the outpatients of the Medical Center for Dementia [inJapanese]. Dementia Japan. 2017; 31: 389–97.
[12] Yorke J, Horton M, Jones PW. A critique of Rasch analysis using the Dyspnoea-12 as an illustrative example. J
Adv Nurs. 2012; 68(1): 191–8.
[13] Adams JW, Stone M, Vincent RD, Muncer SJ. The roleof syllables in anagram solution: a Rasch analysis. J Gen
Psychol. 2011; 138: 94–109.
[14] Reisberg B. Functional assessment staging (FAST). Psychopharmacol Bull. 1988; 24: 653–9.
[15] American Psychiatric Association: Diagnostic andstatistical manual of mental disorders. 4th ed. American
Psychiatric Association, 1994.
[16] Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination
by age and educational level. JAMA. 1993; 269(18):2386–91.
[17] Folstein MF, Folstein SE, McHugh PR. “Mini-mental
state”. A practical method for grading the cognitive stateof patients for the clinician. J Psychiatr Res. 1975; 12(3):
189–98.
[18] Chino N, Tsubahara A, Sonoda S, et al. Nosottyu no kinohyoka—SIAS to FIM [in Japanese]. Kanehara Shuppan,
Tokyo, 2012.
[19] Rasch G. Probabilistic models for some intelligence andattainment tests. Danish Institute for Educational Research, Copenhagen. 1960; xii: 184.
[20] Mul K., Horlings CG, Faber CG, van Engelen BG, Merkies IS. Rasch analysis to evaluate the motor function
measure for patients with facioscapulohumeral muscular
dystrophy. International Journal of Rehabilitation Research. 2021; 44(1), 38–44.
[21] Bond TG, Fox CM. Applying the Rasch model: Fundamental measurement in the human sciences. 2nd ed.
Lawrence Erlbaum Associates, Mahwah, NJ, 2007.
[22] Fischer A, Frewer L, Nauta J. Toward improving foodsafety in the domestic environment: a multi-item Raschscale for the measurement of the safety efficacy of domestic food-handling practices. Risk Anal. 2006; 26(5):1323–38.
[23] Nielsen T, Pontoppidan M, Rayce SB. The Parental Stress
Scale revisited: Rasch-based construct validity for Danish
parents of children 2–18 years old with and without be-havioral problems. Health Qual Life Outcomes. 2020; 18:281.
[24] Devenney E, Bartley L, Hoon C, O’Callaghan C, Kumfor
F, Hornberger M, et al. Progression in behavioral variant
frontotemporal dementia. a longitudinal study. JAMA
Neurol. 2015; 72(12): 1501–9.
[25] Henson S, Blandon J, Cranfield J. Difficulty of healthyeating: a Rasch model approach. Soc Sci Med. 2010; 70:
1574–80.
[26] Linacre JM. A user’s guide to Winsteps Ministep: Raschmodel computer programs. Winsteps, 2009.
[27] Stolt M, Kottorp A, Suhonen R. A Rasch analysis of theself-administered Foot Health Assessment Instrument (SFHAI). BMC nursing. 2021; 20(1): 1–9.
[28] Kielhofner G, Forsyth K, Kramer J, Iyenger A. Developing the Occupational Self Assessment: the use of Raschanalysis to assure internal validity, sensitivity and reliability. Br J Occup Ther. 2009; 72(3): 94–104.
[29] Linacre JM. Rasch measurement. Sample size and item
calibration (or person measure) stability. http://www.
rasch.org/rmt/rmt74m.htm. Accessed 9 Dec 2020.
[30] Kazui H, Yoshiyama K, Kanemoto H, Suzuki Y, Sato S,
Hashimoto M, et al. Differences of behavioral and psychological symptoms of dementia in disease severity infour major dementia. PLoS One. 2016; 11: e0161092.
[31] Mizoguchi T, Iijima S, Eto F, Ishizuka A, Orimo H. Reliability and validity of a Japanese version of the Dementia
Behavior Disturbance Scale. [in Japanese]. Nihon Ronen
Igakkai Zasshi. 1993; 30(10): 835–40.
[32] Ang YH, Au SYL, Yap LKP, Ee CH. Functional declineof the elderly in a nursing home. Singapore Med J. 2006;
47(3): 219–24.
[33] McConnell ES, Pieper CF, Sloane RJ, Branch LG. Effectsof cognitive performance on change in physical function
in long-stay nursing home residents. J Gerontol A Biol
Sci Med Sci. 2002; 57(12): M778–M784.
[34] Kaufer DI, Cummings JL, Ketchel P, Smith V, MacMillan A, Shelley T, et al. Validation of the NPI-Q, a briefclinical form of the Neuropsychiatric Inventory. J Neuropsychiatry Clin Neurosci. 2000;12: 233–9.
[35] Godinho C, Camozzato A, Kochhann R, Chaves MLF.
Association of caregiver demographic variables with neuropsychiatric symptoms in Alzheimer’s disease patientsfor distress on the Neuropsychiatric Inventory (NPI).
Dement Neuropsychol. 2008; 2: 211–6.
[36] Nukariya K, Furukawa H, Nagata T, Manabe T, Ochiai
Y, Itou T, et al. BPSD of Alzheimer’s disease and factorsthat affect care burden [in Japanese]. Jpn J Gen Hosp
Psychiatry. 2013; 25(3): 278–86.
[37] Gilmore MC, Stebbins L, Argüelles-Borge S, Trinidad B,
Golden CJ. Development and treatment of aggression in
individuals with dementia. Aggression and violent behavior. 2020; 54: 101415.

■ORIGINAL ARTICLE

Prism Adaptation Induces Allocentric Neglect-Like
Behavior in Healthy Participants
Toshiki Takeuchi1, Hidekazu Saito2, Hisaaki Ota1, 2
1
2

Graduate School of Health Sciences, Sapporo Medical University
Department of Occupational Therapy, School of Health Sciences, Sapporo Medical University

Abstract: Introduction: Prism adaptation (PA) is a promising treatment to improve unilateral spatial neglect (USN).
Egocentric neglect and allocentric neglect are the two types of USN in terms of spatial reference frames, but no study
was reported the PA affects allocentric frame selectively. This study therefore aimed to investigate whether the PA effectcould be observed only on allocentric frame in healthy participants.
Method: Thirty right-handed participants (12 females and 18 males, mean age 22.6 years), wore the right wedged prismatic glasses that created an optical shift of 5.7° to the left. They were asked to reach two visual targets with the rightindex finger 100 times alternately. Outcomes were measured through the line bisection task where lines of two different
lengths (200 mm and 50 mm) were presented one by one in front of or on the left or right side of the participants.
Results: The subjective midpoint on the 200-mm line shifted significantly to the right after the PA, but not on the 50mm line. Additionally, the degree of rightward deviation was not affected by the position of the presented line regardless of its length.
Discussion: These results indicate that the PA task induced allocentric neglect-like behavior. Hence, PA affected only
the allocentric frame among healthy participants. The results of this study may contribute to the evaluation and treatment of allocentric neglect.
Keywords: unilateral spatial neglect, prism adaptation, allocentric neglect, line bisection task, healthy participants(Asian J Occup Ther 19: 117−123, 2023)

Introduction
Unilateral spatial neglect (USN) is defined as a deficit in responding, orienting, or initiating action toward
contralesional stimuli [1]. This condition is observed in
40–50% of patients who have right brain injury duringhospitalization [2], and often leads to difficulties in dailyliving and rehabilitation, hindering the achievement oftherapeutic goals [3–4]. Therefore, various treatments
have been developed to manage USN [5–7].
One such treatment, prism adaptation (PA) is apromising treatment, as supported by randomized control trials [5–6] and stroke rehabilitation guidelines [7].
PA involves the use of prismatic glasses that create arightward optical shift, and the repetitive reaching task
Received: 6 July 2022, Accepted: 3 February 2023
Corresponding to: Toshiki Takeuchi, Graduate School of Health Sciences, Sapporo Medical University, Japan, S1 W17, Chuo-ku, Sapporo,
Hokkaido, 060-8556, Japane-mail: toshikitakeuchi@sapmed.ac.jp©2023 Japanese Association of Occupational Therapists

for visual targets. This relatively simple task can becompleted in a short time, yet be observed significant
improvements in USN immediately after completion,
which lasts for at least 2 hours [8]. These improvements
have been observed in patients’ paper and pencil task
scores and functional performance, including postural
imbalance [9], wheelchair driving [10], and activities
of daily living [11]. Moreover, PA has been shown to
improve USN symptoms on mental representation tasks[12], with additional effects on dichotic listening [13]and tactile extinction [14]. These findings suggest that
adaptation to the prismatic shift induces amelioration ofvarious aspects of USN and its related symptoms.
USN is classified into two types, based on thespatial frame of reference affected: egocentric and allocentric neglect. Egocentric neglect is characterized byinattention toward the contralesional side of space basedon the patient’s position [15–17]. Allocentric neglect
is defined as inattention toward the contralesional sideof stimuli, regardless of the patient’s position [17–18].
These subtypes of USN can be assessed by a copyingtask [19], the Ota task [16], and the Apples test [20]. Ad-

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PA INDUCES ALLOCENTRIC NEGLECT-LIKE BEHAVIOR

ditionally, Medina et al. [17] proposed that the administrating neglect tests to the left and right of the patient’s
midline can be used to distinguish between egocentricand allocentric neglect; patients with left egocentric neglect will tend to fail to respond to stimuli presented intheir left trunk field, while responding to stimuli presented in the right trunk field. In contrast, participants withleft allocentric neglect will tend to not respond to theleft side of the stimuli regardless of where it is presented
with respect to the patient.
Currently, the evidence on the effectiveness of
PA on allocentric reference frames remains unclear.
The first PA study, conducted by Rossetti et al. [8],revealed that the PA task ameliorated both egocentricand allocentric neglect on the Gainotti copying task [19].
However, in some studies that used the Apples test [20],
PA only affected egocentric neglect [21–23]. Michel
et al. [24] found that, in healthy participants, the PA task
only affected the egocentric frame on the line bisection(LB) task, in which a line is presented at the front, right,
and left sides of the participant, as the position of line
presentation affected the decision of the subjective midpoint. However, it remains unknown whether PA affects
the allocentric frame in healthy participants.
Previous studies revealed that the appearance of
deficits in each reference frame depends on the task
demands [25–26]. Even subtle changes in the stimuli ortask instruction can alter the apparent reference frame.
As changes in the deficits in each reference frame havebeen observed within a single participant, it has beensuggested that participants can distribute attention
flexibly and strategically assign a reference frame, depending on the demands of the task [25–26]. Based onthese findings, in the LB task for healthy participants,
the application of different line lengths and presentationon the left and right, as well as in the center, may elicit
attention to the length of the presented line, but not its
position, and result in the subjective midpoint being determined in relation to the allocentric frame. Therefore,
it is hypothesized that by utilizing these LB task settings
to assess the effect of the PA task, it may be possible
to induce the PA effect in the allocentric frame among
healthy participants.
This study aimed to reveal whether the PA effectappears only allocentric frame in healthy participants,
using an LB task in which lines of two different lengths
were presented individually in front, or on the left or
right side, of the participants. We predicted that the
subjective midpoints of the lines on the LB task after PA
might show significant rightward deviations comparedto that after a control task (flat lens; see Repetitive
reaching task in the Materials and Methods), regardlessof the position of the lines.

Materials and Methods
ParticipantsThis preclinical study included 30 healthy volunteers (12 women and 18 men, age range 20–30 years,
mean 22.6 ± 2.2 years) in the experiments. All participants were right-handed, as confirmed with the Flanders
handedness test [27], had a normal or corrected-tonormal vision, and had no history of neurological or
psychiatric illness. The study complied with the tenetsof the Declaration of Helsinki and was approved by the
local ethics committee of Sapporo Medical University(approved number: 30-2-29). Prior to their participation,
all participants provided written informed consent.
ProcedureThis study employed a crossover design, in whichhalf of the participants were randomly assigned to either
the prismatic condition or the flat lens condition, serving
as the control condition, for the first experiment. Theirassignments were reversed for the second experiment.
As outcome measures, the open-loop pointing (OLP)
and the LB tasks were performed immediately before
and after a repetitive reaching task in each experiment.
To eliminate any carryover effects of repetitive reachingtasks, a de-adaptation task was completed during theinterval between experiments.
During the experiments, each participant sat at adesk with a height of 70 cm. The seat height was adjusted to ensure a vertical distance of 50 cm from the surface of the table to the root of the nose was maintained.
Repetitive reaching task (Fig. 1-A)
Two visual targets, blue on the right and red on
the left, were presented on a black A3 sheet in front of
the participants, positioned 8 mm in diameter and 10°
to either side from the midline of the participants. The
distance between the abdomen and each target was 51
cm. A black board was placed on the desk to obscure theextraneous movements of participants’ index fingers, allowing them to only view their index fingers when they
were reaching the targets. A thin non-slip mat (4.5 cm ×3.5 cm) that was easily found by tactile perception wasplaced in front of the participants as a starting place for
their reaching movements.
In the prismatic condition, participants wore rightwedged prismatic glasses (Fuji Optical Co., Ltd., Sapporo, Japan) that created an optical shift of 5.7° to theleft. This was the maximum angle of the commerciallyavailable lens. A previous study demonstrated the PA
effect in patients with left USN using the same angle[28]. In the flat lens condition, participants wore flat lensglasses (Fuji Optical Co., Ltd., Sapporo, Japan) that cre-

Asian J Occup Ther 19: 117−123, 2023

Takeuchi T et al.

119

Fig. 1. A: Schematic view of the repetitive reaching task. The black rectangle represents a flat plate that limits the visibility of the
trajectory of the reaching movement. The gray rectangle represents the monitor that displays the targets, with the white circles
representing the targets. B: Schematic view of the line bisection task. The gray rectangle represents the placement of the tablet for
presenting a line in the left position. The broken line rectangle represents the position of the tablet in the center position.

ated no optical shift. Participants were instructed to wear
the assigned glasses and to repetitively reach the visualtargets with their index fingers at a fast but comfortablespeed. In both conditions, the reaching movement fromthe starting point to the targets was repeated alternately
100 times.
Outcome measures
OLP task
We employed this task to verify the alteration ofhand-eye coordination by adapting the prismatic opticalshift. An 8 mm diameter red visual target was placed ona desk at a distance of 40 cm in front of the participants.
Participants were instructed to fixate on the target andmemorize its location. They were then instructed toreach for it with their right index fingers with theireyes closed. The trial was repeated five times, and theexperimenter manually recorded the position of the tipof their index fingers on a sheet placed on the desk usinga marker. The lateral deviation from the midsagittal line
to the terminal reaching position was measured to thenearest mm. The deviations of their finger to the right orleft of the midsagittal line were represented as positiveor negative values, respectively. The average values ofthe five trials from each participant were adopted fordata analysis.
LB task (Fig. 1-B)
The LB task quantitatively evaluated the effect of
the PA on the participants’ perceptual-motor response.
We presented a line in three different spatial locations todetermine the effect of PA on egocentric and allocentric
frames.
This task was performed using a tablet PC (Micro­
soft Surface Pro, sampling rate = 60 Hz, resolution =1024 × 768 pixels, monitor size = 231 × 173 mm, 0.23
mm per 1 pixel). A camera in the PC display was cov-

ered to eliminate the possibility of judging the subjective midpoint of the presented lines. Two black lines ofdifferent lengths (50 and 200 mm) and 2 mm thickness
were prepared to confirm the differentiating effect of PA
on spatial attentional function compared to peripheral
physical hand-eye coordination. The midpoint of eachline was aligned with the center of the monitor and individually presented on the tablet. The tablet was placed
in one of three locations: front, left, or right side of theparticipants. For these locations, the center, right side,
and left side of the tablet were aligned with the midsagittal plane, respectively. The lateral displacement of
the tablet to either side from the center position was approximately 115 mm. The distance between the xiphoidprocess of the participants and the tablet PC was 30 cm.
Five trials were conducted for each combined conditionof the line length and its location; in total, 30 trials were
performed with a pseudo-random order of line presentation. For this task, each participant was instructed toplace their chin on the chin rest to prevent movement of
the head and trunk. Participants were then instructed tomark the subjective midpoint of a presented line using a
dedicated tablet pen held in the right hand.
The deviation of the subjective midpoint from thetrue center was quantified in the nearest mm for eachline. Positive values were assigned for rightward deviations from the midpoint, whereas negative values wereassigned for leftward deviations. For each participant,the average values of the results of 5 trials with combined line length and position conditions were used forstatistical analysis.
De-adaptation of repetitive reaching task
To eliminate the carryover effect of the repetitive
reaching task, participants engaged in a different type of
repetitive reaching task between experiments. The tablet
PC used in the LB task was placed in front of the par-120

PA INDUCES ALLOCENTRIC NEGLECT-LIKE BEHAVIOR

ticipants. A singular green dot with a diameter of 8 mm
was presented on the tablet monitor in a pseudo-random
order. This visual target was presented for 1 s, and thesubsequent target was displayed after a 1-s interval.
Participants without experimental glasses were instructed to reach a dot from the thin non-slip mat. During
the de-adaptation, the black board covering the desk
was removed, thus allowing participants to discern the
trajectory of their index fingers during the pointing task.
The participants were given a 10 min rest following thistask.
Statistical analysis
To determine the effect on the OLP task, the resultsof the task performed before and after the repetitive
reaching task in each condition were compared usinga paired t-test. Additionally, to confirm the de-adaptation, we divided the participants into two groups thatfirst performed the prismatic condition (prismatic firstgroup) and the flat lens condition (flat lens first group).
Then, we compared the results of the task after the first
repetitive reaching task and before the second repetitive
reaching task in each group using the paired t-test or the
Wilcoxon signed rank test.
The effect of PA was determined by comparing theresults of the LB task using three-way repeated measure
ANOVA, with glass conditions (prism or flat lens), line
locations (left, center, or right), and line lengths (200 or
50 mm) as independent variables. In this analysis, thedependent variable was the value obtained when subtracting the result of the pre-task from that of the posttask. Post-hoc comparisons were performed using the
Bonferroni test.
The normality of the distribution of the data obtained from each lens condition and divided groups in
the OLP task, and the LB results obtained from eachcondition combining the line length and its position wereassessed with the Shapiro-Wilk test. Additionally, thesphericity for each condition level in the LB task wasassessed with Mauchly’s test and Greenhouse-Geisser
correction was used where appropriate cases. Data wereanalyzed with SPSS version 25 (IBM Corporation,
Armonk, NY, USA). The level of statistical significancewas set at P < 0.05.

Results
OLP task (Fig. 2)
In the prismatic condition, the mean responses ±standard deviation (SD) of pre- and post-task were −0.75± 18.0 mm and 23.11 ± 18.11 mm, respectively. They
were significantly different (t = −5.09, df = 29, P <0.001), indicating a rightward shift after the reaching

Fig. 2. Results of the open-loop pointing task. A significant
rightward deviation was found only in the prismaticcondition (P < 0.001). Horizontal bars indicate standard deviations.

task. On the other hand, no significant difference wasobserved between the mean responses ± SD of pre-and
post-task (2.60 ± 18.25 mm, 2.90 ± 19.87 mm, respectively) in the flat lens condition (t = 0.22, df = 29, P =0.83).
Next, we confirmed the effect of the de-adaptation
task. The mean response ± SD of results of the OLP
task after the first repetitive reaching task and before thesecond task was 22.63 ± 4.51 mm and 0.76 ± 5.07 mm
in the prismatic first group, and 5.92 ± 4.14 mm, 6.57 ±3.79 mm in the flat lens first group, respectively. In theflat lens first group, the result before the second task was
not normally distributed, thus we used the Wilcoxon
signed rank test. It revealed they were significantly different (t = 6.77, df =14, P < 0.001), indicating a leftward
shift after the de-adaptation task. In the flat lens firstgroup, the data followed the normal distribution (P >0.05) and we used the paired t-test. No significant difference was observed between them (t = 0.26, df = 14, P =0.80).
LB task
On the 200-mm line in the prismatic condition,
the differences between the positions of the subjective
midpoint before and after the repetitive reaching task
were 0.77 (mean) ± 1.36 (SD) mm for the left position,
0.49 ± 1.32 mm for the center position, and 0.57 ± 1.56mm for the right position, respectively. Under the flatlens condition, they were −0.08 ± 1.92 mm for the left
position, −0.08 ± 1.31 mm for the center position, and−0.29 ± 1.39 mm for the right position, respectively (Fig.
3-A).

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121

Fig. 3. Results of line bisection (LB) task. (A): Results of
the LB task for 200-mm lines. Vertical bars indicate standard deviations. A significant rightward
deviation of the subjective midpoint was foundin the prismatic condition compared to that in theflat lens condition. However, the deviation did not
differ according to the position of lines. (B): Resultof the LB task for 50-mm lines. Neither PA nor
the line presentation position had any observableeffect.

On the 50-mm line under the prismatic condition,
they were 0.03 ± 0.69 mm for the left position, 0.19 ±0.72 mm for the center position, and −0.01 ± 0.81 mm
for the right position, respectively. Under the flat lenscondition, they were −0.01 ± 0.57 mm for the left position, 0.19 ± 0.61 mm for the center position, and −0.07± 0.79 mm for the right position, respectively.
As Mauchly’s test of sphericity showed no significant difference (P > 0.05) except for glass conditions
× line locations (P = 0.003), we adopted GreenhouseGeisser correction for this analysis. Three-way repeated
ANOVA showed the main effect of glass conditions (F1,29= 13.20, P = 0.04) and a significant interaction between
glass conditions and line lengths (F1,29 = 8.52, P = 0.01).
Post-hoc comparison using Bonferroni correction
revealed a significant difference between the prismaticcondition and flat lens condition in 200-mm line length(P = 0.01) but not in 50-mm line length (P = 0.98). No
main effects or interactions were found in the otherfactors (line locations F2,58 = 0.78, P = 0.46; line lengths

F1,29 = 3.10, P = 0.09; glass conditions * line locations
F1.50, 43.34 = 0.15, P = 0.80; line locations * line lengths
F2.58 = 0.68, P = 0.51; glass conditions * line locations *line lengths F2.58 = 0.17, P = 0.84) (Fig. 3-B).

Discussion
In the present study, we evaluated the effect of PA
on the allocentric frame in healthy participants using an
LB task, which involved lines of two different lengths
at three different positions. The results of the OLP task
showed a significant rightward deviation in the prismaticcondition only. The subjective midpoint of the 200-mm
LB task showed significantly greater rightward deviationin the prismatic condition than in the flat lens condition,
however, no significant difference was observed in
the position of line presentation. The 50-mm LB task
revealed no PA effect or line presentation position. This
study is the first to demonstrate the effectiveness of PA
on the allocentric frame only in healthy participants.

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In the OLP task, deviation of the reaching point
towards the right after the repetitive reaching task wasfound in the prismatic condition, but not in the flatlens condition. These findings suggest that rightward
deviation was not caused by repetitive pointing itself,
but by adaptation to the prism lenses through repetitive
pointing.
Presuming that adaptation to prismatic lenses produces a simple physical after-effect, one would expect
to observe deviation for both 200-mm and 50-mm
lines. However, we found that a significant rightward
deviation of the subjective midpoint was found only forthe 200-mm line in the prismatic condition. A previous
study showed a relationship between the displacementof the subjective midpoint on the LB task and the lengthof the presented line in a patient with left USN [29]. In
this previous study, a larger rightward deviation of thesubjective midpoint from the true center was found for
longer lines than for shorter lines. Additionally, when aline of 2 inches (approximately 50 mm) was presented,
the subjective midpoint was located near the true center.
These behavioral characteristics of patients with left
USN are consistent with the present results for the LB
task using two different lengths of line. The present
study indicates that an alteration in the distribution of
spatial attention was induced by the PA task. furthermore, In the prismatic first group, the significant leftward shift after the de-adaptation task was confirmed.
This could be interpreted as the PA-induced hand-eye
coordination disappeared through the de-adaptation task,
indicating that the first condition with the prism glasses
had no after-effect on the second one with the flat lens.
As hypothesized, our results for the PA effect on
the LB task in healthy participants were not affected by
the position of line presentation. That is, PA induced
allocentric neglect-like behavior. This is inconsistent
with the results of Michel et al. [24], possibly due tothe difference in LB task settings between the studies.
Several studies on patients with USN suggest that task
requirements can affect how deficits appear on different
reference frames [25–26]. In particular, the foci andwidth of spatial attention are guided by task demands,
which define the perceptual representation of the space[30–31]. In the study by Michel et al. [24], since only
one type of line length was adopted in the LB task,
participants may have gradually attended to its position
in relation to their own position rather than the length ofthe line. In contrast, because two different line lengths
were presented in the present study, participants might
have needed to pay more attention to the line lengths.
This task setting might lead participants to attend to thelines themselves regardless of their relative spatial positions, rendering the allocentric frame dominant.

Our findings may contribute to the assessment andtreatment of patients with allocentric neglect. Abbruzzese et al. [23] stated that only a few tests are available
for evaluating allocentric neglect. The Apples test [20]and Ota test [16], for example, are visual cancellation
tasks that allow for the simultaneous evaluation of egocentric and allocentric neglect. In these tasks, allocentric
neglect is determined by a failure to detect the missing
left part of the targets. Another type of test is a copy
task, comprising multiple items arranged side-by-side ona sheet, like Gainotti’s task [19]. On these tasks, allocentric neglect is determined by a failure to detect the left
portion of the sample item(s). All of these tests evaluate
the degree of allocentric neglect by counting the numberof false performances. In contrast, our LB task can evaluate the severity of allocentric neglect by measuring thelateral deviation of the subjective midpoint.
The present study has some limitations. Firstly,since this is the first study to focus on the immediate
PA effect on the allocentric frame, the duration of theseeffects remains unclear. Additionally, as the PA effect inpatients with left USN was not investigated, the generalizability of these findings may be limited. Further studies are needed to clarify the effect of PA on allocentric
neglect in patients with left USN.

Conclusion
Our findings in this study indicate that the effectof PA, as measured by the LB task, was confined to theallocentric frame. This suggests that participants may
attend to the length of the line itself, regardless of thepresentation position. This implies that the PA affected
the task processing of the reference frame. This result
serves as evidence that the effect of PA depends on task
settings. Finally, these findings may have implications
for the evaluation and treatment of allocentric neglect.

Declaration of conflicting interests
The authors declare that they have no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.

References[1] Heilman KM, Valenstein E, Watson RT. Neglect andrelated disorders. Semin Neurol. 2000; 20(4): 463–70.
[2] Bowen A, McKenna K, Tallis RC. Reasons for variability
in the reported rate of occurrence of unilateral spatial
neglect after stroke. Stroke. 1999; 30(6): 1196–202.
[3] Gialanella B, Mattioli F. Anosognosia and extrapersonal
neglect as predictors of functional recovery followingAsian J Occup Ther 19: 117−123, 2023

right hemisphere stroke. Neuropsychol Rehabil. 1992;
2(3): 169–78.
[4] Sea MJC, Henderson A, Cermak SA. Patterns of visual
spatial inattention and their functional significance instroke patients. Arch Phys Med Rehabil. 1993; 74(4):355–60.
[5] Bowen A, Hazelton C, Pollock A, Lincoln NB. Cognitive
rehabilitation for spatial neglect following stroke. Cochrane Database Syst Rev. 2013; 7: CD003586.
[6] Yang NY, Zhou D, Chung RC, Li-Tsang CW, Fong KN.
Rehabilitation interventions for unilateral neglect after
stroke: a systematic review from 1997 through 2012.
Front Hum Neurosci. 2013; 7: 187.
[7] Teasell R, Salbach NM, Foley N, Mountain A, Cameron
JI, de Jong AI, et al. Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Community Participation following Stroke. Part One: Rehabilitation and Recovery Following Stroke; 6th Edition Update2019. Int J Stroke. 2020; 15(7): 763–88.
[8] Rossetti Y, Rode G, Pisella L, Farné A, Li L, Boisson D,
et al. Prism adaptation to a rightward optical deviation
rehabilitates left hemispatial neglect. Nature. 1998; 395(6698): 166–9.
[9] Tilikete C, Rode G, Rossetti Y, Pichon J, Li L, Boisson D.
Prism adaptation to rightward optical deviation improves
postural imbalance in left-hemiparetic patients. Curr Biol.
2001; 11(7): 524–8.
[10] Jacquin-Courtois S, Rode G, Pisella L, Boisson D, Rossetti Y. Wheel-chair driving improvement following visuomanual prism adaptation. Cortex. 2008; 44(1): 90–6.
[11] Mizuno K, Tsuji T, Takebayashi T, Fujiwara T, Hase K,
Liu M. Prism adaptation therapy enhances rehabilitationof stroke patients with unilateral spatial neglect: a randomized, controlled trial. Neurorehabil Neural Repair.
2011; 25(8): 711–20.
[12] Rode G, Rossetti Y, Boisson D. Prism adaptation improves representational neglect. Neuropsychologia. 2001;
39(11): 1250–4.
[13] Jacquin-Courtois S, Rode G, Pavani F, O’Shea J, Giard
MH, Boisson D, et al. Effect of prism adaptation on left
dichotic listening deficit in neglect patients: glasses tohear better? Brain. 2010; 133(3): 895–908.
[14] Maravita A, McNeil J, Malhotra P, Greenwood R, Husain
M, Driver, J. Prism adaptation can improve contralesional
tactile perception in neglect. Neurology. 2003; 60(11):1829–31.
[15] Driver J, Halligan PW. Can visual neglect operate inobject-centered coordinates? An affirmative single-casestudy. Cogn Neuropsychol. 1991; 8(6): 465–79.
[16] Ota H, Fujii T, Suzuki K, Fukatsu R, Yamadori A. Dissociation of body-centered and stimulus-centered representations in unilateral neglect. Neurology. 2001; 57(11):2064–9.
[17] Medina J, Kannan V, Pawlak MA, Kleinman JT, Newhart

Takeuchi T et al.

123

M, Davis C, et al. Neural substrates of visuospatial
processing in distinct reference frames: Evidence fromunilateral spatial neglect. J Cogn Neurosci. 2009; 21(11):2073–84.
[18] Karnath HO, Rorden C. The anatomy of spatial neglect.
Neuropsychologia. 2012; 50(6): 1010–7.
[19] Gainotti G, Miceli G, Caltagirone C. Constructional
apraxia in left brain-damaged patients: a planning disorder? Cortex. 1977; 13(2): 109–18.
[20] Bickerton WL, Samson D, Williamson J, Humphreys
GW. Separating forms of neglect using the Apples Test:
validation and functional prediction in chronic and acutestroke. Neuropsychology. 2011; 25(5): 567–80.
[21] Mancuso M, Damora A, Abbruzzese L, Zoccolotti P.
Prism adaptation improves egocentric but not allocentricunilateral neglect: a case study. Eur J Phys Rehabil Med.
2018; 54(1): 85–9.
[22] Gossmann A, Kastrup A, Kerkhoff G, Lopez-Herrero C,
Hildebrandt H. Prism adaptation improves ego-centered
but not allocentric neglect in early rehabilitation patients.
Neurorehabil Neural Repair. 2013; 27(6): 534–41.
[23] Abbruzzese L, Damora A, Antonucci G, Zoccolotti P,
Mancuso M. Effects of prism adaptation on reference
systems for extrapersonal space in neglect patients. Brain
Sci. 2019; 9(11): 327.
[24] Michel C, Pisella L, Halligan PW, Luauté J, Rode G,
Boisson D, et al. Simulating unilateral neglect in normals
using prism adaptation: implications for theory. Neuropsychologia. 2003; 41(1): 25–39.
[25] Behrmann M, Tipper SP. Attention accesses multiplereference frames: Evidence from visual neglect. J Exp
Psychol Hum Percept Perform. 1999; 25(1): 83–101.
[26] Leyland LA, Godwin HJ, Benson V, Liversedge SP.
Neglect Patients Exhibit Egocentric or Allocentric
Neglect for the Same Stimulus Contingent upon Task
Demands. Sci Rep. 2017; 7(1): 1941.
[27] Okubo M, Suzuki H, Nicholls ME. A Japanese version of
the Flanders handedness questionnaire (in Japanese). The
Japanese Journal of Psychology (Shinrigaku Kenkyu).
2014; 85(5): 474–81.
[28] Ota H, Murakami I, Taniguchi M, Isoya A. Ameliorationof left spatial neglect with revised prism adaptation task
(in Japanese). Hokkaido Journal of Occupational Therapy(Hokkaido Sagyouryouhou). 2004; 21(1): 2–6.
[29] Marshall JC, Halligan PW. When right goes left: aninvestigation of line bisection in a case of visual neglect.
Cortex. 1989; 25(3): 503–15.
[30] Karnath HO, Niemeier M. Task-dependent differences inthe exploratory behavior of patients with spatial neglect.
Neuropsychologia. 2002; 40(2): 1577–85.
[31] Baylis GC, Baylis LL, Gore CL. Visual neglect can beobject-based or scene-based depending on task representation. Cortex, 2004; 40(2): 237–46.

■ORIGINAL ARTICLE

Positional Stability of the Non-Dominant Hand
is Associated with Difficulties
in Daily Functioning in Schizophrenia
Yoshiro Nakagawa1, Haruka Kumoi2, Hironori Sasaki3, Sumie Yamada4
1

Department of Occupational Therapy, Chubu University
Marui Clinic
3
Nagaoka Healthcare Center
4
Graduate School of Medicine and Faculty Kyoto University, Kyoto University
2

Abstract: Background: Patients with schizophrenia have difficulty performing activities of daily living (ADLs) that
require fine motor skills. This study investigated the hand instability of 24 patients with schizophrenia and 20 healthy
controls during a finger opposition task.
Methods: We evaluated the path length of the hand position during the finger task from a motion capture system. Subjective difficulties in ADLs were assessed using a visual analog scale.
Results: The path lengths of both hands were significantly greater for patients with schizophrenia than for healthy controls. Significant associations were found between the path length of the non-dominant hand and subjective difficulties
encountered by patients with schizophrenia while performing ADLs.
Conclusion: The findings suggest that instability in the non-dominant hand is a potential marker of daily functioning inschizophrenia.
Keywords: activities of daily living, arm posture, fine motor skill, hand stability(Asian J Occup Ther 19: 124−131, 2023)

Introduction
The most characteristic symptoms of schizophrenia
are delusions, verbal hallucinations, and disorganizedthinking. A growing body of evidence suggests thatmotor disturbances, which also affect fine motor skills,
may be other symptoms of schizophrenia [1]. Traditionally, motor disturbances, such as dyskinesia andparkinsonism, have been regarded as side effects of antipsychotic treatment. However, some motor disturbances
are independent of medication use. Disturbances infine motor skills appear during the early developmental
stages and in drug-naïve patients with schizophrenia[2, 3]. Moreover, children of patients with schizophrenia have shown impaired manual dexterity relative to
Received: 2 June 2022, Accepted: 15 February 2023
Corresponding to: Yoshiro Nakagawa, Department of Occupational
Therapy, Chubu University, 1200 Matsumoto-cho, Kasugai-shi, Aichi
487-8501, Japane-mail: y-nakagawa@isc.chubu.ac.jp©2023 Japanese Association of Occupational Therapists

typically developing children [4, 5], and adolescentsat high risk for schizophrenia have shown reduced
accuracy during a line drawing task [6]. Recent studies
have revealed that motor disturbances in schizophrenia
are associated with neuronal dysfunction. Specifically,
impairment of fine motor skills is associated with frontostriatal dysconnectivity and dopaminergic activity inthe striatum [7]. Thus, fine motor tasks, such as finger
tapping tasks, are potential tools for detecting neuronalvulnerability in schizophrenia [8, 9]. Although the effects
of antipsychotic drugs should be considered, impairment
in fine motor skills is becoming increasingly understoodas a symptom of schizophrenia [10].
Fine motor skills comprise fine finger movements
and the maintenance of arm posture; however, little is
known about the maintenance of hand posture while
performing fine movements in patients with schizophrenia. Previous studies on fine motor skills havefocused on the outcomes of fine motor performance atthe behavioral and kinematic levels [7, 8]. Task-specificmovements require the recruitment of specific muscle
groups. The ratio and timing of the co-activation ofAsian J Occup Ther 19: 124−131, 2023

specific muscle groups is called muscle synergy [11].
A dysfunction in the forearm muscle synergy causes aloss of dexterity during finger motion and instability ofarm posture during fine motor tasks [12]. Fine motor
skills require the minimization of positional errors at
the endpoint. Arm posture stability during fine motor
performance leads to high accuracy, speed of fine motor
skills, and reduces the cost associated with completingtasks [13]. In addition, dominant and non-dominanthands play different roles in the activities of daily living(ADLs) [14]. The dominant hand performs fine tasks,
such as writing and using chopsticks, more accurately
than the non-dominant hand, while the non-dominant
hand can hold objects and minimize positional errors for
improved fine motor performance. Therefore, the studyof fine motor skills should also focus on the positionalvariability of the non-dominant hand during fine motor
tasks. However, the relationship between the ability tomaintain hand position and the performance of ADLs
in patients with schizophrenia is not fully understood.
A previous neurological study reported functional connectivity between the sensorimotor cortex and the visualcortex during arm posture maintenance, suggesting thatmotor commands are adjusted based on sensory information [15]. Patients with schizophrenia show sensorimotor coordination dysfunction [16]. We hypothesizedthat the instability of the hand position in schizophrenia
may cause unnecessary processing for sensorimotor
integration and subjective difficulties with ADLs.
In this study, we aimed to compare hand stability inpatients with schizophrenia and healthy controls (HCs)
during a bilateral finger task. The finger task was set toperturb the position of the hand. We also investigated
the relationship between hand instability and ADLs inpatients with schizophrenia.

Participants and Methods
Participants
Patients with schizophrenia were recruited from a
daycare center. They had been previously diagnosed bytheir respective psychiatrists according to the criteria of
the Diagnostic and Statistical Manual of Mental Disorders. Age-matched HCs were recruited from the same
local community.
Only individuals with clinically stable disease were
included in the study. Stable disease was defined as nothaving required a change in medications within the previous month. The exclusion criteria were as follows: (a)essential tremor; (b) functional tremor and Parkinson’s
disease; (c) substance use and addictive disorders; (d)history of developmental delay; (e) neurological diseases
and musculoskeletal problems of the upper limbs; (f) in-

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125

telligence quotient score of < 80 according to a previous
study [17] and Mini-Mental State Examination (MMSE)
score of < 26; and (g) mixed handedness. Mixed-handed
individuals were excluded to allow investigation of thedifference in the relationship between the performanceof ADLs and the stability of the dominant/non-dominanthand. Handedness was assessed using the Flanders
Handedness Survey.
This study was approved by the Ethics Committee
and Faculty of Medicine of the Kyoto University Graduate School (approval: R1639-1; date: 2018-10-4). All
participants provided written informed consent.
Thumb-to-index finger opposition task
All participants completed a bimanual thumb-toindex finger opposition task. They sat on a chair andheld their hands over the fast-tracking system (Leap
Motion Controller [LMC]; Ultraleap, Mountain View,
CA, USA). They were instructed to repeatedly tap the
tip of their thumb to the tip of their index finger withboth hands without resting their elbows on the desk, tentimes. All participants performed five trials and rested
for a minute rest between trials. We measured the center
positions of each hand using an LMC connected to apersonal computer (Windows version 10).
The LMC system allowed the detection and measurement of the three-dimensional positions of the hands
within milliseconds [18]. This device consists of three
infrared LEDs and a stereo camera, which can produce
pairs of grayscale images at 60 frames per second.
The disparity between the positions of the matchingpixels in the two grayscale images produced real threedimensional positions of each fingertip in each frame(Fig. 1). The center position of the hands was calculated
from the positions of each fingertip based on the handmodel created by the LMC. The LMC tracked the threedimensional positions of the hands at 60 Hz. A previous
study revealed that the LMC is a reliable measure of
motor performance [19]. Interestingly, the LMC canmeasure the position of each hand without referring to
the attached sensors or markers. Thus, the LMC canmeasure hand positions without disturbing the natural
hand movements.
Subjective difficulties in ADLs
Subjective difficulties in performing ADLs were assessed using a visual analog scale for ADLs (VAS-ADL).
The VAS-ADL used in this study was a modified versionof the scale for patients with rheumatoid arthritis [20].
It consisted of 64 items (e.g., flipping a page, wringing
out a towel, buttoning up a shirt, using chopsticks, andtying a string) with 11 domains (fine motor skills, grossmotor skills, personal hygiene, face washing, reading

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HAND INSTABILITY IN SCHIZOPHRENIA

Fig. 1. Measuring the center position of the hands with the Leap Motion Controller (LMC) system. (a) Two cameras are installed in the
LMC, which capture the fingertips. The 3-dimensional positions of the fingertip and the center of the hand are calculated from thebaseline, and the disparity between the matching positions corresponding to the fingertip in the images is captured by the cameras.
(b) The tridimensional coordination and the centers of both palms were assessed with the motion capture system. The zero point(0, 0, 0) in the graph represents the position of the motion capture camera. (c) Hand trajectories in a representative individual withschizophrenia. (d) Hand trajectories in a representative healthy control (HC). HC, healthy control; PC, personal computer.

books, writing and texting on a cell phone and personal
computer, tool-using skills, dressing, preparing meals
and feeding, toileting, and doing laundry) (Table 1).
Each question was assessed with a straight-line scalefrom no difficulty (0 mm) to the worst possible difficulty(100 mm). The average of all the VAS-ADL scores was
also calculated.
Statistical analysis
The sample size was calculated using a power analysis. We calculated the sample size based on an alphaerror of 0.05 and a power of 0.8. We set the difference as
0.5 m between groups and the standard deviation as 0.58
m. The ratio of the numbers in the two groups was set at1.2. The required sample included 24 individuals withschizophrenia and 20 HCs.
The present study assessed the stability of the hand
position during a finger opposition task. The data that
did not contain hand position information for morethan one second were excluded from the analysis. Forsmoothing data, the moving average method was used(low pass below 3 Hz) to exclude artifacts, including
drug-induced tremors [21]. The stability of the hand
position was quantified based on the path length of thehand position during the finger opposition task. The
path length until the beginning of the pinch motion was
calculated as the baseline. All data were processed using
MATLAB (version R2020a; MathWorks, Natick, MA,
USA).
Student’s t-test was used to assess group differences in the path length of the hand position. The path
length at baseline was analyzed using Student’s t-test.
Spearman’s rank correlation test was used to analyze thecorrelations between the path length of the hand position, VAS-ADL, and chlorpromazine (CPZ) equivalentdoses in schizophrenia. The difference in the VAS-ADL
score was examined using the Mann–Whitney U test.
The significance level was set at p < 0.05. All statisticalanalyses were performed using SPSS version 25 (IBM,Armonk, NY, USA).

Asian J Occup Ther 19: 124−131, 2023

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Table 1 Visual analog scale for activities of daily living
Domains

Items

Gross movements

Standing up from sitting with your hands; carrying 10 kg of objects with both hands; moving objects with hands

Reading-related movements

Holding a book while reading; flipping a page of book/paper/magazine

Self-care

Turning a faucet on/off; shower; wringing a towel; wiping face/body with a towel

Dressing

Wearing t-shirts, pants, skirts, or socks; buttoning a shirt; fastening buttons on sleeves; fastening a belt, watch,or bracelet; tying shoelaces; using fingernail clippers; brushing the teeth; cleaning the ears; shaving/applying
make-up; self-administering eye drops; inserting contact lenses; combing the hairPreparing meals and feeding

Eating with chopsticks or with a spoon; using a knife; lifting a bowl when eating; holding a mug; holding a
glass; drinking from a cup; pouring tea; serving rice; serving soup; carrying plates; taking the lid off a bottle;
unscrew a plastic bottle; washing the dishes; cutting with a kitchen knife; peel with a peeler; cooking with afrying pan

Tool using

Inserting a key; opening a lock; inserting a coin in a vending machine; pushing buttons in an elevator; using acalculator; pushing the buttons of a vending machine

Writing and texting on a cell
phone and personal computer

Writing; drawing a straight line without a ruler; typing with a keyboard; typing with a cell phone

Toilet hygiene

Cleaning themselves in the washroom

Fine motor skills for sewing

Inserting a thread through the eye in the needle; hand-stitching; using a sewing machine

Laundry

Pouring laundry detergent as needed; hanging clothes; pinning clothes on a clothesline; collecting dry clothes;folding t-shirts; folding pants; reverse the laundry inside out.

Results
Participant demographics
Among the 44 participants who completed five
trials of the finger opposition task, 24 had schizophrenia(15 men, 9 women; mean age, 39.58 ± 12.46 years) and
20 were HCs (12 men, 8 women; mean age, 41.70 ±11.07 years). All patients with schizophrenia were clinically stable and were undergoing treatment with anti­
psychotic drugs (average CPZ equivalent dose, 536.11 ±332.63 mg/day). Two patients received first-generation
antipsychotics (levomepromazine maleate); the remain­ing participants were receiving second-generation medications (risperidone, olanzapine, and aripiprazole). The
average time to complete the finger opposition task was
21.35 ± 7.75 for the patients with schizophrenia and20.20 ± 8.25 seconds for the HCs. All participants wereconfirmed to be right-handed based on the Flanders
handedness questionnaire responses. There were no differences in age ( p > 0.05), MMSE score ( p > 0.05), or
duration of the finger opposition task ( p > 0.05) between
the patients with schizophrenia and HCs.
Path length of the hand position
For the HCs, the path length of the left hand was
longer than that of the right hand (t = 2.20, df = 19, p =0.039). For the patients with schizophrenia, there was nodifference in the path length between the left and righthands (t = 0.54, dt = 23, p = 0.60). No significant differ-Fig. 2. The path length of the hand position during the finger
opposition task. The path lengths of both hands weresignificantly greater in patients with schizophrenia thanin healthy controls (HCs). *p < 0.001. HC, healthy
controls.

ence in the path length at baseline was found between
the groups (left: t = 1.37, dt = 32.38, p = 0.18; right: t =1.41, dt = 42, p = 0.18). The path lengths of both hands
were significantly longer for the patients with schizophrenia than for the HCs (left: t = −4.069, df = 29.49,
p < 0.001; right: t = −4.26, df = 28.49, p < 0.001) (Fig. 2).
No significant association was found between path
length and CPZ equivalent dose in patients with schizo-

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HAND INSTABILITY IN SCHIZOPHRENIA

Fig. 3. Correlation between the hand position path length and the visual analog scale score for activities of daily living (VAS-ADL) scorein patients with schizophrenia. Correlations between the path length of the non-dominant hand and (a) VAS-ADL average scoreand subscores of (b) self-care, (c) preparing meals and feeding, (d) writing and texting on a cell phone and personal computer,(e) toilet hygiene, and (f) fine motor skills for sewing. VAS-ADL, visual analog scale for activities of daily living.

phrenia (left: r = 0.25, p = 0.24; right: r = 0.20, p = 0.35).

Discussion

VAS-ADL in schizophrenia
The Mann–Whitney U test revealed that all VASADL subscores were significantly higher for patientswith schizophrenia than for the HCs ( p < 0.001).

The present study investigated hand instability
during finger tasks. In HCs, the path length of the dominant hand was shorter than that of the non-dominanthand. In patients with schizophrenia, the dominant hand
was not more stable than the non-dominant hand. Thisfinding supports the report of a previous study showingthat the fine skills of the dominant hand are not superior
to those of the non-dominant hand in schizophrenia[22]. As hypothesized, patients with schizophrenia had
a longer path length of the hand position than the HCs
during finger tasks. This hand instability was not correlated with the CPZ equivalent dose; however, it was
positively associated with subjective difficulties in performing ADLs requiring fine motor skills. Interestingly,
the correlation between hand instability and VAS-ADL
appeared stronger in the non-dominant hand than in thedominant hand. The findings improve our understandingof the relationship between subjective difficulties in
performing ADLs and disturbances of fine motor skills
in patients with schizophrenia.
The instability of hand positions in this study indicates motor variability in patients with schizophrenia.

Correlation between the finger task and VAS-ADL
In patients with schizophrenia, a significant correlation was found between the path length of the left hand
and the average VAS-ADL score (r = 0.48, p = 0.017)(Fig. 3). Significant correlations were found between thepath length of the left hand and the VAS-ADL subscore(self-care: r = 0.51, p = 0.010; preparing meals andfeeding: r = 0.45, p = 0.028; writing and texting on cell
phones and personal computers: r = 0.55, p = 0.005;
toilet hygiene: r = 0.60, p = 0.002; sewing fine motor
skills: r = 0.62, p = 0.001). The correlations are shownin Fig. 3. The path length of the right hand was only
significantly correlated with the toilet hygiene subscore(r = 0.43, p = 0.037). There was no correlation between
the CPZ equivalent dose and the VAS-ADL score ( p >0.05). In contrast, there were no correlations between
the parameters and the VAS-ADL score of the HCs.

Asian J Occup Ther 19: 124−131, 2023

These results suggest impairments in the correct timingof activation of proper muscle groups and suppressionof others in patients with schizophrenia. A previous behavioral study indicated increasing instability of the arm
position before pressing a button and excessive force
when pressing a button in patients with schizophrenia[23]. Reduced regularity during finger tapping was also
found in patients with schizophrenia [1]. Even witha simple movement, such as index finger flexion, thebiceps and anterior deltoid are deactivated 100 ms prior
to the onset of the movement itself [24]. This muscle
preparation results in stable hand positions and accurate
end-points of finger tapping. In muscle dyscoordination,
voluntary motion includes the simultaneous involuntary
contraction of other muscles, causing redundant motion
and unsteadiness of the hand position. A previous studyof healthy participants showed that the incorporationand separation of muscle contractions are vaguer in the
non-dominant hand than in the dominant hand [25].
For this reason, the variation of hand position in thisstudy indicated the incorporation of muscle contractions
during finger task execution.
Two possible explanations for these findings are impairments of sensorimotor control when stabilizing hand
positions. First, as mentioned above, several muscles in
the upper limb are inhibited prior to finger tapping, but
the dysfunction in the cerebellum prevents this muscularpreparation [26]. Dysfunctional connectivity, includingthat in the cerebellum, is found in patients with schizophrenia [27]. Cerebellar–cortical hyperconnectivity inpatients with schizophrenia is also related to deficits inthe finger tapping task [28]. Postural instability has also
been reported in patients with schizophrenia, which may
be due to cerebellum dysconnectivity [29]. Second, thisco-contraction for stabilizing hand positions is adjusted
based on sensory feedback, such as visual and proprioceptive information, as well as the predicted sensory
consequence of motion. A previous study on sensory
processing demonstrated that the proprioceptive-evoked
response was decreased in patients with schizophrenia[22]. This low response to proprioceptive stimuli can beobserved following hand posture perturbation in patientswith schizophrenia [30]. Recent neurological studies
have revealed altered functional connectivity between
the frontostriatal and parietal-motor cortices involving
hand movement in patients with schizophrenia [7, 31,32]. These findings suggest that patients with schizophrenia may not be able to effectively integrate proprioceptive information to stabilize the hand position. In
addition, aberrant excitability in the motor cortex has
been reported in patients with schizophrenia, regardlessof whether they are unmedicated or medicated [33].
This hyperexcitability in the motor cortex leads to dis-Nakagawa Y et al.

129

turbances in motor control, suggesting decreased motor
inhibition [34]. Stabilizing forearm posture against
perturbation induced by a finger task demands the contraction of proper muscles and the suppression of inessential muscles due to sensory information. This control
between activation and suppression can be realized witha balance of excitation/suppression in the motor cortex.
Hand instability during a finger task has been suggested
to be a dysfunction in muscle synergy [11]. The present
results suggest that hand instability reflects an imbalance
between inhibition and excitation in the motor cortex
and impairment of sensorimotor integration.
The relationship between hand instability and difficulties in performing ADLs suggests that impairmentof the non-dominant hand can affect the performance of
ADLs. Upper limbs have functional asymmetry, known
as hand preference and laterality. The non-dominant
hand is more capable of maintaining the hand position
than the dominant hand [35]. Fixation by the nondominant hand reduces spatiotemporal coordination offine motor skills [36]. Given this characteristic, the nondominant hand improves and interferes with fine skills.
Most ADLs have bimanual motion during bimanual
performance. For example, scissors are held in the dominant hand and a paper is held in the non-dominant hand.
The method of manipulating the non-dominant handmakes the shearing edge more visible. The non-dominant
hand affects the accuracy and speed of performancein bilateral tasks. In this study, we found a correlation
between the instability of the non-dominant hand and
ADLs. Stability in the non-dominant hand requires additional motor control; in contrast, the dominant hand canabsorb perturbation more efficiently [37]. This relationship between ADLs and the instability of the non-dominant hand suggests that instability in the non-dominant
hand causes distress when performing ADLs in patientswith schizophrenia.
This study has some limitations. The instability of
the hand position is susceptible to drug-induced tremor
and postural sway. In general, tremor in parkinsonism
appears to resolve at 3–5 Hz and is suppressed during
voluntary motion [38]. Tremors in tardive dyskinesia
also appear at frequencies above 3 Hz [39]. Previous
studies have reported postural instability in patients withschizophrenia [28]. For instance, an analysis of the path
length of the center of pressure during standing revealed
that patients with schizophrenia sway more than HCs.
Moreover, patients with schizophrenia and alcohol
dependence demonstrated greater postural sway [29]. A
previous study reported that postural sway in patientswith schizophrenia was above 8 Hz. In this study, alldata were passed through a low-pass filter of 3 Hz to exclude tremor due to side effects and postural sway based

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HAND INSTABILITY IN SCHIZOPHRENIA

on a previous study [21]. Besides, tremor and additive
disorder were excluded according to the exclusion criteria. Oscillations, including dyskinesia, parkinsonism,
and postural sway, were removed in this study.
The method for measuring hand position in thisstudy was advantageous for evaluating natural hand
movements. The fast-tracking system can precisely
detect three-dimensional positions without affecting
natural motion. Further research is needed to investigate
motor control in schizophrenia in detail to elucidate
motor deficits caused by neuroleptic treatment and theneurodevelopmental aspects of schizophrenia.
In conclusion, positional instability of the hand isa key facet of daily outcomes in patients with schizophrenia. In particular, instability in the non-dominant
hand may cause difficulties with ADLs. The longer path
length of the hand position found in patients with schizophrenia may be related to an impairment in muscle
synergy based on neural dysfunctions of motor control,
although other side effects should also be considered.
The important aspect of this study is that instability of
the non-dominant hand may be used as a marker of dailyfunctioning in patients with schizophrenia. The present
findings can contribute to the understanding of difficulties in performing ADLs requiring fine motor skills inpatients with schizophrenia.

Acknowledgments
We would like to thank Tomonori Yasui at Nagaoka
Health Care Center and Kazuki Wakasa at Ujioubaku
Hospital for participant recruitment and Yuki Shigetsura
at the Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, for providing valuable suggestions.

Funding
This project was supported by a Grant-in-Aid for
Scientific Research (KAKENHI) under Grant number
18K10346 to Sumie Yamada and by Otsuka Pharmaceutical to Sumie Yamada.

Disclosure statement
The authors declare no conflicts of interest.

References[1] Térémetz M, Carment L, Brénugat-Herne L, Croca M,
Bleton JP, Krebs MO, et al. Manual dexterity in schizophrenia—a neglected clinical marker? Front Psychiatry.
2017; 8: 120, doi:10.3389/fpsyt.2017.00120.

[2] Burton BK, Thorup A, Jepsen JR, Poulsen G, Ellersgaard
D, Spang KS, et al. Impairments of motor function
among children with a familial risk of schizophrenia or
bipolar disorder at 7 years old in Denmark: an observational cohort study. Lancet Psychiatry. 2017; 4(5): 400–8,
doi:10.1016/S2215-0366(17)30103-7.
[3] Byrial P, Nyboe L, Thomsen, PH, Clausen L. Motor
impairments in early onset schizophrenia. Early Interv
Psychiatry. 2022; 16(5): 481–91, doi:10.1111/eip.13185.
[4] Dickson H, Roberts RE, To M, Wild K, Loh M, Laurens
KR. Adolescent trajectories of fine motor and coordination skills and risk for schizophrenia. Schizophr Res.
2020; 215: 263–9, doi:10.1016/j.schres.2019.10.018.
[5] Rosso IM, Bearden CE, Hollister JM, Gasperoni TL,
Sanchez LE, Hadley T, et al. Childhood neuromotor
dysfunction in schizophrenia patients and their unaffected
siblings: a prospective cohort study. Schizophr Bull.
2000; 26(2): 367–78, doi:10.1093/oxfordjournals.schbul.
a033459.
[6] Manschreck TC, Chun J, Merrill AM, Maher BA, Boshes
RA, Glatt SJ, et al. Impaired motor performance in adolescents at familial high-risk for schizophrenia. Schizophr
Res. 2015; 168(1–2): 44–9, doi:10.1016/j.schres.2015.06.
013.
[7] Viher PV, Docx L, van Hecke W, Parizel PM, Sabbe B,
Federspiel A, et al. Aberrant fronto-striatal connectivity
and fine motor function in schizophrenia. Psychiatry Res
Neuroimaging. 2019; 288: 44–50, doi:10.1016/j.pscych
resns.2019.04.010.
[8] Janssens S, Moens H, Coppens V, Vandendriessche F,
Hulstijn W, Sabbe B, et al. Psychomotor assessment as atool to differentiate schizophrenia from other psychotic
disorders. Schizophr Res. 2018; 200; 92–6, doi:10.1016/
j.schres.2017.06.047.
[9] Schäppi L, Stegmayer K, Viher PV, Walther S. Distinct
associations of motor domains in relatives of schizophrenia patients—different pathways to motor abnormalitiesin schizophrenia? Front Psychiatry. 2018; 9: 129, doi:
10.3389/fpsyt.2018.00129.
[10] Walther S, Mittal VA. Motor system pathology in psychosis. Curr Psychiatry Rep. 2017; 19(12): 97, doi:10.1007/
s11920-017-0856-9.
[11] Cheung V, Seki K. Approaches to revealing the neuralbasis of muscle synergies: a review and a critique. J Neurophysiol. 2021; 125(5): 1580–97, doi:10.1152/jn.00625.
2019.
[12] Eisen A, Lemon, R. The motor deficit of ALS reflects
failure to generate muscle synergies for complex motor
tasks, not just muscle strength. Neurosci Lett. 2021; 762:
136171, doi:10.1016/j.neulet.2021.136171.
[13] Heald JB, Franklin DW, Wolpert DM. Increasing muscle
co-contraction speeds up internal model acquisition
during dynamic motor learning. Sci Rep. 2018; 8(1):16355, doi:10.1038/s41598-018-34737-5.
[14] Sainburg RL. Convergent models of handedness andbrain lateralization. Front Psychol. 2014; 5: 1092, doi:
10.3389/fpsyg.2014.01092.

Asian J Occup Ther 19: 124−131, 2023

[15] Snyder DB, Beardsley SA, Schmit BD. Role of the cortex
in visuomotor control of arm stability. J Neurophysiol.
2019; 122(5): 2156–72, doi:10.1152/jn.00003.2019.
[16] Zhang Y, Xu L, Hu Y, Wu J, Li C, Wang J, et al. Functional connectivity between sensory-motor subnetworks
reflects the duration of untreated psychosis and predicts
treatment outcome of first-episode drug-naïve schizophrenia. Biol Psychiatry Cogn Neurosci Neuroimaging.
2019; 4(8): 697–705, doi:10.1016/j.bpsc.2019.04.002.
[17] Siddi S, Preti A, Lara E, Brébion G, Vila R, Iglesias M,
et al. Comparison of the touch-screen and traditionalversions of the Corsi block-tapping test in patients withpsychosis and healthy controls. BMC Psychiatry. 2020;20(1): 329, doi:10.1186/s12888-020-02716-8.
[18] Guzsvinecz T, Szucs V, Sik-Lanyi C. Suitability of theKinect sensor and Leap motion controller—a literature
review. Sensors (Basel, Switzerland). 2019; 19(5): 1072,
doi:10.3390/s19051072.
[19] Tung JY, Lulic T, Gonzalez DA, Tran J, Dickerson CR,
Roy EA. Evaluation of a portable markerless finger
position capture device: accuracy of the Leap Motion
controller in healthy adults. Physiol Meas. 2015; 36(5):1025–35, doi:10.1088/0967-3334/36/5/1025.
[20] Toyama S, Tokunaga D, Fujiwara H, Oda R, Kobashi H,
Okumura H, et al. Rheumatoid arthritis of the hand: afive-year longitudinal analysis of clinical and radiographic findings. Mod Rheumatol. 2013; 24(1): 69–77, doi:
10.3109/14397595.2013.854054.
[21] Mittal VA, Dean DJ, Pelletier A, Caligiuri M. Associations between spontaneous movement abnormalities andpsychotic-like experiences in the general population.
Schizophr Res. 2011; 132(2–3): 194–6, doi:10.1016/
j.schres.2011.06.028.
[22] Arnfred SM, Raballo A, Morup M, Parnas J. Self-disorderand brain processing of proprioception in schizophrenia
spectrum patients: A re-analysis. Psychopathology. 2015;
48(1): 60–4, doi:10.1159/000366081.
[23] Vrtunski PB, Simpson DM, Weiss KM, Davis GC.
Abnormalities of fine motor control in schizophrenia.
Psychiatry Res. 1986; 18(3): 275–84, doi:10.1016/01651781(86)90114-9.
[24] Caronni A, Cavallari P. Anticipatory postural adjustments
stabilise the whole upper-limb prior to a gentle index
finger tap. Exp Brain Res. 2009; 194(1): 59–66.
[25] Heuer H. Control of the dominant and nondominant hand:
exploitation and taming of nonmuscular forces. Exp
Brain Res. 2007; 178(3): 363–73, doi:10.1007/s00221006-0747-5.
[26] Bruttini C, Esposti R, Bolzoni F, Vanotti A, Mariotti C,
Cavallari P. Temporal disruption of upper-limb anticipatory postural adjustments in cerebellar ataxic patients.
Exp Brain Res. 2015; 233: 197–203, doi:10.1007/s00221014-4103-x.

Nakagawa Y et al.

131[27] Cao H, Wei X, Zhang W, Xiao Y, Zeng J, Sweeney JA, et
al. Cerebellar Functional dysconnectivity in drug-naïve
patients with first-episode schizophrenia. Schizophr Bull.
2022; sbac121, doi:10.1093/schbul/sbac121.
[28] Apthorp D, Bolbecker AR, Bartolomeo LA, O’Donnell
BF, Hetrick WP. Postural sway abnormalities in schizotypal personality disorder. Schizophr Bull. 2019; 45(3):512–21, doi:10.1093/schbul/sby14.
[29] Marvel CL, Schwartz BL, Rosse RB. A quantitative measure of postural sway deficits in schizophrenia. Schizophr
Res. 2004; 68(2–3): 363–72, doi:10.1016/j.schres.2003.
09.003.
[30] Arnfred SM, Mørup M, Thalbitzer J, Jansson L, Parnas
J. Attenuation of beta and gamma oscillations in schizophrenia spectrum patients following hand posture perturbation. Psychiatry Res. 2011; 185(1–2): 215–24, doi:
10.1016/j.psychres.2009.10.005.
[31] Koch G, Ribolsi M, Mori F, Sacchetti L, Codecà C,
Rubino IA, et al. Connectivity between posterior parietal
cortex and ipsilateral motor cortex is altered in schizophrenia. Biol Psychiatry. 2008; 64(9): 815–819, doi:
10.1016/j.biopsych.2008.05.026.
[32] Walther S, Stegmayer K, Federspiel A, Bohlhalter S,
Wiest R, Viher PV. Aberrant hyperconnectivity in the
motor system at rest is linked to motor abnormalities inschizophrenia spectrum disorders. Schizophr Bull. 2017;
43(5): 982–92, doi:10.1093/schbul/sbx091.
[33] Rogasch NC, Daskalakis ZJ, Fitzgerald PB. Corticalinhibition, excitation, and connectivity in schizophrenia:
a review of insights from transcranial magnetic stimulation. Schizophr Bull. 2014; 40(3): 685–96, doi:10.1093/
schbul/sbt078.
[34] Carment L, Dupin L, Guedj L, Térémetz M, Cuenca M,
Krebs MO, et al. Neural noise and cortical inhibition inschizophrenia. Brain Stimul. 2020; 13(5): 1298–304, doi:
10.1016/j.brs.2020.06.015.
[35] Sainburg RL. Evidence for a dynamic-dominance hypothesis of handedness. Exp Brain Res. 2002; 142(2): 241–58, doi:10.1007/s00221-001-0913-8.
[36] Yao K, Sternad D, Billard A. Hand pose selection in abimanual fine-manipulation task. J Neurophysiol. 2021;
126(1): 195–212, doi:10.1152/jn.00635.2020.
[37] Takagi A, Maxwell S, Melendez-Calderon A, Burdet E.
The dominant limb preferentially stabilizes posture in abimanual task with physical coupling. J Neurophysiol.
2020; 123(6): 2154–60, doi:10.1152/jn.00047.2020.
[38] Mathews M, Gratz S, Adetunji B, George V, Mathews
M, Basil B. Antipsychotic-induced movement disorders:
evaluation and treatment. Psychiatry (Edgmont). 2005;
2(3): 36–41.
[39] Stacy M, Jankovic J. Tardive tremor. Mov Disord. 1992;
7(1): 53–7, doi:10.1002/mds.870070110.

■REVIEW

Relationship between Occupations and Cognitive
Impairment in Patients with Chronic Obstructive
Pulmonary Disease: A Scoping Review
Masahiro Ogawa1, Kouya Oshita2, Kouta Matsumoto3,
Sousuke Nakatsuka3, Hajime Tomita4, Daisuke Tashiro1
1

Faculty of Rehabilitation, Kobe Gakuin University
Nishinomiya Kyoritsu Rehabilitation Hospital
3
Ishikawa Hospital
4
Kobe City Medical Center General Hospital2

Abstract: Background: The number of studies on cognitive impairment in patients with chronic obstructive pulmonary
disease (COPD) has been increasing in recent years. However, no study has comprehensively examined the relationshipbetween cognitive impairment and occupation. Thus, the relationship between cognitive impairment and occupation inpatients with COPD remains unclear.
Objectives: This study aimed to conduct a scoping review and summarize the findings on the relationship between occupation and cognitive impairments in patients with COPD.
Methods: A scoping review of articles published in English from 2001 to 2020 was conducted in MEDLINE, PsychINFO, and OTseeker. A key search term was employed using “COPD,” “occupation,” and “cognitive impairment.” Twoinvestigators independently screened article titles and abstracts (primary screening) and then conducted full text review(secondary screening).
Results: After screening, 22 articles were included in the analysis. The results of the analysis of the relationship between cognitive impairment and occupations in patients with COPD revealed that many studies have examined inhaler
use and medication management in patients with COPD, whereas only a few studies were conducted in areas such asactivities of daily living (ADL) and driving.
Conclusion: Since occupations such as ADL and driving are critical for patients with COPD, further studies on theseoccupations are warranted.
Keywords: COPD, cognitive impairment, occupation, scoping review(Asian J Occup Ther 19: 132−139, 2023)

Introduction
Chronic obstructive pulmonary disease (COPD)
is the third leading cause of death worldwide, and it ischaracterized by conditions requiring care and long-term
medical treatment [1]. COPD is one of the conditions
that chronically restrict activities and participations indaily life due to impaired respiratory and physical funcReceived: 17 March 2022, Accepted: 22 February 2023
Corresponding to: Masahiro Ogawa, Faculty of Rehabilitation, Kobe
Gakuin University, 518 Arise, Ikawadani-cho, Nishi-ku, Kobe 6512180, Japane-mail: mogawa@reha.kobegakuin.ac.jp©2023 Japanese Association of Occupational Therapists

tions. In a study of the needs of patients with COPD,
patients need interventions for activities of daily living(ADL) and instrumental activities of daily living (IADL)[2]. A study pointed that activity and participation
limitations were caused by COPD-related cognitive,
respiratory, and physical impairment [3]. Approaches
to limited activities and participations in daily living
are key issues in occupational therapy; thus, the current
knowledge in occupational therapy for patients with
COPD is a crucial topic.
In recent years, several studies have indicated theeffectiveness of occupational therapy for patients with
COPD. For example, occupational therapy interventions
for ambulatory patients [4] and at home [5] were foundto improve the ADLs of people with COPD. In addition,

Asian J Occup Ther 19: 132−139, 2023

occupational therapy interventions for ADL, which consider the outcomes of cardiopulmonary exercise tests,
were reported to contribute to prolonged lifetime inpatients with severe COPD [6]. Thus, the effects of occupational therapy on patients with COPD are becoming
more evident, and expansion of occupational therapy forpatients with COPD is expected in the future.
Moreover, the number of studies on cognitive
impairment in patients with COPD has been increasing
in recent years. In a review on cognitive impairment inpatients with COPD, the prevalence of cognitive impairment in patients with COPD ranged from 6% to 63%[7]. Cognitive impairments in patients with COPD werecharacterized by disorders of frontal lobe function suchas attention and performance function [8]. Cognitive impairment has been reported to be related with disabilities
of ADL and IADL [9–11], inhaler use [12], medication
administration [13], and driving [14]. However, no studies have comprehensively reported the relationship between cognitive impairment and occupation. Thus, what
occupations were related with cognitive impairments inpatients with COPD, which should be studied to consider in future clinical practice, remain unclear. Moreover,it can be meaningful to systematically examine resultsof previous research studies and to summarize present
knowledge about the relationship between occupations
and cognitive impairment and COPD. This task will determine a research area where occupational therapy canbe beneficial for patients with COPD.
A possible significance of this research will be
explained. Cognitive impairment in COPD has beencharacterized by attention deficits, and some problems
have been seen especially when acquiring new behavior
patterns. Therefore, when supporting the acquisitionof new behavioral patterns, which is also instructedin hospitals, it would be necessary to understand their
cognitive function and consider a suitable guidance
method, such as guidance on inhaler use, ADL, and exercise habits. By knowing problems of occupation withcognitive impairment, it may be possible to more clarify
which areas occupational therapy will be required tocontribute in the future.
To this end, this study mainly aimed to conduct a
scoping review and summarize the findings on the relationship between occupation and cognitive impairmentsin patients with COPD, which would be necessary forfurther investigation and management of cognitive impairment in patients with COPD.

Methods
A scoping review was conducted to enable researchers map the current literature and identify gaps.

Ogawa M et al.

133

The PRISMA Extension for Scoping Reviews: Checklist
and Explanation [15] was used to guide the scoping
review.
A. Criteria for the selection of target papers
This review included original peer-reviewed articles
and excluded conference records. Review articles werealso excluded because they were difficult to treat equallywith original articles as primary literature.
Articles that dealt with patients diagnosed with
COPD, as well as articles that comprehensively examined other diseases, were included in the review.
Furthermore, cognitive impairment may be aggravatedby an acute exacerbation of COPD, and a relationshipbetween cognitive impairment at this period and occupations may be affected by factors from different those in
the stable period [16]; therefore, we excluded research
articles that included patients who had experienced
acute exacerbations of COPD for ≤ 6 months. Articles
that could be judged to have evaluated cognitive function were included. Evaluation methods and cognitive
functions evaluated were not restricted. In addition, to
extract occupations, the search terms of activity andoccupation were used. Inhaler use and driving were indicated to be related to cognitive impairment in patientswith COPD [12, 14]; thus, those words were also usedas search terms.
B. Literature retrieval method
MEDLINE, PsychINFO, and OTseeker databases
were searched for relevant articles. All articles were
written in English, and the search period ranged from2001 to 2020.
As a search condition, we extracted articles ofwhich the study participants were diagnosed with COPD
and which showed the relationship between cognitive
dysfunction and occupation. In the database search, thesearch keywords were divided into three items, namely,
COPD, occupations, and cognitive impairment, and thesearch was conducted. In the COPD item, “COPD” and“chronic obstructive pulmonary disease” were used. In
the occupation section, six terms were used, namely,“occupation,” “activity,” “ADL,” “activity of dailyliving,” “inhaler,” and “driving.” In the “cognitive impairment” section, seven terms were used, namely, “cognitive performance,” “cognitive impairment,” “cognitive
status,” “cognitive function,” “cognitive impairment,”“neuropsychological,” and “cognition.” The literaturesearch date was conducted on September 6, 2021.
C. Selection method
The inclusion criteria were as follows: (1) research
participants were patients with stable COPD without

OCCUPATIONS AND COGNITIVE IMPAIRMENT IN COPD

Identification

134

Records in the literature extracted at thearticle search site (n=557)

Literatures added from otherinformation (n=1)

Screening

Duplicate literature (n=84)

Title and abstract review (n=473)

Eligibility

Full text review (n=38)

Included

Excluded literatures (n=436)

Included literatures (n=22)

Excluded literatures (n=16)

Fig. 1. Flow diagram

acute exacerbations for the previous 6 months, (2)cognitive function had been assessed, (3) association
between cognitive impairment and occupation has been
pointed out, and (4) papers were written in English.
Review papers were excluded. In principle, when conducting a literature review, original articles should be
used because raw information of the researchers should
be highly prioritized rather than secondary informationsuch as reviews [17].
In the primary screening, the titles and abstracts of
the retrieved articles were checked by two independent
authors according to the selection criteria. When theopinions of both authors were different, multiple authors
discussed and decided on the selection.
The texts of articles selected in the primary screening were fully checked in the secondary screening by
two independent authors. Articles with discrepancies in
the judgment and opinions were reviewed by multiple
authors and decided on whether to accept them. The
following contents were extracted from the selected articles: authors, publication year, number of participants,
assessment of cognitive function and results, and occupation, and these data were arranged in a chart. As thisstudy focused on problems related to “occupation,” oursummary should be in the framework of “occupation.”
Thus, we referred to the category of “occupation” inthe domain of occupational therapy in the Occupational
Therapy Practice Framework: Domain and Process(3rd Edition) issued by of the American Occupational
Therapy Association [18]. Articles that were determined
to not fall under the category of “occupation” in thisframework were excluded from this study.
D. Extracting occupations
From the included articles, we extracted occupations that were related to cognitive impairment. In
addition, the number of participants and methods ofcognitive function assessment were extracted from each
paper, and the results were summarized in a table. Thesetasks were completed by two independent authors, andarticles that were difficult to judge were examined bymultiple authors.

Results
A flow diagram of this review is shown in Fig. 1.
The literature search identified 417 articles in MEDLINE, 10 in OTseeker, and 75 in PsychINFO. Initially,
84 duplicate articles were excluded.
In the primary screening, 473 titles and abstracts
were reviewed, of which 436 were excluded from thestudy. A total of 38 reports were selected as a result of
adding one additional record from other articles wereidentified from the references of the included articles.
In the secondary screening, the full text of articles
selected in the primary screening was checked. Accordingly, 16 articles were excluded and 22 were included
for the analysis.
The reasons for exclusion in the secondary screening were as follows: seven articles could not be classified into the “occupation” domain, three did not involve
patients with COPD, two did not examine cognitive

Asian J Occup Ther 19: 132−139, 2023

function, two did not examine occupation, one was a
protocol study, and one was a review. For example,
articles that could not be classified into “occupation”
domain examined the relationship between cognitive
functions and finger sophistication [19] and appropriateness of measuring spirometry [20].
Finally, 22 articles that were included in theanalysis were categorized by occupations, and a summary of the number of participants in each article andcognitive assessments used is presented in Table 1. The
Mini-Mental State Examination (MMSE) and Montreal
Cognitive Assessment (MoCA) accounted for 68.1% of
the total cognitive assessments employed in the articles
included in this review, and many studies investigatedother cognitive assessments. According to the occupation categories, 4 articles were classified as ADL, 17
articles as IADL, and 1 article as work. The results aredescribed in detail in the following sections and are
divided into categories.
A. ADL
Four studies have reported that cognitive impairment in patients with COPD was associated with ADL
disability [11, 21–23]. Antonelli-Incalzi et al. [24] used
the Katz Index to assess ADL, and the other three studies used a comprehensive questionnaire about ADL to
ask about difficulties in each activity such as clothing
and bathing [11, 22, 23]. In these studies, cognitive
function was compared with one variable, which was a
result of summarizing multiple items of ADL.
Gong et al. [22] examined cognitive function indetail and suggested that disorientation to time andreduced visuospatial ability may have significant effects
on ADL impairment. Kobayashi et al. [23] reported thatcognitive impairment was significantly worse in older
patients with COPD than in younger ones, which was
related to poorer ADL performance.
B. IADL1) Health management and maintenance (healthcare andmaintenance)
The healthcare and maintenance category included
articles on inhaler use and medication management. A
total of nine articles found associations between cognitive impairment and inhaler use. Seven investigatedadherence to inhaler use. Moreover, six articles revealed
a significant association between cognitive function andadherence [12, 25, 26]. However, Pierobon et al. [30]did not find any association between cognitive function
and adherence to inhaler use.
Two articles reported significant associations between cognitive impairment and inhaler use techniques.
Quinet et al. [31] indicated that inhaler use was inappro-

Ogawa M et al.

135

priate for patients who scored ≤ 24 points in the MMSE.
A countermeasure of inappropriate inhaler technique
was examined, and the study reported that an intensive
training program significantly reduced the use of inappropriate inhalation techniques because of cognitive
impairment [32].
2) Driving and community mobility (driving/mobility)
Three articles focused on the driving performanceof patients with COPD. All articles that assessed driving
performance using a driving simulator [14, 33, 34]
showed a significant reduction in driving performance inpatients with COPD. One study assessed cognitive function in patients with COPD, without a driving simulator[35]. The study suggested that significantly delayed response times to visual and sound stimuli and perceptual
velocity relative to changes in traffic circumstances wereassociated with a risk of accidents while driving.
3) Other IADLs
Five articles examined the association between
cognitive impairment and various IADL, including
cooking, shopping, money management, and medication
management [9, 11, 24, 36, 37]. All these articles also
assessed medication management. Antonelli-Incalzi et al.
[37] examined sub-items of MMSE. Disorientation totime and place, memory recall, and verbal fluency weresignificantly associated with inefficient medication andmoney management.
C. Work
Only one study examined work in a large cohort[38]. Patients with comorbid cognitive impairment and
COPD were reported to experience more difficulties
with work and social activities than those with cognitive
impairment or COPD alone. This suggests that thosewith comorbid COPD and cognitive dysfunction may
have severe disability to work.

Discussion
A review of 22 articles revealed that cognitive
impairment in patients with COPD was associated withdisabilities in some occupations regarding ADL and
IADL, such as medication management, driving, andwork. The results of this review are discussed in relationship between cognitive impairment and occupations
in patients with COPD.
1) ADLAll four articles that assessed ADL in patientswith COPD found associations between cognitive
impairment and ADL abilities with COPD. However, aJob performance/
Volunteer participation

Driving and community
mobility

Financial management(Monetary Control)

Health management andmaintenance

149 patients with COPD
30 patients (patients with COPD who have a driver’s licence)
32 subjects (including COPD, ILD, and healthy subjects)
27 patients (patients with COPD: healthy = 17 patients: 10 subjects)
45 patients (patients with COPD: healthy = 35 patients: 10 subjectts)

Antonelli-Incalzi R, et al. (2007) [36]Pretto JJ, et al. (2008) [33]Prior TS, et al. (2015) [34]Orth M, et al. (2008) [14]Karakontaki F, et al. (2013) [35]105332 patients (patients with COPD: healthy = 10476 patients:
94856 subjects)

2450 (elderly subjects including patient with COPD)

Feng L, et al. (2012) [37]Greenlund KJ, et al. (2016) [38]26 patients (aged 65 years and older with COPD)

25 patients (aged 65 years and older with COPD)

Quinet P, et al. (2010) [31]91 patients with COPD

184 patients with COPD

Moran C, et al. (2017) [29]Luley MC, et al. (2020) [32]121 patients (COPD: asthmatics = 88 patients: 33 patients)

Turan O, et al. (2017) [12]Yazar EE, et al. (2018) [9]299 patients with COPD
244 patients with COPDO’Conor R, et al. (2019) [27]Sulaiman I, et al. (2017) [28]100 patients with COPD

Mochizuki H, et al. (2013) [26]84 patients with COPD

44 patients (aged 65 years and older with COPD)

Maricoto T, et al. (2020) [25]Dulohery MM, et al. (2015) [21]130 subjects (including patients with COPD and healthy subjects)

Antonelli-Incalzi R, et al. (2008) [24]Pierobon A, et al. (2017) [30]149 patients with COPD

Martinez CH, et al. (2014) [11]279 patients with COPD

Kobayashi S, et al. (2014) [23]17535 patients (patients with COPD: healthy = 15870 patients: 1665
subjects).

1022 patients with COPD

Number of subjetss

Gong B, et al. (2020) [22]Authors (year of publication)

○

○

○

○

○

○

○

○

○

○

○

○

○

MMSE

○

○

○

○

MoCA

BRFSS

Driving Simulator※2

Driving Simulator

Driving Simulator

Driving Simulator
PVT

MDB

Digit Span
Spatial Span
Verbal Learning Test
Design Fluency
Symbol Digit Modality Test

CDT

MMAS-4

GDS-15※1

The HRS cognitive
instrument

OthersCognitive assessment

ILD: Interstitial lung disease, MMSE: Mini Mental State Examination, MoCA: Montreal Cognitive Assessment, GDS-15: Geriatric depression scale 15, MMAS-4: Morisky Medication Adherence
Scales 4, CDT: Clock Drawing Test, MDB: Mental Deterioration Battery, PVT: Psychomotor vigilance task, BRFSS: Behavioral Risk Factor Surveillance System※1: Raven’s progressive matrices, Verbal fluency, Visual span, Verbal span, Verbal memory, Albert’s test, Copying drawings, Copying drawing with landmarks, Immediate visual memory, Sentence
construction.
※2: Viennese test system-based attention/alert test; selective attention test; sustained attention test; response times to acoustic stimuli; visual perceptual assessment.

Work

IADL

ADL

Toileting and toilet
hygiene, swallowing/
eating, functional mobility,and personal hygiene andgrooming

Occupations

Table 1 Summary of results

136
OCCUPATIONS AND COGNITIVE IMPAIRMENT IN COPD

Asian J Occup Ther 19: 132−139, 2023

comprehensive assessment of ADL abilities were usedin all articles. Therefore, it has not been investigated
how cognitive impairments in patients with COPD
affect individual ADLs (e.g., clothing and bathing). The
results suggest that assessment of each ADL activity remains a challenge. Moreover, as regards the reason why
each individual ADL has not been examined, it could
be considered that patients with minor ADL disabilities
conspicuously lower their physical function, whichmight have masked their mild cognitive impairment.
Since disability limitations are usually a major factor in
ADL disability in patients with COPD, it is assumed thatthe association between ADL and cognitive impairment
is less explored. However, given the indications of an
association between ADL and cognitive impairment thatemerged from this study, it is not unlikely that not only
physical dysfunctions but also cognitive impairments
affect disabilities in ADL in patients with COPD. Therefore, it could be necessary to comprehensively examine
how cognitive impairment affects ADL disabilities.
2) IADL: Medication administration
This study found that many articles have examined
the association between medication management andcognitive impairment in patients with COPD. Among
all articles examined in this study, articles on IADL
(adherence to medication and inhaler use, monetary andmedication management) accounted for 59.1% of thetotal, which was the highest rate. Two possible reasonscan explain why many studies have examined medication management. First, cognitive impairment can easily
affect inhaler use because the process is complicated;
thus, guidance and practice are needed for proper use of
inhalers. Second, long-term medication management in
COPD is important; pharmacists have evaluated competence, adherence, and compliance of patients to instruction at hospitals; thus, it may be easy to analyze theproblem of inhaler use and management. For patientswith chronic disease, medication management should be
an important ADL. Considering the effect of cognitive
impairment on medication management, occupational
therapists should participate in the evaluation and intervention on inhaler use and medication management.
3) IADL: driving a car
Three articles investigated driving skills in patientswith COPD using driving simulators and found a reduction in their driving performance. Although driving
simulators have been validated for the assessment ofdriving performance, assessment by driving simulator
alone may be unable to identify individual cognitive
impairment such as working memory and attention.
Unique cognitive impairment in patients with COPD is

Ogawa M et al.

137

related to frontal lobe hypofunctions such as attention
and working memory [8]. A possibility of diminisheddriving performance in patients with COPD could beconsidered because drivers use more frontal lobe functions such as attention and judgment. In addition, on the
grounds that patients with COPD have reduced walking
capacity and walking endurance, being able to drive
could be crucial as a compensation for outside mobility.
Moreover, driving is often utilized routinely, such as
when shopping and hospital visits. Given these points,
further studies incorporating cognitive tests are necessary to further clarify the relationship between cognitive
function and driving in patients with COPD.
4) Summary of this review
The results of the analysis of the relationship between cognitive impairment and occupations in patientswith COPD revealed that relatively many studies havefocused on inhaler use and medication management,
whereas only a few studies have investigated ADL anddriving. Since these occupations are critical for patientswith COPD, more studies on these topics are warrantedin the future.

Limitations of this study
This scoping review included articles whose topics
fall on the “occupation” domain. Therefore, several
articles that did not focus on occupation were excluded.
However, it could be important to focus on two studies
to improve occupational therapy. First, Tomruk et al. [19]reported an association between finger dexterity andcognitive impairment in patients with COPD. Finger
dexterity may affect various occupations, and relation
between cognitive decline and finger function should
also be focused on in occupational therapy in the future.
Second, a study examined an association between cognitive function and appropriate use of spirometry [20].
This study suggested that a decreased MMSE score wascorrelated with inappropriate use of spirometry. Thus,
awareness of the potential effect of COPD-related cognitive impairment is important, even in topics that do not
fall within the occupation domain, as the topic may be
medically significant, for example, physical functioning
indirectly affect occupations. Although not addressedin the review, further studies on these topics are needed
to better clarify the effect of cognitive impairment onpatients with COPD.
As other limitations, this study focused on summarizing only reliable peer-reviewed articles and determining a research area where further studies will be needed.
Therefore, the study did not include various literaturematerials such as gray literature, past review articles,

138

OCCUPATIONS AND COGNITIVE IMPAIRMENT IN COPD

and papers reporting non-significant results between
cognitive impairment and occupation. Furthermore, oneof the limitations of this study is that there have been
still few studies focusing on cognitive impairment with
COPD, because the main factor in problems of occupations in patients with COPD is motor dysfunction. Especially in severe cases who have disabilities, it may havebeen less explored in the past, especially because thelimitation of motor impairment may be more limiting of
ADL than cognitive function. As the results, few studies
which focused on relation between cognitive decline
and ADL may have been reported. From these things,
it was not possible to include more detailed and broad
content materials on the relationship between cognitive
impairment and occupation. Examining associations ofcognitive function on specific occupations in individual
cases will contribute to the improvement of occupational
therapy for patients with COPD.

Conclusion
In this study, we conducted a scoping review ofpeer-reviewed articles published between 2001 and 2020
to comprehensively examine what occupations wereassociated with cognitive impairment in patients with
COPD and to summarize the findings. The results ofthis study revealed that cognitive impairment in patientswith COPD was related to ADL, IADL (such as inhaleruse, medication management, and driving a car), andwork. In addition, the current review revealed a scarcity
on research in areas such as ADL and car driving. Thus,
further studies are needed because these occupations are
crucial for patients with COPD.

References[1] World Health Organization. [online] Geneva: Chronic
obstructive pulmonary disease. [cited 2022 Junuary19].
Available from: https://www.who.int/news-room/factsheets/detail/chronic-obstructive-pulmonary-disease(copd).
[2] Martinsen U, Bentzen H, Holter MK, Nilsen T, Skullerud
H, et al. The effect of occupational therapy in patientswith chronic obstructive pulmonary disease: A randomized controlled trial. Scand J Occup Ther. 2017; 24(2):89–97.
[3] Schou L, Ostergaard B, Rasmussen SRH, Phanareth K.
Cognitive dysfunction in patients with chronic obstructive pulmonary disease – A systematic review. Respir
Med. 2012; 106: 1071–81.
[4] Bendstrup KE, Jensen JI, Holm S, Bengtsson B. Outpatient rehabilitation improve activities of daily living,
quality of life and exercise tolerance in chronic obstructive pulmonary disease. Eur Respir J. 1997; 10: 2801–6.

[5] Koolen EH, Spruit MA, de Man M, Antons JC, Nijhuis E,
et al. Effectiveness of home-based occupational therapy
on COPM performance and satisfaction scores in patientswith COPD. Can J Occup Ther. 2021; 88(1): 26–37.
[6] Maekura R, Hiraga T, Miki K, Kitada S, Miki M, et al.
Personalized pulmonary rehabilitation and occupational
therapy based on cardiopulmonary exercise testing forpatients with advanced. Int J Chronic Obstr Pulm Dis.
2015; 10: 1787–800.
[7] Singh B, Mielke MM, Parsaik AK, Cha RH, Roberts RO,
et al. A prospective of chronic obstructive pulmonary disease and the risk for mild cognitive impairment. JAMA
Neurol. 2014; 71: 581–8.
[8] Cleutjens FA, Franssen FM, Spruit MA, Vanfleteren LE,
Gijsen C, et al. Domain-specific cognitive impairment inpatients with COPD and control subjects. Int J Chronic
Obstr Pulm Dis. 2017; 12: 1–11.
[9] Yazar EE, Aydin S, Gunluoglu G, Kamat S, Gungen AC,
et al. Clinical effects of cognitive impairment in patientswith chronic obstructive pulmonary disease. Chronic
Respir Dis. 2018; 15: 306–14.
[10] Andrianopoulos V, Gloeckl R, Vogiatzis I, Kenn K. Cognitive impairment in COPD: should impairment cognitive
evaluation be part of respiratory assessment? Breathe.
2017; 13: e1–e9.
[11] Martinez Ch, Richardson CR, Han MK, Cigolle CT.
Chronic obstructive pulmonary disease, cognitive impairment, and development of disability: the health and retirement study. Ann Am Thorac Soc. 2014; 11: 1362–70.
[12] Turan O, Turan PA, Mirici A. Parameter affecting inhalation therapy adherence in elderly patients with chronic
obstructive lung disease and asthma. Geriatr Gerontol Int.
2017; 17: 999–1005.
[13] Baird C, Lovell J, Johnson M, Shiell K, Ibrahim HE.
The impact of cognitive impairment on self-managementin chronic obstructive pulmonary disease: A systematic
review. Respir Med. 2017; 129: 130–9.
[14] Orth M, Diekmann C, Suchan B, Duchna HW, Widdig G,
et al. Driving performance in patients with chronic obstructive pulmonary disease. J Physiol Pharmacol. 2008;
59: 539–47.
[15] Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun
H, et al. PRISMA Extension for Scoping Reviews (PRISMAScR): Checklist and Explanation. Ann Intern Med.
2018; 169: 467–73.
[16] James W, Rebecca A, Martin D, Paul W. Cognitive dysfunction in patients hospitalized with acute exacerbationof COPD. CHEST. 2013; 114(1): 119–27.
[17] Ooki S. Literature review from the basics (in Japanese).
Tokyo: Ishiyaku Publishers Inc.; 2013.
[18] American Occupational Therapy Association. Occupational therapy practice framework: Domain andprocess (4th ed.). Am J Occup Ther. 2020; 74(Suppl. 2):74124100010.
[19] Tomruk SM, Ozalevli S, Dizdar G, Narin S, Kilinc O.
Determination of the relationship between cognitive
function and hand dexterity in patients with chronicAsian J Occup Ther 19: 132−139, 2023

obstructive pulmonary disease (COPD): a cross-sectional
study: Physio Ther Theory Pract. 2015; 31(5): 313–7.
[20] Turkeshi E, Zelenukha D, Vaes B, Andreeva E, Frolova
E. Predictors of poor-quality spirometry in two cohortsof older adults in Russia and Belgium: a cross-sectional
study: NPJ Prim Care Respir Med. 2015; 25: 15048.
[21] Dulohery MM, Schroeder DR, Benzo RP. Cognitive function and living situation in COPD: is there a relationshipwith self-management and quality of life? Int J Chronic
Obstr Pulm Dis. 2015; 10: 1883–9.
[22] Gong B, Shang S, Wu C. Association between cognitive
declines and disability in activities of daily living in older
adults with COPD: evidence from the China health andretirement longitudinal study. BMJ Open. 2020; 10(10):e040098.
[23] Kobayashi S, Yanai M, Hanagama M, Yamanda S.
Burden of chronic obstructive pulmonary disease in theelderly population. Respir Investigation. 2014; 52(5):296–301.
[24] Antonelli-Incalzi R, Corsonello A, Trojano L, Acanfora D,
Spada A, et al. Correlation between cognitive impairment
and dependence in hypoxemic COPD. J Clin Exp Neuropsychol. 2008; 30(2): 141–50.
[25] Maricoto T, Santos D, Carvalho C, Teles I, Correia-deSousa J. Assessment of poor inhaler technique in older
patients with asthma or COPD: a predictive tool forclinical risk and inhaler performance. Drugs Aging. 2020;
37(8): 605–16.
[26] Mochizuki H, Nanjo Y, Takahashi H. Better adherence toa transdermal tulobuterol patch than inhaled salmeterol inelderly chronic obstructive pulmonary disease patients.
Geriatr Gerontol Int. 2013; 13(2): 398–404.
[27] O’Conor R, Muellers K, Arvanitis M, Vicencio DP, Wolf
MS. Effects of health literacy and cognitive abilities on
COPD self-management behaviors: A prospective cohort
study. Respir Med. 2019; 160: 105630.
[28] Sulaiman I, Cushen B, Greene G, Seheult J, Seow D.
Objective assessment of adherence to inhalers by patientswith Chronic Obstructive Pulmonary Disease. Am J
Respir Crit Care Med. 2017; 195(10): 1333–43.
[29] Moran C, Doyle F, Sulaiman I, Bennett K, Greene G. The
INCATM (Inhaler Compliance AssessmentTM): A com-

Ogawa M et al.

139

parison with established measures of adherence. Psychol
Health. 2017; 32(10): 1266–87.
[30] Pierobon A, Bottelli ES, Ranzini L, Bruschi C, Maestri
R. COPD patients’ self-reported adherence, psychosocial
factors and mild cognitive impairment in pulmonary rehabilitation. Int J Chron Obstruct Pulmon Dis. 2017; 12:2059–67.
[31] Quinet P, Young CA, Héritier F. The use of dry powder
inhaler devices by elderly patients suffering from chronic
obstructive pulmonary disease. Ann Phys Rehabil Med.
2010; 53(2): 69–76.
[32] Luley MC, Loleit T, Knopf E, Djukic M, Criée CP, et al.
Training improves the handling of inhaler devices andreduces the severity of symptoms in geriatric patients suffering from chronic-obstructive pulmonary disease. BMC
Geriatr. 2020; 20: 398.
[33] Pretto JJ, McDonald CF. Acute oxygen therapy does not
improve cognitive and driving performance in hypoxaemic COPD. Respirology. 2008; 13(7): 1039–44.
[34] Prior TS, Troelsen T, Hilberg O. Driving performance inpatients with chronic obstructive lung disease, interstitiallung disease and healthy controls: a crossover intervention study. BMJ Open Respir Research. 2015; 17: 2(1)e000092.
[35] Karakontaki F, Gennimata SA, Palamidas AF, Anagnostakos T, Kosmas EN. Driving-related neuropsychological
performance in stable COPD patients. Pulm Med. 2013;2013: 297371.
[36] Antonelli-Incalzi R, Corsonello A, Trojano L, Pedone C,
Acanfora D. Screening of cognitive impairment in chronic obstructive pulmonary disease. Dement Geriatr Cogn
Disord. 2007; 23(4): 264–70.
[37] Feng L, Lim ML, Collinson S, Ng TP. Pulmonary function and cognitive decline in an older Chinese populationin Singapore. Journal of COPD. 2012; 9(5): 555–62.
[38] Greenlund KJ, Liu Y, Deokar AJ, Wheaton AG, Croft JB.
Association of chronic obstructive pulmonary disease
with increased confusion or memory loss and functional
limitations among adults in 21 states, 2011 Behavioral
Risk Factor Surveillance System. Prev Chronic Dis. 2016;
13: E02.

■ORIGINAL ARTICLE

Learning Effects of Multiple Driving Simulator Runs
in Older Adults
Tsutomu Sasaki1, Kyohei Yamada1, Tomoki Ikeda2,
Hatsune Obuchi3, Tomoaki Yamada4
1

Department of Occupational Therapy, Hokkaido Chitose College of Rehabilitation
Community Health Care Organization Hokkaido Hospital3
Shinsapporo Driving School
4
Soen Driving School
2

Abstract: Driving simulators (DS) have been used in medical institutions to evaluate a participant’s driving abilities.
Despite the empirical fact that the learning effects of multiple DS runs have been observed in clinical practice, few
studies have examined the learning effects. The learning effects of multiple DS runs were examined among 25 older
adults and 27 young participants. The participants drove the same course thrice without receiving any advice on theoperation. The older adults had significantly more accidents than the young ( p < 0.05) in all the trials. The numberof accidents was significantly higher ( p < 0.05) among older adults in the first trial than in the second. No significant
difference was observed in the number of accidents between the second and third trials ( p = 0.94). No significant difference in the number of accidents was found among all trials in the younger age groups. Among the different types ofaccidents noted, “Rear-end collisions due to inadequate deceleration” were observed more frequently among the older
adults. “Collisions with a wall or vehicle due to improper maneuvering when turning right or left” were observed more
frequently among young drivers. The results suggest that, the older adults may reveal their true driving abilities afterat least three trials in the course used in this study. Furthermore, the results suggest that the quality of accidents differ
between the older adults and the young.
Keywords: older drivers, driving simulator, learning effect(Asian J Occup Ther 19: 140−145, 2023)

Introduction
Mobility support is one of the important roles ofoccupational therapists. Among the various means oftransportation, driving a car greatly affects quality of life[1]. Recently, driving simulators (DS) have been usedin medical institutions to evaluate a participant’s driving
abilities. DS can easily evaluate safe driving performance, such as maneuvering a car (operating the steering wheel, gas pedal, and brakes), hazard prediction, andcompliance with laws and regulations. Although previous
studies have found that DS can predict accidents andReceived: 14 February 2023, Accepted: 10 March 2023
Corresponding to: Tsutomu Sasaki, Department of Occupational Therapy, Hokkaido Chitose College of Rehabilitation, 2-10 Satomi, Chitosecity, Hokkaido, 066-0055, Japane-mail: t-sasaki@chitose-reha.ac.jp©2023 Japanese Association of Occupational Therapists

on-road driving performance [2–5], the findings are contradictory [6–7]. Possible reasons for these contradictory
findings include differences in the attributes of the participants, type of DS used, indicators of on-road driving
performance, and amount of prior practice. Despite theempirical fact that the learning effects of multiple DSruns have been observed in clinical practice, few studies
have examined the learning effects.
To the best of our knowledge, only Kawano et al.
(2012) [8] reported that habituation occurs during thethird execution of a given course. However, the qualitative characteristics of driving performance on a DS were
not analyzed by the authors. Additionally, the DS used intheir study differed from those frequently used in Japa­
nese medical institutions. Therefore, in this study, wequantitatively and qualitatively examined the effects ofmultiple DS sessions on the performance of participants
using the DS that is frequently used by occupational
therapists in Japan.

Asian J Occup Ther 19: 140−145, 2023

Sasaki T et al.

141

Fig. 1. Outline of the course. Edited by authors from [9].

Methods
Participants
Consent to participate in the study was obtained
from 43 older adults with valid driver’s licenses. Participants were recruited from community health promotion
classes, public lectures, and the Silver Human Resource
Center through oral and poster presentations. Of these,
18 participants who could not complete the scheduled
number of DS trials (three trials) because of DS sickness
were excluded (16 participants stopped after the firsttrial, while the other two stopped after the second trial)(DS sickness rate: 41.9%). Ultimately, 25 participants
were included in the analysis. The mean age of theparticipants was 75.0 ± 6.0 years (range, 65–89 years;
median, 74 years), and 20 were men. The mean score ofmini-mental state examination (MMSE) was 27.5 ± 2.0
points (range, 23–30 points; median, 27 points). Additionally, 21 participants had valid licenses for more than
40 years, whereas the other four drivers had been drivingfor 20–30 years. Twenty-one participants drove daily,
and the remaining four drove 3–5 days per week.
The comparison group consisted of 27 young adults
with valid driver’s licenses. A total of 57 second- andthird-year university students were recruited to participate in the study, and 27 of them cooperated andconsented to participate in the study. The mean age ofthe these participants was 20.3 ± 0.7 years (range, 19–21
years; median, 20 years), and eight were men. All participants had obtained their driver’s licenses less than two
years ago and drove only a few times a year. Additionally, none of the participants had any prior DS experience.
DS

The DS used in this study was Honda Safety Navi®
(HONDA GIKEN, Japan). The course used was the
KIKEN YOSOKU TAIKEN Course 6 (intermediate level,
daytime, estimated distance of 1.2 km, and estimateddriving time of 3 min). The course with the shortest
driving time was selected taking into consideration theendurance of the older participants. The course content
included entering the roadway from a parking lot; driving downhill, including straight lines and curves; overtaking stopped vehicles (with oncoming traffic); railroad
crossing; sudden appearance of a bicycle from behindthe car when turning left; turning left on a narrow road;dealing with oncoming traffic on a narrow road; andcontinuing straight after taking a right turn (with approaching vehicles and road crossers) (Fig. 1) [9].
Procedure
Prior to starting the session, the participants weretold that if they felt sick, they could alleviate the symptoms by taking their eyes off the screen or taking a deep142

LEARNING EFFECTS OF MULTIPLE DS RUNS

breath, and that if they judged that it was difficult tocontinue, they could immediately stop the DS by reporting it. The DS included a fan blowing air from the left
side and rear. After explaining about the steering wheel,
accelerator, brake, blinkers, and how to read the screen(side and rearview mirrors and speedometer), the participants were given the following instructions, “We will
not provide any advice in case of any accidents while
operating the DS. Please familiarize yourselves with theoperations. We plan to conduct the trial three times witha break of approximately 15 min. If you feel sick, please
let us know and we will stop.” Subsequently, a DS session was initiated.
Analysis
The number of accidents automatically measured by
the DS was used as an indicator of the repeated learning
effect. Inter-trial and intergroup comparisons included
the number of accidents. Normality and equal variancefor the number of accidents could not be confirmed;
therefore, the Friedman test was used for comparisons
between trials, and the Scheffé’s method was used for
multiple comparison methods. The Mann-Whitney U
test was used for intergroup comparisons. The significance level was set at 5%. The effect size (r) was calculated for the amount of effect.

Results
The number of accidents in the older participants
was 42, 17, and 15 in the three trials, respectively. The
number of accidents in younger participants was 17,
6, and 5 in the three trials, respectively. The Friedman
test revealed a significant difference in the number ofaccidents between trials between the groups (older participants: X2(2) = 19.1, p < 0.001; younger participants:
X2(2) = 6.0, p < 0.05). Scheffé’s method revealed thatolder participants had fewer accidents in the 2nd or 3rdtrials than in the 1st trial (1st vs. 2nd trial: X2(2) = 12.9,
p < 0.01, r = 0.61; 1st vs. 3rd trial: X2(2) = 15.6, p < 0.01,
r = 0.67; 2nd vs. 3rd trial: X2(2) = 0.13, p = 0.94, r = 0.11).
Younger participants performance did not differ significantly between the trials. However, a moderate difference effect was observed between the 1st and 2nd trials
and between the 1st and 3rd trials (1st vs. 2nd trial: X2(2) =4.30, p = 0.12, r = 0.38; 1st vs. 3rd trial: X2(2) = 4.76, p =0.09, r = 0.41; 2nd vs. 3rd: X2(2) = 0.01, p = 0.9, r = 0.05).
The Mann-Whitney U test revealed that older drivers
had more accidents than younger participants in all trials(1st trial: Z = 2.89, p < 0.01, r = 0.56; 2nd trial: Z = 2.93,
p < 0.01, r = 0.57; 3rd trial: Z = 2.37, p < 0.05, r = 0.46)(Fig. 2).
Regarding the qualitative parameters of the acci-

Fig. 2. The mean number of accidents

dents, over 90% of the accidents in older participantsgroup were observed in the first half of the course (between the starting point and railroad crossing), whereas
most of the accidents in younger participants groupoccurred in the second half of the course. The ratio of
the number of accidents in the first half of the course
to the total number of accidents in the three trials were
97.6%, 94.1%, and 100%, respectively, in the older participants, and 52.9%, 50.0%, and 20.0%, respectively, inthe younger participants (Fig. 3–5).
Overall, 102 accidents were noted and these wereclassified into the following four categories: (1) collision
with a wall or vehicle owing to improper maneuvering
when driving straight or turning, (2) collision with a wallor vehicle owing to improper maneuvering when turning
right or left, (3) rear-end collisions owing to inadequate
deceleration, and (4) rear-end collisions owing to improper entry into the road. Irrespective of the number oftrials, older participants were most commonly involvedin type 3 and rarely in type 2 collisions. In contrast, type2 accidents were observed most frequently in younger
participants, whereas type 3 accidents were rare. Type4 accidents were observed in a certain number of older
participants irrespective of the trial, whereas they decreased in younger participants in each successive trial(Fig. 6).

Discussion
This study is the first reports that show the learning
effects of multiple driving simulator runs in older drivers
using Honda Safety Navi® which is the most frequently
used in Japanese medical institutions. The number ofaccidents decreased with successive trials for both theolder and younger participants. In this study, a repeatedlearning effect was expected in the third trial. Kawano

Asian J Occup Ther 19: 140−145, 2023

Sasaki T et al.

Fig. 3. Accidents observed in the 1st trial. Categories of accidents; 1; collision with a wall or vehicle owing to improper maneuvering
when driving straight or turning, 2; collision with a wall or vehicle owing to improper maneuvering when turning right or left, 3;
rear-end collisions owing to inadequate deceleration, and 4; rear-end collisions owing to improper entry into the road.

Fig. 4. Accidents in the 2nd trial.

Fig. 5. Accidents in the 3rd trial.

143

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LEARNING EFFECTS OF MULTIPLE DS RUNS

Fig. 6. The proportion of accidents across trials.

et al. (2012) [8] examined the effects of repeated sessions of DS on maintenance of speed (100 km/h) andlane position, and reported that older drivers become
accustomed by the 4th trial. Despite differences in theexperimental procedures, their results were similar to
those of the present study.
DS is a visuomotor learning task that involves
several brain regions, including the cerebellum, visualcortex, motor cortex, parietal lobe, hippocampus, andcingulate gyrus [10]. The refinements in this DS-related
neural network are influenced by individual functional
and age differences; older drivers take longer than
younger drivers. Therefore, the possibility cannot be
ruled out that a participant’s performance may improve,albeit slightly, after the fourth trial in the DS course usedin this study. Unsafe driving performance in the initial
DS trials may be the result of a combination of both
unfamiliarity with the DS operation and the participants
actual driving ability. However, it is expected that after
multiple trials (e.g., the fourth trial), the unfamiliarity
component will decrease and the performance will more
likely reflect the participants actual driving ability.
Two results were apparent in the analysis of theaccident characteristics. First, accidents in older participants were predominant in the first half of the course(especially type 3 accidents were common in the 2nd and3rd third trials), whereas accidents in younger participants (especially type 2 accidents) were predominant
in the second half of the course (between the railroad
crossing and the finish line). The first half of the course
was characterized by driving downhill, adjusting the
speed, dealing with stopped vehicles and oncoming
traffic, and driving around curves in an unfamiliar DS
environment. Older participants may have responded

to the high cognitive load of operating the DS against
the rapidly changing screen from the 2nd trial using
inadequate deceleration [11]. By contrast, younger
participants may have judged that they could cope with
rapid changes on the screen without slowing down,
although their DS operations were poor. This speculation is consistent with the finding that information
processing speed decreases with age [12]; however, anin-depth analysis of the relationship between speeding
locations and accidents is required. As in the first half ofthe course, in the second half the driver was required todeal with stopped vehicles and oncoming traffic, and to
make multiple right and left turns on a flat road without
curves. A sensory understanding of the steering wheel
rotation angle and the left-right turn angle of the vehicle
body depends on the driving experience; consequently,
several accidents may have been observed in younger
participants with less driving experience. In contrast, theolder participants, even in an unfamiliar DS environment, were able to turn right and left without collisions
at moderate speeds based on their previous experiences.
The second important accident characteristic wasthat a certain number of rear-end collisions due toimproper entry into the road were observed in older
participants, irrespective of the number of trials. Such
accidents were not observed in the 3rd trial among theyounger participants. In terms of traffic accident statistics, both novice and experienced drivers experienced
the highest number of accidents due to unsafe driving,
and the ratio of unsafe driving to all violations that
led to traffic accidents was higher among experienced
drivers [13]. Although the relevance of the results of thisstudy is a matter of speculation, it is interesting to notethat there were differences between the groups in acci-

Asian J Occup Ther 19: 140−145, 2023

dents related to safe driving awareness when entering
the road. In the future, it will be necessary to measureand verify rearview-checking during DS sessions.

Limitations
This study has several limitations. First, the causesof accidents remain unclear. It is not clear whether theaccidents were caused by unfamiliarity with the movements of the car on the screen in response to the DSspecific steering wheel and brake operations or by a lackof safety awareness, such as insufficient rear-checking
when starting, or whether they were the result of theinteraction of the two. The background factors of the repeated learning effect should continue to be analyzed byincreasing the amount of data, including changes in theexperimental methods, such as increasing the number ofrepetitions to four or more. Second, because the sample
size was small and the age range of the older participants was large, the possibility cannot be ruled out thatthe number of repetitions until habituation may havediffered between individuals of 65–74, 75–80, and ≥ 80
years of age. Third, it should be noted that the present
findings are limited to HONDA Safety Navi®, KIKENYOSOKU TAIKEN Course 6 (intermediate, daytime).

Ethical consideration
All participants gave their informed consent to participate in this study. Experimental procedures followed
the ethical standards of the Declaration of Helsinki. This
study was approved by the Research Ethics Committeeof Hokkaido Chitose College of Rehabilitation (Approval No. 18008).

Funding
This work was supported by the Japan Society for
the Promotion of Science, Grant-in-Aid for Scientific
Research (C) under Grant number 18K10685.

Conflict of interest
The authors declared no potential conflicts of interest with respect to the research, and/or publication ofthis article.

Sasaki T et al.

145

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

References[1] Chiburi S, Mielenz TJ, DiMaggio CJ, Betz ME,
DiGuiseppi C, Jones VC, Li G. Driving cessation andhealth outcomes in older adults. J Am Geriatr Soc. 2016;
64: 332–41.
[2] Nouri FM, Tinson DJ. A comparison of a driving simulator and a road test in the assessment of driving ability
after a stroke. Clin Rehabil. 1988; 2: 99–104.
[3] Lee HC, Cameron D, Lee AH. Assessing the driving performance of older adult drivers: on-road versus simulated
driving. Accid Anal Prev. 2003; 35(5): 797–803.
[4] Shechtman O, Classen S, Awadzi K, Mann W. Comparison of driving errors between on-the-road and simulated
driving assessment: a validation study. Traffic Inj Prev
2009; 10(4): 379–85.
[5] Fuermaier AB, Piersma D, de Waard D, Davidse RJ, deGroot J, Doumen MJ, Bredewoud RA, Claesen R, Lemstra AW, Scheltens P, Vermeeren A, Ponds R, Verhey F,
Brouwer WH, Tucha O. Assessing fitness to drive-A validation study on patients with mild cognitive impairment.
Traffic Inj Prev. 2017; 18(2): 145–9.
[6] Lee HC, Lee AH. Identifying older drivers at risk of traffic violations by using a driving simulator: a 3-year longitudinal study. Am J Occup Ther. 2005; 59(1): 97–100.
[7] Imhoff S, Lavallière M, Germain-Robitaille M, Teasdale
N, Fait P. Training driving ability in a traumatic braininjured individual using a driving simulator: a casereport. Int Med Case Rep J. 2017; 10: 41–5.
[8] Kawano N, Iwamoto K, Ebe K, Aleksic B, Noda A,
Umegaki H, Kuzuya M, Iidaka T, Ozaki N. Slower adaptation to driving simulator and simulator sickness in older
adults. Aging Clin Exp Res. 2012; 24(3): 285–9.
[9] Driving ability evaluation support software. instruction
manual. HONDA, pp.89–94.
[10] Uchiyama Y, Ebe K, Kozato A, Okada T, Sadato N. The
neural substrates of driving at a safe distance: a functional MRI study. Neurosci Lett. 2003; 352(3): 199–202.
[11] Doroudgar S, Chuang HM, Perry PJ, Thomas K, Bohnert
K, Canedo J. Driving performance comparing older versus
younger drivers. Traffic Inj Prev. 2017; 18(1): 41–6.
[12] Verhaeghen P. Aging and executive control: reports of ademise greatly exaggerated. Curr Dir Psychol Sci. 2011;20(3): 174–80.
[13] Institute for Traffic Accident Research and Data analysis(ITRDA). Traffic statistical report; 2020: p.198, p.206–7.

■ORIGINAL ARTICLE

Comparison of Stroke Patients’ Motor Performancein the Dual Task Stepping Test Immediately afterand Up to 15 Seconds after Cognitive Task Loading
Takayuki Watabe1, 2, Hisayoshi Suzuki2, Marina Abe2, 3, Kengo Uchibori2,3
1

Rehabilitation Division, Showa University Northern Yokohama Hospital
Department of Occupational Therapy, School of Nursing and Rehabilitation Sciences, Showa University
3
Rehabilitation Center, Showa University Fujigaoka Rehabilitation Hospital2

Abstract: Objective: This study identifies differences in the motor performance immediately after and 15 s after cognitive task loading during the dual task stepping test in patients who experienced a stroke.
Methods: Twenty-seven patients who experienced a stroke were included in the study. The paralyzed lower limb elevation was measured during the dual task stepping test. The task was performed for 30 s, with measurement time periodsof 5 s immediately after starting the single task, 5 s immediately after cognitive task loading, and 5 s beginning 10 safter cognitive task loading. The mean lower limb elevation during each time period was determined. The amount ofparalyzed lower limb elevation during each time period was compared, and correlations between the amount of change
in each time period and assessment scores were examined. The relationships between the patients’ walking abilities andthe amounts of change during each time period were also analyzed.
Results: The amount of lower limb elevation decreased after cognitive task loading ( p < 0.01). The change in lower
limb elevation from the motor task to after cognitive task loading was negatively correlated with the attention rating
scale score (rs = −0.40, p = 0.04). Patients who could walk independently had a significantly lower change in lower
limb elevation immediately after cognitive task loading than patients who required walking supervision ( p < 0.01).
Conclusion: Additional specific dual training assessments and their applications to dual task training must be investigated in future studies.
Keywords: stroke, dual task, evaluation, motor performance(Asian J Occup Ther 19: 146−152, 2023)

Introduction
Daily life involves a series of dual task movements,
including walking while thinking or working while
talking. These situations demand safe and precise motor
performances. Dual tasks, in which motor and cognitive
tasks are performed simultaneously, are widely used inrehabilitation to predict the risk of falling and to determine the degree of movement independence. Evaluationof the dual tasks is important for occupational therapists
who help patients lead meaningful and safe lives. It has
Received: 21 December 2022, Accepted: 27 March 2023
Corresponding to: Takayuki Watabe, Rehabilitation Division, Showa
University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzukiku Yokohama-shi, Kanagawa, 224-8503 Japane-mail: taka1021@cmed.showa-u.ac.jp©2023 Japanese Association of Occupational Therapists

been reported that patients with brain injuries have adecreased ability to perform dual tasks [1, 2]. Therefore,
the movement independence of these patients must be
evaluated using dual task assessments, and these patients
must undergo dual task training.
The Stop Walking When Talking Test developed by
Olsson et al. [3], Timed Up and Go Test with an added
cognitive task [4], and Trail Walking Test [5], in which
participants walk a course of 15 randomly placed landmarks in order, are dual task assessments that have beenreported to be clinically significant. Other assessment
methods combine various motor and cognitive tasks[6–8]. The dual task stepping test, in which a cognitive
task is performed while stepping in a sitting posture,
was found to be correlated with the patients’ abilities
to perform activities of daily living (ADLs) [9]. This
assessment can be performed easily and safely in 30 s
and does not require special equipment. The risk of fall-Asian J Occup Ther 19: 146−152, 2023

Watabe T et al.

147

Table 1 Patient characteristics and assessment results.
Age (years)−

65.6 ± 11.8

Male/Female

16/11

−

41.9 ± 35.6

Diagnosis

Cerebral infarction
Cerebral hemorrhage

18
9Disability

Right hemiplegia
Left hemiplegia
No paralysis

12
9
6

Sex
Duration from stroke onset (days)
Patient characteristics

BBS (points)−

48.1 ± 7.3

ⅣⅤ
Ⅵ
No paralysis

3
5
13
6

−

27.8 ± 2.6−

4.6 ± 6.6

Independent/Supervised

14/13

Lower limb Br. stage
Assessment results

MMSE (points)
Attention rating scale (points)
Walking ability
FIM motor item total (points)−

81 (71−88)

FIM cognitive item total (points)−

32 (27.5−35)

Data are shown as mean ± standard deviation or median (range).
Abbreviations: Berg Balance Scale; MMSE: Mini-Mental State Examination; FIM: Functional Independence Measure.

ing during the assessment is minimal, leading to a highsafety level. The task’s intra- and inter-rater reliability
have also been confirmed, including for therapists withlimited clinical experience [10], indicating that thisassessment can be applied widely in clinical practice.
Traditional dual task assessment methods comparea patient’s performance of a single motor task to thepatient’s performance of a dual task that includes a
cognitive task. However, differences in the changes in
performance immediately after the cognitive task andover time have not been examined. In clinical practice,some patients lose their balance immediately after being
spoken to while walking, while others do so after aperiod of walking while talking. These phenomena arepresumably caused by the interference of the cognitivetask, which prevents brains with limited processing
resources from adequately covering the load of the dual
task. Understanding which of these phenomena occur inpatients with stroke is important.
The accuracy of dual task assessment methods may
be improved by measuring the patient’s motor performance immediately after the cognitive task is added
to the motor task and after a certain period of time has
elapsed since the performance of the cognitive task. It
is also important to consider these changes in motor
performance when occupational therapists provide dual
task training programs to patients to prevent falls.
This study examines the differences in the motor
performance of patients who have experienced a stroke

during the dual task stepping test immediately after
cognitive task loading and up to 15 s after cognitive task
loading.

Methods
Patients
Of 128 patients with stroke admitted to Hospital A’s
recovery and rehabilitation ward between January andDecember 2017, 27 met the study’s inclusion criteria(Table 1). Patients who had experienced stroke between
2 weeks and 6 months at the time of the dual task assessment with no history of brain injuries were includedin the study. All patients included in the study performed
their ADLs independently prior to the stroke, were able
to step by raising the lower limbs to a constant heightfor 30 s while sitting on the edge of a chair, were able
to walk with supervision or independently, could follow
simple verbal instructions, had no pain that affected theassessment results, and had not been instructed by aphysician to limit their movement. The study was fully
explained to the patients, who each provided informed
consent prior to their participation in the study. Patients
who did not meet the inclusion criteria and those who
did not provide consent were excluded from the study.
This study was approved by the appropriate ethics
committee (approval number: 366) and was conductedfollowing the principles of the Declaration of Helsinki.

148

STROKE PATIENTS' MOTOR PERFORMANCE IN THE DUAL TASK

Fig. 1. Sections for measuring the lower limb elevation.

Study procedure
A video camera was used to record the patientsduring the dual task stepping test. The dual task stepping
test was conducted by the patient responding to a cognitive task while stepping in a seated position and evaluated the patient’s stepping performance. The procedure
for the dual task stepping test was the same as that performed in a previous study [9], which has been shown
to be reliable and valid. The assessment began with thepatient sitting on a chair 40 cm from the ground. The examiner sat 3 m in front of the patient and instructed thepatient to take alternating steps for 30 s at a comfortablespeed, a consistent height, and a consistent pace. The
patients were shown an example and practiced steppingfor 30 s. Then, the examiner instructed the patient tocontinue stepping while they answered a question. Fiveseconds after the patient began stepping, the examiner
asked, “What did you eat for breakfast today?” Theexaminer did not make any further statements andevaluated the patient’s motor performance. Patients
who could not maintain a constant lower limb elevation
height during the single task owing to muscle fatigue or
attention problems were excluded from the assessment.
To examine the change in motor performance
immediately after the cognitive task loading and later,
the distance the paralyzed lower limb was raised wasmeasured during different time periods. The distanceof vertical movement was measured using the height ofthe superior border of the patella. The measurements
were obtained using three-dimensional motion analysis
software (Dipp Motion V, version 1.2.6; DeTect, Inc.,
Panama City, FL, USA). Markers were placed on the
superior border of the patella on the paralyzed lower
limb to quantify the distance the knee was raised during
each time period. The height of the superior border ofthe patella was measured for 5 s after the single task was

initiated (the ST time period), for 5 s after cognitive task
loading (DT1 time period), and for 5 s beginning at 10 safter cognitive task loading (DT2 time period) (Fig. 1).
The mean vertical distance traveled by the marker during
each time period was analyzed.
Patient age, sex, health course since the stroke,
diagnosis, and disabilities were obtained from the
medical records. The Berg Balance Scale (BBS) [11],a useful balance assessment; Mini-Mental State Examination (MMSE) [12], a cognitive function assessment;
Motor-Functional Independence Measure (MFD) [13],an attention function assessment; and Motor-Functional
Independence Measure (M-FIM) and Cognitive Functional Independence Measure (C-FIM), which assess
ADL, were conducted within two days of the dual task
stepping test.
Analytical methods
Comparison of lower limb elevation heights during eachtime period
The distances that the paralyzed lower limb waselevated during the ST, DT1, and DT2 time periods
were compared.
Correlations of changes in lower limb elevation during
each time period with patients’ characteristics and assessment scores
Changes in paralyzed lower limb elevation between
the ST and DT1 time periods are expressed as ∆ST/DT1(ST/DT1), those between the DT1 and DT2 time periods
are expressed as ∆DT1/DT2 (DT1/DT2), and thosebetween the ST and DT2 time periods are expressed as∆ST/DT2 (ST/DT2). The correlations of each change
and patient age, days since the stroke, BBS score,
MMSE score, attention rating scale score, M-FIM score,
and C-FIM score were determined.

Asian J Occup Ther 19: 146−152, 2023

Watabe T et al.

149

Comparison of changes in lower limb elevation during
each time period, patient characteristics, and assessment scores between patients with different walking
abilities
The patients were divided into the independentwalking and supervised-walking groups based on theirabilities. Patients who scored ≥ 6 on a FIM motor item
(walking) were included in the independent walking
group. Those who scored ≤ 5 were included in the
supervised-walking group. The ∆ST/DT1 (ST/DT1),∆DT1/DT2 (DT1/DT2), ∆ST/DT2 (ST/DT2), age, sex,days since the stroke, diagnosis, disability, BBS score,
MMSE score, attention rating scale score, M-FIM score,
and C-FIM score were compared between the groups.
Statistical analysis
Continuous variables are expressed as meanand standard deviation, and categorical variables are
expressed as number and frequency. Spearman’s rankcorrelation coefficient was used to examine the correlations between the variables. The Mann–Whitney U test
and Fisher’s exact test were used to compare the groups.
The Kruskal–Wallis and Steel–Dwass tests were used
for multiple comparisons. All analyses were conductedusing JMP Pro statistical software (version 16; SAS Institute Inc., Cary, NC, USA). Statistical significance wasset at p < 0.05.

Results
Comparison of lower limb elevation during each time
periodThe mean number of steps during each time period
were 5.1 ± 1.8, 5.0 ± 2.2, and 5.1 ± 2.5 in the ST, DT1,
and DT2 time periods, respectively. The mean heights
during the ST, DT1, and DT2 time periods were 7.6 ±
3.4, 6.5 ± 3.2, and 6.0 ± 3.1 cm ( p < 0.01), respectively(Fig. 2). The lower limb elevation decreased as time
passed after the cognitive task loading ( p < 0.01).
Correlations of changes in lower limb elevation during
each time period with patients’ characteristics and assessment scores∆ST/DT1 (ST/DT1) was negatively correlated withthe attention rating scale score (rs = −0.40, p = 0.04)(Table 2); patients with lower attention scores had ahigher percentage of reduced lower limb elevation immediately after the cognitive task loading. ∆DT1/DT2(DT1/DT2) and ∆ST/DT2 (ST/DT2) were not correlatedwith patient characteristics or assessment scores.

Fig. 2. Comparison of lower limb elevation in each section.

Comparison of walking ability with changes in lower
limb elevation during each time period, patient characteristics, and assessment scores
The independent walking group included 14 patients, and the supervised-walking group included 13
patients. The BBS scores ( p < 0.01), MMSE scores ( p =0.02), and attention rating scale scores ( p < 0.01) weresignificantly different between the groups (Table 3).
Patients in the supervised-walking group had a significantly greater ∆ST/DT1 (ST/DT1) than those in the
independent-walking group ( p < 0.01).

Discussion
In this study, the motor performance of patients
who had experienced a stroke declined immediately
after cognitive task loading and declined even more beginning 10 s after cognitive task loading during the dual
task stepping test. Woollacott et al. [14] reported that, ingeneral, older adults tend to prioritize cognitive tasks indual task environments and that the motor performanceof older adults is affected by secondary tasks. Immediately after cognitive task loading, the patients’ attention
was prioritized to the cognitive task, resulting in a
decline in motor performance. Patients with lower attention rating scale scores had a lower motor performance
immediately after cognitive task loading, suggesting the
involvement of attention functions, especially the ability
to instantaneously and appropriately allocate attention to
the motor and cognitive tasks. The results of this study
emphasize the importance of assessing the motor task
and dual task abilities of patients with impaired attention
after a stroke to determine their movement independence.
Although the patients’ motor performance declined
further as time passed compared to immediately after

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STROKE PATIENTS' MOTOR PERFORMANCE IN THE DUAL TASK

Table 2 Correlations of change in lower limb elevation during each time period with patient characteristics and assessment results.
∆ST ∙ DT1

∆DT1 ∙ DT2∆ST ∙ DT2

Coefficientp-value

Coefficientp-value

Coefficientp-value

Patient characteristics

Age
Duration from onset

−0.09
0.17

0.65
0.39

0.11
0.19

0.60
0.36

−0.06
0.11

0.75
0.42

Assessment results

BBS
MMSE
Attention rating scale
M-FIM
C-FIM

0.27
0.31
−0.40
0.30
0.22

0.18
0.11
0.04*
0.13
0.28

−0.11
−0.12
0.06
−0.05
−0.10

0.57
0.55
0.77
0.81
0.62

0.17
0.28
−0.38
0.26
0.21

0.40
0.15
0.05
0.19
0.29

Abbreviations: ST: 1–5 s from starting evaluation of the single task; DT1: 10–15 s immediately after cognitive task loading; DT2: 20–25 s after
cognitive task loading; ∆ST ∙ DT1: change in ST and DT1 (ST/DT1); Spearman’s rank correlation coefficient; ∆DT1 ∙ DT2: change in DT1 andDT2 (DT1/DT2); ∆ST ∙ DT2: change in ST and DT2 (ST/DT2); BBS: Berg Balance Scale; MMSE: Mini-Mental State Examination; M-FIM:
Motor-Functional Independence Measure; C-FIM: Cognitive- Functional Independence Measure.

Table 3 Comparison of changes in lower limb elevation during each time period, patient characteristics, and assessment results based on walking ability.
Independent walking group
N = 14

Supervised walking group
N = 13p-value

Effect size

Change in lower limb
elevation (cm)∆ST ∙ DT1
∆DT1 ∙ DT2∆ST ∙ DT1

1.01 ± 0.35
0.89 ± 0.11
0.91 ± 0.36

0.69 ± 0.33
1.11 ± 0.81
0.64 ± 0.36

< 0.01*
0.42
0.10

0.26
0.08
0.10

Patient characteristics

Age (years)
Male/Female
Duration from stroke onset (days)
Cerebral infarction/
cerebral hemorrhage
Right hemiplegia/left hemiplegia/
no paralysis

61.9 ± 12.0
10/4
39.3 ± 39.3

69.7 ± 10.5
6/7
49.2 ± 31.1

0.09
0.25
0.21

0.17
0.13
0.09

11/3

8/5

0.41

0.09

7/4/3

5/5/3

0.88

0.08

BBS (points)
Lower limb Br. stage
IV/V/VI/no paralysis
MMSE (points)
Attention rating scale (points)
M-FIM (points)
C-FIM (points)

51.6 ± 4.8

44.3 ± 7.1< 0.01*

0.26

0/8/3/3

3/2/5/3

0.07

0.22

28.9 ± 1.6
1.6 ± 2.6
83.1 ± 7.7
31.8 ± 4.6

26.6 ± 2.9
7.9 ± 8.1
73.3 ± 13.2
29.9 ± 5.9

0.02*< 0.01*
0.06
0.31

0.18
0.27
0.20
0.10

Assessment results

Mann–Whitney U test, Fisher’s exact test
Abbreviations: ST: 1–5 s from starting evaluation of the single task; DT1: 10–15 s immediately after cognitive task loading; DT2: 20–25 s after
cognitive task loading; ∆ST ∙ DT1: change in ST and DT1 (ST/DT1); Spearman’s rank correlation coefficient; ∆DT1 ∙ DT2: change in DT1 andDT2 (DT1/DT2); ∆ST ∙ DT2: change in ST and DT2 (ST/DT2); BBS: Berg Balance Scale; MMSE: Mini-Mental State Examination; M-FIM:
Motor-Functional Independence Measure; C-FIM: Cognitive-Functional Independence Measure.

cognitive task loading, the amount of change was notcorrelated with patient characteristics or assessmentscores, suggesting that the patients’ performances
declined over time due to a combination of factors or
highly individualized problems. Various cognitive tasks
have been used during dual task training in patients after
a stroke, including serial mental arithmetic tasks [15, 16],
auditory Stroop tasks [17], and visual tasks [18]. The
serial mental arithmetic tasks are characterized by thesustained loading of a single cognitive task, while theauditory Stroop tasks and responses to visual stimuli arecharacterized by the repeated loading of new cognitive
tasks. During dual task training, the cognitive task
should be selected based on the reason the patient performs poorly in dual task assessments.
When evaluating a patient’s walking independence,
the risk of falling must be considered. Patients who haveexperienced a stroke have a higher risk of falling thanhealthy elderly people due to physical and cognitive
function difficulties [19]. Falls during hospital stays

Asian J Occup Ther 19: 146−152, 2023

are more likely to occur when a new task is added,
such as having the patient change direction or pick up
objects, compared to when walking straight [20, 21].
In the current study, patients in the supervised-walking
group had a greater decline in their motor performanceafter cognitive task loading than patients in the independent-walking group. Although the usefulness of thedual task method for determining walking independence
in patients who have experienced a stroke has beenreported [3–5], evaluating the performance immediately
after cognitive task loading is useful to determine a patient’s walking independence with greater accuracy. The
findings of our study may be useful for occupational
therapists who assist patients with stroke to safely perform their ADLs. In addition to walking, it is necessary
to examine the relationship between other ADLs, suchas toileting and bathing, and evaluate performance
immediately after the loading of the dual task cognitive
challenge.
This study has some limitations. First, the appropriate sample size was not determined. Second, we did not
eliminate the effects of fatigue on motor performance.
Third, the study was conducted at a single institution,
resulting in a lack of external validity. Fourth, the measurements were not repeated.
Despite these limitations, the results of this study
demonstrate changes in motor performance immediately
after cognitive task loading and after time had passed
during a dual task assessment in patients who experienc­
ed a stroke. More specific methods to evaluate motor performance immediately after cognitive task loading must
be investigated and applied during dual task training.

Conclusion
The differences in the motor performances during
the dual task stepping test immediately and at 10–15 safter cognitive task loading were analyzed in patients
who had experienced a stroke. The motor performancesof patients decreased immediately after cognitive task
loading and 10–15 s after cognitive task loading, andthe decline in performance immediately after the task
was associated with the patients’ attention rating scalescores. In addition, patients in the supervised-walking
group had a greater decline in motor performance
immediately after cognitive task loading than patientsin the independent-walking group. Additional dual task
assessment methods and their application to dual task
training should be investigated in future studies.

Conflicts of interest
There are no conflicts of interest to disclose with

Watabe T et al.

151

regards to this study.

References[1] Park NW, Moscovitch M, Robertson IH. Divided attention impairments after traumatic brain injury. Neuropsychologia. 1999; 37(10): 1119–33.
[2] Takatori K, Okada Y, Shomoto K, Ikuno K, Nagino K,
Tokuhisa K. Effect of a cognitive task during obstacle
crossing on risk of fall in hemiparetic stroke patients.
Physiother Theory Pract. 2012; 28(4): 292–8.
[3] Lundin-Olsson L, Nyberg L, Gustafson Y. “Stop walking
when talking” as a predictor of falls in elderly people.
Lancet. 1997; 349(9052): 617.
[4] Yamada M, Ichihachi M. Predicting the probability offalls in community-dwelling elderly individuals using thetrail-walking test. Environ Health Prev Med. 2010; 15(6):386–91.
[5] Morishita S, Shimaoka H, Hujimoto H. Influence on theexecution time of operation on Timed Up & Go Test in
addition to cognitive task: comparison in fall group andnon–fall group. Jpn J Phys Ther. 2013; 47(1): 259–64.
[6] Harley C, Boyd JE, Cockburn J, Collin C, Haggard P,
Wann JP, et al. Disruption of sitting balance after stroke:
Influence of spoken output. J Neurol Neurosurg Psychiatry. 2006; 77(5): 674–6.
[7] Cockburn J, Haggard P, Cock J, Fordham C. Changing
patterns of cognitive-motor interference (CMI) over time
during recovery from stroke. Clin Rehabil. 2003; 17(2):167–73.
[8] Bourlon C, Lehenaff L, Batifoulier C, Bordier A, Chatenet A, Desailly E, et al. Dual tasking postural control inpatients with right brain damage. Gait Posture. 2014;
39(1): 188–93.
[9] Watabe T, Suzuki H, Nagashima J, Sasaki S, Kawate N.
Usefulness of the dual-task stepping test to determine
the independent toileting ability of patients with stroke
who could perform stepping in a seated position. Asian J
Occup Ther. 2020; 16(1): 55–62.
[10] Watabe T, Suzuki H, Nagashima J, Kabe K, Yoda M.
Judging toileting independence of stroke patients: a reliability study of dual task stepping test. J Japan Occupat
Ther Assoc. 2021; 40(4): 424–30.
[11] Berg KO, Wood-Dauphinee SL, Williams JI, Maki B.
Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992; 83(Suppl 2): S7–11.
[12] Folstein MF, Folstein SE, McHugh PR. “Mini-mental
state.” A practical method for grading the cognitive stateof patients for the clinician. J Psychiatr Res. 1975; 12(3):
189–98.
[13] Ponsford J, Kinsella G. The use of a rating scale ofattentional behaviour. Neuropsychol Rehabil. 1991; 1(4):241–57.
[14] Woollacott M, Shumway-Cook A. Attention and the control of posture and gait: a review of an emerging area of
research. Gait Posture. 2002; 16(1): 1–14.

152

STROKE PATIENTS' MOTOR PERFORMANCE IN THE DUAL TASK[15] Al-Yahya E, Johansen-Berg H, Kischka U, Zarei M,
Cockburn J, Dawes H. Prefrontal cortex activation while
walking under dual-task conditions in stroke: a multimodal imaging study. Neurorehabil Neural Repair. 2016;30(6): 591–9.
[16] Yang L, Lam FM, Huang M, He C, Pang MY. Dual-task
mobility among individuals with chronic stroke: changes
in cognitive-motor interference patterns and relationshipto difficulty level of mobility and cognitive tasks. Eur J
Phys Rehabil Med. 2018; 54(4): 526–35.
[17] Feld JA, Zukowski LA, Howard AG, Giuliani CA,
Altmann LJP, Najafi B, et al. Relationship between dualtask gait speed and walking activity poststroke. Stroke.
2018; 49(5): 1296–8.
[18] Regnaux JP, David D, Daniel O, Smail DB, Combeaud M,
Bussel B. Evidence for cognitive processes involved in
the control of steady state of walking in healthy subjects

and after cerebral damage. Neurorehabil Neural Repair.
2005; 19(2): 125–32.
[19] Jorgensen L, Engstad T, Jacobsen BK. Higher incidenceof fall in long-term stroke survivors than in population
controls: depressive symptoms predict falls after stroke.
Stroke. 2002; 33(2): 542–7.
[20] Watanabe S, Sannomia K, Fujita M, Shibata T, Umetsu
H, Sugimoto M, et al. Preventing patient falls in convalescent rehabilitation ward: concurrent action on activity
improvement and prevention of serious accidents with
an approach from the perspective of clinical ethics. Jpn J
Rehabil Med. 2014; 51(1): 262–6.
[21] Okamoto T, Sugimoto M, Suzuki K, Fukue R, Okita K,
Okada M, et al. Preventive measures against falls in the
Kaifukuki rehabilitation ward. General Rehabilitation.
2011; 39(1): 123–9.

■ORIGINAL ARTICLE

Characteristics of Occupational Therapists’ Advice
in School Consultations:Content Analysis of Advice for Consultation
on Problem Behavior in a Special Needs Schoolfor Intellectual Disability
Shun Harada1, 2, Kiyomi Tateyama3, Shigeki Kurasawa4, Hiroyuki Tanba5,
Kazuyo Nakaoka3, Ippei Kawasaki1, Kuniaki Nagai1
1Department of Occupational Therapy, Kyoto Tachibana University
Graduate School of Comprehensive Rehabilitation, Osaka Prefecture University
3
Graduate School of Rehabilitation Science, Osaka Metropolitan University
4
Department of Occupational Therapy, Fukushima Medical University
5
Department of Occupational Therapy, Kansai University of Welfare Sciences
2

Abstract: Introduction: This study examined consultations by occupational therapists (OTs) regarding problem behaviors in a school for special needs education (Intellectual Disabilities) to clarify (1) the kind of advice provided, (2) the
extent to which advice is put into practice in the classroom, and (3) the characteristics of the advice most frequently put
into practice.
Methodology: In total, reports on 78 school consultations conducted in 2015 and 2016 were examined; advice provided
by the OTs was analyzed using Berelson’s content analysis method. The OTs gave advice on the following: introducing and changing activities, adjusting the environment, ways of interacting to increase desirable behaviors, responding
directly to problem behaviors, methods of talking with and instructing students, methods of visual support, and introducing alternatives to satisfy sensory needs.
Results: Advice on methods of visual support and advice on introducing alternative ways to satisfy sensory needs were
especially linked to practice.
Conclusion: The results also indicated that the kind of advice frequently implemented in practice was that in which “who,what, when, and how” were clearly stated. Furthermore, it was found that discussing classroom feasibility with teachers
based on specific advice improved the efficiency of consultations.
Keywords: special needs education, developmental disability, occupational therapy in school(Asian J Occup Ther 19: 153−160, 2023)

1. Introduction
1.1. Special needs education and occupational therapy
In April 2007, a new system of special needs education was established in Japan through an amendment to
the School Education Act, and efforts have since focused
Received: 23 May 2022, Accepted: 30 March 2023
Corresponding to: Shun Harada, Faculty of Health Sciences, Kyoto
Tachibana University, 34 Yamada-cho Oyake Yamashina-ku Kyoto
607-8175 Japane-mail: harada-s@tachibana-u.ac.jp©2023 Japanese Association of Occupational Therapists

on utilizing personnel inside and outside of schools,
while cooperating with related organizations, to provide
education tailored to individual needs. Due to the declining birthrate and aging population, the total numberof children attending Japanese schools has decreased.
Nevertheless, the number of children receiving a special
needs education continues to increase [1]. In particular,
there has been an increase in the numbers of children
with autism spectrum disorder (ASD) and attention deficit hyperactivity disorder, and occupational therapists(OTs), who specialize in supporting children with these
conditions, are now expected to apply their expertisein school settings. In “The Third Five Year Strategy for

154

CHARACTERISTICS OF OT’S ADVICE IN SPECIAL NEEDS SCHOOL CONSULTATIONS

Occupational Therapy,” the Japan Association of Occupational Therapists identified “occupational therapy forchildren with special needs enrolled in mainstream
schools” as a key focus area [2], and the task of training
OTs to leverage their expertise in special needs education was positioned as a priority goal.
1.2. Occupational therapist consultation in schools
The United States led the way in deploying OTs inschools with its “The Education for All Handicapped
Children Act” law, established in 1975, which included
occupational therapy as one of the services to be provided where necessary in education for children with disabilities [3]. OTs now work in many schools across theUnited States, and the American Occupational Therapy
Association has developed three interventional models
that OTs provide in regular schools (direct intervention,
monitoring, and consultation).
Consultation refers to the process by which
multiple practitioners with different areas of expertise
examine the problems of the support targets and discuss
better ways of providing support. According to Dunn,
OTs working in schools often employ direct therapeuticinterventions, whereas consultation is the least familiar
method employed [4]. However, studies have also
focused on the benefits of consultation. For example,
Kemmis et al., demonstrated that consultations held in
collaboration with teachers were effective for achieving
students’ goals in diverse areas; moreover, in addition totherapeutic goals, OTs play a role in linking educational
goals and support [5]. Davies et al., found that consultations were not only beneficial for the target students
but could also play a role in changing attitudes andbehaviors among consultees (teachers) [6]. However,these studies were based on weekly interventions by
OTs employed at target schools, and the context differs
considerably from the way in which OTs are involved inschools in Japan today.
As a result of various initiatives, the number of OTs
involved in educational settings has increased; however,in Japan, the number of OTs working in schools remains
very low throughout the country [7]. Primarily, OTs
provide support by visiting the school and supporting
target students indirectly through consultations. In
recent years, an interview study of OTs who delivered
interventions for students attending regular classes [8]and questionnaire studies targeting teachers of regularclasses [9, 10] revealed that OTs tend to provide indirect
support by proposing improvements to environmental
settings, tools/equipment, and strategies of support, andthat teachers’ understanding and awareness with respect
to OTs is increasing. OT consultations take place during
one-off visits, which limits the range of opportunities

for providing support. Thus, OTs are required to (1) understand a situation based on the details of the requests
they receive and (2) provide advice that can be put into
practice, within a limited time.
However, questions regarding research on OT consultation for special needs education, such as how often
advice is put into practice and which types of advice are
more likely to be put into practice, remain unanswered.
1.3. Research purpose
When the authors examined the content of consultations by OTs in a school for special needs education(intellectual disabilities), it was found that consultations
on “problem behaviors” were the most common type inboth the elementary and lower secondary divisions of
the school [11]. In this study, we examined problem behavior consultations by OTs in special needs schools (i.e.,schools for people with intellectual disabilities), and weused content analysis to determine (1) the kind of advice
provided, (2) the extent to which the advice was put into
practice in the classroom, and (3) the characteristics ofthe advice most frequently put into practice.

2. Methods
2.1. Research design
This study employed a mixed type design (backward-looking research study based on the report).
2.2. Research field
We examined the reports from 78 teacher-initiatedconsultations conducted by OTs in special needs school
B, City A, in the academic years 2015 and 2016 (including 40 consultations in the elementary divisionand 38 in the lower secondary division of the school).
These reports were prepared in collaboration with theteacher, mainly by special education coordinators, basedon the assessments and advice given by OTs during theschool consultations. Specifically, the special education
coordinators prepared content for teacher consultation,
informed the OT in advance, and accompanied the OT
during the consultation. At the end of the consultation,
the OT and the special education coordinator took time
to review the target student’s assessment and advice,
which was videotaped for sharing and confirmation.
Information regarding the (1) attributes of the target
student, (2) content of the consultation (information recorded before consultation and details added at the timeof the consultation), and (3) advice provided was enteredinto the report before the end of the month in which theconsultation took place, and details of (4) actions implemented and their (5) results were added in the report
before the end of the academic year. This enables third

Asian J Occup Ther 19: 153−160, 2023

parties to get details about the content and the results ofeach consultation.
City A is actively promoting the use of external
specialists to support children with special needs by
dispatching external specialists in response to the needsof elementary and lower secondary schools in the local
area. Since 2010, a team of eight OTs, including theauthors, has been involved in this project as external
specialists, and currently delivers around 20–40 consultations per year; speech therapists and clinical psychologists are also involved in the project. In the academic
year 2015, four OTs provided services at Special School
B, for 70 students in the elementary division and 117
students in the lower secondary level. Although data
were not available on the breakdown of disorders anddisabilities, the Special Needs Education Coordinators
confirmed that ASD was the most common disability
type, present in more than half of all consultations.
Intellectual disabilities (ID) were present in almost allcases, and many students in the elementary division had
moderate or severe/profound ID. In the lower secondary
division, about half of the students had previously attended special needs classes at local elementary schools,
and ID was present in varying degrees. There were four
students per class in the lower elementary grades andfive or six for the middle elementary grades and above;
two teachers were assigned to each class, and dependingon the situation, another teacher would join them whenavailable.
2.3. Data collection
The (1) school year and gender of the target student,(2) content of the teacher-initiated consultation(s), and(3) advice provided by the OT were extracted from thereports. Instances of advice given in response to consultations on problem behaviors were included for analysis,
with reference to previous research in which the content
of consultations was categorized [11]. In addition, the(4) actions implemented, and their (5) results sectionsof each report were examined, and consistency withthe advice provided was verified to determine whether
action was taken based on the advice provided andwhether it was effective. If the results sections demonstrated a negative change or no change in the student, it
was considered “ineffective.” Similarly, if the sections
did not contain anything that corresponded to the actions
implemented sections, it was considered “ineffective.”
At this point, steps were taken to ensure that the opinions of the lead and co-authors (a total of five OTs) werealigned.

Harada S et al.

155

2.4. Data analysis
2.4.1. Content analysis of advice
To identify the kind of advice provided, the content of advice dispensed by OTs was analyzed using
Berelson’s content analysis method. Berelson’s content
analysis technique is used to describe the content ofcommunication in an objective, systematic, and quantitative manner [12], and was considered a suitable
method for systematically organizing the content ofadvice expressed in various ways. The specific worktasks and procedures are as follows:
Organization of target data: If two consultations wereconducted for the same student, any advice that had
already been dispensed was excluded from the analysis.
Creation of recording units: The lead author categorized
the OT advices extracted from the report into recording
units to ensure that each sentence had only one meaning.
Consolidation of similar recording units: The lead authorgrouped identical and similarly worded recording units
as well as assigned labels to these units.
Consolidation into record unit groups: The lead author
organized the recording units into groups of similar recording units and assigned labels based on the similarityof the semantic content.
Categorization: The lead author consolidated similargroups of recording units and assigned category names
based on the similarity of the semantic content.
Review and revision of results: Three authors withexpertise in research, and more than five years of practical experience in the field of special needs education,
confirmed that the names assigned to the groups ofsimilar recording units and categories aptly reflected thesemantic content of the recoding unit labels, and madecorrections where necessary.
Verification of reliability: Two OTs with more than five
years of practical experience in the field of special needs
education classified the recording unit codes into categories and assessed the reliability by calculating Cohen’s
kappa value.
Calculation of the frequency of appearance: The frequencies of recording units, groups of similar recording
units, and categories were calculated.
Calculation of the implementation and effectiveness rateof advice: The rate of implementation of advice wascalculated for each category (instances of implemented
advice/instances of advice × 100). The rate of effectiveness of advice was calculated for each category (instances of effective advice/instances of implemented advice ×100).
2.4.2. C omparison of implemented and non-implemented
adviceTo clarify the characteristics of advice most fre-

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CHARACTERISTICS OF OT’S ADVICE IN SPECIAL NEEDS SCHOOL CONSULTATIONS

quently put into practice, the recording units were assigned to an “implemented” group (advice that was implemented) and a “non-implemented” group (advice thatwas not implemented), and these groups were compared.
Based on the Person-Environment-Occupation model, it
was considered that specificity regarding person (“who”
should carry out the action), environment (“where”
and “when” it should take place), and occupation (the“reason/purpose” as well as the necessary “objects” andprocedures) would influence whether the advice provided was implemented. Next, judgments were made as towhether there were clear and specific references to thefive items of time, person, object/behavior, place, andreason/purpose that could be extracted from the content
of the recording units. For example, “Do not react whenbad behaviors occur (the child throws an object, etc.),
and respond with praise when the child tidies up well,”which was a recording unit for consultations related to“throwing objects,” was classified as [time O], [person
×], [object/behavior O], [place ×], and [reason/purpose
×]. The frequency of [O] classifications for each item
was calculated for the “implemented” and “non-implemented” groups, and the two groups were comparedon each item using the chi-squared test and residual
analysis. IBM SPSS Statistics Ver.24 was used for thestatistical analysis, and statistical significance was set at
P < 0.05.
2.5. Ethical considerations
This study was approved by the research ethics
committee of the primary author’s affiliation. We explained the study in writing and orally to the principalof special needs school B and obtained his consent. The
reports were provided and used in an anonymized form.

3. Results
3.1. Attributes of the OTs, target students, and teachers
Four OTs (not including the author) conducted a
total of 78 consultations. The average years of experience in occupational therapy was 22.5 ± 9.4, and theaverage years of involvement in special needs education was 5.3 ± 2.9. The involved OTs were relatively
experienced, and they had experience in using sensory
integration, applied behavior analysis, the Treatment
and Education of Autistic and Related Communication
Handicapped Children (TEACCH) program, and activity analysis in therapy. Consultations were conducted forabout 77 target students (one student was discussed in
two separate consultations) and involved 88 teachers (44classes). Of these, 41 students and 56 teachers (28 classes) were involved in consultations related to problem
behaviors. Overall, 27 students were boys, nine wereTable 1 Distributions of students and teachers involved in consultations across the year groups.
Student (n = 41)
Boy

Girl

Unknown

Teacher(n = 56)

E1
E2
E3
E4
E5
E6
LS 1
LS 2
LS 3

0
1
1
4
3
2
5
7
4

0
0
0
0
0
0
0
6
3

0
0
0
0
1
0
3
1
0

0
2
2
4
8
4
12
16
8

Total

27

9

5

56

Year

Note. The number of consultations related to problem behavior is indicated.

girls, and there were five students whose gender was
not stated; 12 students were studying in the elementary
division and 29 in the lower secondary division of theschool (Table 1).
3.2. Content analysis of advice
In total, 67 consultations related to problem behaviors were conducted about 41 students. The main content
of the consultations was inappropriate behavior, taking
frustrations out on objects, harming others, control ofemotions, behavior switching, fastidiousness, etc. (inthe order of frequency of occurrence in previous studies[11]). The content analysis of the advice yielded 148
recording units, approximating two items of advice per
consultation. Out of these, six units consisted of praise
or affirmation of the teachers, or instructions to continue
the current support, and were therefore excluded fromthe analysis. From the remaining 142 recording units,
92 recording unit codes, 29 groups of similar recording
units, and 12 categories were extracted. Cohen’s kappa
coefficient was 0.84, indicating adequate agreement
among the coders. Category names, numbers of recording units, frequencies, implementation rates, and examples of advice are shown in Table 2. Implementation
was confirmed for 58 of the 142 recording units (41.1%),
among which 53 were considered effective, corresponding to an effectiveness rate of 91.2%. Categories withhigh rates of implementation were methods of visual
support (frequency 8.5%, implementation rate 58.3%),
introducing alternative ways to satisfy sensory needs(frequency 7.7%, implementation rate 54.5%), and waysof interacting to increase desirable behaviors (frequency
13.4%, implementation rate 52.6%). Categories withlow rates of implementation were proposals to parents(frequency 7.0%, implementation rate 10.0%), adjustingAsian J Occup Ther 19: 153−160, 2023

Harada S et al.

157

Table 2 Content analysis of advice, implementation rates, and examples of advice.
Category

NRU

FR

PAI

Example of advice (excerpts from the advice implemented)

Introducing and changing
activities

21

14.8

38.1

Introduce activities, such as trampoline play during break time

Adjusting the environment

20

14.1

35.0

Keep stimuli that might encourage out-of-seat behavior, such as sound-emitting picture
books, in locked locations

Ways of interacting toincrease desirable behaviors

19

13.4

52.6

Respond with praise when the child tidies up well

Direct responses to problem
behaviors

19

13.4

42.1

Do not react when bad behaviors occur (the child throws an object, etc.)

Methods of talking to andinstructing the child

13

9.2

46.2

Try using a countdown as a way to stimulate action

Methods of visual support

12

8.5

58.3

Use a voice meter visual containing facial expressions because it is difficult for the childto compare voice levels

Introducing alternative ways
to satisfy sensory needs

11

7.7

54.5

Attach patches to clothing to satisfy tactile needs

Proposals to parents

10

7.0

10.0

Suggest that parents bring forward the morning medication time (to prevent forgetting totake medicine)

Others

17

4.2

16.7

It is necessary to understand hyperesthesia and take steps to prevent careless contact, etc.

Total

142

100

41.1

Note. NRU = number of recording units; FR = frequency (%); PAI = percentage of advice implemented. Units with a frequency of less than 5%
are included in the others category.

Fig. 1.

Proportions of Recording Units with Clear and Specific References; ** p < 0.01.

the environment (frequency 14.1%, implementation rate
35.0%), and introducing and changing activities (frequency 14.8%, implementation rate 38.1%).

of recording units with specific references to place
and reason/purpose were higher in the “implemented”
group, the differences were not statistically significant.

3.3. Comparison of implemented and non-implemented
adviceThe proportions of recording units with clear andspecific references to time, person, object/behavior,place, and reason/purpose for the “implemented” and“non-implemented” groups are shown in Fig. 1. The
chi-square test and residual analysis indicated that the
proportions of recording units with specific references
to time, person, and object/behavior were significantly
higher in the “implemented” group. Although the rates

4. Discussion
4.1. Subject attributes and characteristics of the field
Male students outnumbered female students by aratio of 3:1. There were many children with ASD in thetarget field. Given that the male-to-female ratio in ASD
is reported as 4:1 [13], the sample distribution in thisstudy, where the children were attending a school for
special needs education in the ID category, was not significantly skewed; however, it should be noted that the

158

CHARACTERISTICS OF OT’S ADVICE IN SPECIAL NEEDS SCHOOL CONSULTATIONS

distribution of students was somewhat skewed toward
the secondary division of the school.
4.2. Characteristics of frequently implemented advice
The results of the study revealed that OTs proposed
about two items of advice per consultation on problem
behaviors, and approximately 40% of this advice wasput into practice. Though this overall rate of implementation was by no means high, almost all advice
that was implemented was effective to some degree;
therefore, it would seem important to consider how OTs
can offer advice that is more likely to be put into practice. Methods of visual support, the category with thehighest implementation rate, included many instancesof advice that focused on helping students think ahead,through visualization and structuring of schedules. One
supporting framework used by OTs to provide visual
support and structure is the TEACCH program [14].
Visual support and structuring for ASD is also common
in the field of education [15], and in the present study,
the ease by which theoretical underpinnings could beshared between OTs and teachers may explain the highrate of implementation observed in this category. The
category with the second highest implementation rate
was introducing alternative ways to satisfy sensory
needs, which included many items of advice aimed at
reducing problem behaviors rooted in sensory needs bysatisfying these needs in other ways. Previous research
has shown that sensory modulation disorder leads toproblem behaviors [16]. OTs tend to be skilled in interpreting the underlying causes of certain behaviors fromthe perspective of sensory integration [14], and werethus able to give advice in a form that teachers could
easily understand. In addition, since methods of interacting with children, such as tapping on the back, can be
implemented easily, whereas it was far more difficult toimplement advice, such as introducing objects that thechild could chew, it would seem necessary to consider
the ease with which alternative methods can be introduced when giving advice. The category with the third
highest implementation rate was ways of interacting toincrease desirable behaviors, which had a high frequency and often appeared in the advice given by the OTs.
Such advice was intended to increase desirable behavior
and reduce problematic behavior through positive feedback in response to good behavior and has its theoreticalroots in applied behavior analysis. Applied behavior
analysis is a support approach backed by substantial
evidence that aims to identify environmental variables
that influence certain behaviors and induce behavioral
change by controlling aspects of the environment thatact as triggers [17, 18]. This approach has been shown tobe effective in consultations with children who display

behavioral problems and have a high affinity with OT
interventions [19]. Consultations on problem behaviors
often focused on reducing, or increasing, certain behaviors, and the results of the study suggested that advice
grounded in applied behavior analysis is frequently
implemented as a form of top-down support.
4.3. Issues in hard-to-practice advice
Proposals to parents, which was the category withthe lowest implementation rate included a large amountof content related to the adjustment and consideration of
medication. As these changes cannot be accomplishedby the school alone, but also require the involvement of
parents and/or healthcare facilities, it is reasonable toassume that the barriers to implementation were high inthis category. In cases where such proposals are made,it may be necessary to keep written records of specificinteractions with parents and healthcare facilities. Introducing and changing activities and adjusting the environment were key methods of intervention employed by
OTs, and although the frequencies of these categories
were high, the implementation rates were relatively
low at 38.1% and 35.0%, respectively. For introducing
and changing activities, advice, such as “playing withtrampolines or bicycles during break time,” was often
implemented, whereas other break time activities that
required a teacher to accompany the child, such as walking or stretching, were less likely to be put into practice.
Trampolines and bicycles are concrete objects and areoften incorporated into break time activities; therefore,
we can assume that both teachers and children could
easily imagine how they might be used, culminating in ahigher frequency of implementation. This highlights theimportance of ensuring that advice can be implemented through small changes, using existing objects andequipment, and considering what manpower would be
required to implement the change. Regarding advice on
adjusting the environment, which mainly concerned theposition of seats, people, and objects, advice to change
the specific seating positions or tidy away objects thatmight serve as stimuli was frequently implemented,
whereas advice to adjust the allocation of teachers or thesystem itself was less likely to translate into action.
4.4. Key points to be considered while proposing support
strategies
The comparison of advice that was and was not
implemented revealed that the proportion of advice withclear and specific references to time, person, and object/behavior was significantly higher in the implemented
group than in the non-implemented group, and this
proportion was more than two times higher for time andperson. Thus, it is reasonable to conclude that clarifica-

Asian J Occup Ther 19: 153−160, 2023

tion of when an action should be taken, and who shouldtake it, led to discussions on whether the advice could
be implemented in the school setting and was effective
in increasing the implementation rate. In the Occupation
Therapy Manuals issued by the Japanese Association of
Occupational Therapists, it is recommended that OTs
focus on “5W1H” when proposing specific support
strategies [20], and the results of the present study add
weight to this idea. The results of the study indicatedthat, even in the “implemented” group, only about 40%–
50% of advice included clear references to time andperson, leaving room for further improvement in specificity, and the effectiveness of consultations could be
improved by endeavoring to give advice in which “who,what, when, and how” are clearly and specifically stated.
4.5. Limitations of this study
The results of this study are limited to consultations
initiated in response to problematic behavior at a single
special needs education school. Further, the four people
involved in the consultation were relatively experienced
OTs. It is expected that the content of the consultation
will be influenced by their experience as OTs. Therefore,a more comprehensive survey is needed to generalize
the results of the present study. Moreover, as the analysis
focused on the content of reports, the method is limited
as a means of examining whether teachers understood
the advice given by OTs and whether each individual
item of advice was implemented. However, these reports
were compiled based not only on records created by
OTs after the consultations, but also on video-based
communications. Thus, it can be considered that thereports were written in detail and were largely free fromomissions, and that the content of the consultations waseasy to understand. Accordingly, the findings can be
regarded as a valid representation of the analysis resultsof how the OT consultations were understood and how
the advice was implemented, by the consultee-teachers.

5. Conclusion
OTs provide a wide range of advice in school consultations initiated in response to problem behaviors.
Advice on methods of visual support and advice on introducing alternative ways to satisfy sensory needs were
often put into practice. While advice on introducing
and changing activities and adjusting the environment
was frequently dispensed, the results suggested that
introduction of new activities or activities that required
manpower or adjustments in the deployment of the personnel at school were less likely to be implemented. The
findings show that when providing this kind of advice,
it is important to ensure that advice can be implemented

Harada S et al.

159

through small changes using existing resources andconsidering manpower requirements. The results also
indicated that the kind of advice that was frequently put
into practice was advice in which “who, what, when,and how” were clearly stated, and that discussing classroom feasibility with teachers based on specific advice
can improve the efficiency of consultations.

References[1] Ministry of Education, Culture, Sports, Science andTechnology [online]. The situation of special needs education in Japan [cited 2022 February 2]. Available from:https://www.mext.go.jp/kaigisiryo/2019/09/__icsFiles/
afieldfile/2019/09/24/1421554_3_1.pdf.
[2] Japanese Association of Occupational Therapists [online].
The third five-year strategy for occupational therapy[cited 2022 February 2]. Available from: https://www.jaot.
or.jp/files/news/wp-content/uploads/2019/01/3rd-5yearsstrategy.pdf.
[3] Colman W. The Evolution of occupational therapy in the
public schools: the laws mandating practice. Am J Occup
Ther. 1988; 42(11): 701–5.
[4] Dunn W. Models of occupational therapy service provision in the school system. Am J Occup Ther. 1988;
42(11): 718–23.
[5] Kemmis BL, Dunn W. Collaborative consultation: theefficacy of remedial and compensatory interventions inschool contexts. Am J Occup Ther. 1996; 50(9): 709–17.
[6] Davies PL, Gavin WJ. Comparison of individual andgroup/consultation treatment methods for preschool children with developmental delays. Am J Occup Ther. 1994;
48(2): 155–61.
[7] Japanese Association of Occupational Therapists, Healthand Welfare Department [online]. Report on the proposedmodel for the participation of occupational therapists
in special support education (in Japanese) [cited 2022
February 2]. Available from: https://www.jaot.or.jp/files/
page/wp-content/uploads/2010/08/tokubetsushien-report.
pdf.
[8] Hikino R, Tutida R. Occupational therapy for special
education: regular classrooms in elementary schools (inJapanese). Jpn Occup Ther Res (sagyouryouhou). 2010;29(5): 577–86.
[9] Nishioka A, Karashima C, Igarashi G. Outcomes of school
visits by occupational therapists in special needs education: how do teachers understand occupational therapists?
(in Japanese). Jpn Occup Ther Res (sagyouryouhou).
2015; 34(3): 257–68.
[10] Koyama C, Takagi M, Yoshioka K. Collaboration between occupational therapists and school teachers in special needs schools: questionnaire survey of school teachers (in Japanese). Humanity and Science Journal of theFaculty of Health and Welfare. Prefectural University ofHiroshima (ningentokagaku kenrithuhiroshimadaigaku­
hokenhukusigakubushi). 2018; 18(1): 79–88.

160

CHARACTERISTICS OF OT’S ADVICE IN SPECIAL NEEDS SCHOOL CONSULTATIONS[11] Harada S, Tateyama K, Kurasawa S, Tanba H, Nakaoka K.
Tendency of consultation in the special needs education
school (intellectual disability section) by occupational
therapists and comparison between the elementary andjunior high school (in Japanese). Jpn J Occup Ther Pediatr (nihonhattatukeisagyouryouhougakkaishi). 2021; 8(1):23–31.
[12] Funashima N. Qualitative Research Methodologies That
Have Been Used in Nursing Research. 2nd ed (in Japanese). Tokyo: Igaku-Shoin; 2007.
[13] Takahashi S, Ono Y. Diagnostic and Statistical Manual of
Mental Disorders DSM-5. 5th ed (in Japanese). Tokyo:
Igaku-Shoin; 2014.
[14] Case-Smith J, Arbesman M. Evidence-based review ofinterventions for autism used in or of relevance to occupational therapy. Am J Occup Ther. 2008; 62(4): 416–29.
[15] Ministry of Education, Culture, Sports, Science and Technology [online]. Educational support materials - School­
ing procedures for children with disabilities and theenhancement of consistent support from the early stage[cited 2022 February 2]. Available from: https://www.
mext.go.jp/component/a_menu/education/micro_detail/__icsFiles/afieldfile/2014/06/13/1340247_13.pdf.
[16] Shelley O’D, Jean D, Deborah K, Theresa N, Geraldine D.
Sensory processing, problem behavior, adaptive behavior,and cognition in preschool children with autism spectrum
disorders. Am J Occup Ther. 2012; 66(5): 586–94.
[17] Dawson G, Rogers S, Munson J, Smith M, Winter J,
Greenson J, et al. Randomized, controlled trial of an intervention for toddlers with autism: the early start denvermodel. Pediatrics. 2010; 125(1): e17–e23.
[18] Kasari C, Lawton K, Shih W, Barker TV, Landa R, Lord C,
et al. Caregiver-mediated intervention for low-resourced
preschoolers with autism: an RCT. Pediatrics. 2014;
134(1): e72–9.
[19] Kurasawa S, Tateyama K, Shiozu H, Nakaoka K, Ohtoshi
T. School consultations by an occupational therapist for
astudent with behavioral problems (in Japanese). Jpn
Occup Ther Res (sagyouryouhou). 2021; 40(3): 359–69.
[20] Japanese Association of Occupational Therapists. Occupational Therapy Manual 65; Special Needs Education
and Occupational Therapy (in Japanese). Tokyo: Chuou­
houki-Shuppan; 2018.

■ORIGINAL ARTICLE

Occupational Balance and Quality of Life
Among Hospital-Based Occupational Therapists
During the COVID-19 Pandemic
Christopher Jeffrey Bernaldo Streegan1, Ivan Neil Benitez Gomez2
12

Department of Rehabilitation Medicine, Philippine General Hospital
Department of Occupational Therapy, College of Rehabilitation Sciences, University of Santo Tomas

Abstract: The Coronavirus disease (COVID-19) pandemic has affected the practice of hospital-based occupational
therapists (OTs) and this may have influenced their occupational balance (OB) and quality of life (QOL). There is limit­
ed literature exploring OTs’ OB, QOL, and the relationship between these. This study aimed to measure OB and QOL
and their relationship among hospital-based OTs during the pandemic. Using a descriptive-correlational and crosssectional design, n = 64 participants answered electronic versions of the Occupational Balance Questionnaire-11(OBQ11) and World Health Organization Quality of Life-BREF (WHOQOL-BREF). Friedman test with a post-hoc
pairwise Wilcoxon signed-rank test was used to compare QOL domain scores within-group. Independent t-test andMann-Whitney Test were used to compare the subgroups’ OB and QOL, respectively. 54.69% were classified to have
low OB. Mean overall QOL score was 3.59 ± 0.68. QoL domain scores were relatively moderate: 66.67 ± 11.41 (physical); 55.58 ± 15.60 (psychological); 64.48 ± 21.81 (social); and 62.42 ± 14.74 (environmental). OB was significantly
correlated with overall QOL ( p < 0.001), physical health domain ( p < 0.001), psychological domain ( p < 0.001), social
domain ( p = 0.022), and environmental domains ( p = 0.005). Low OB and moderate QoL, regardless of sex, work
schedule, and hospital funding type, validates the need for improved personal strategies and enhanced organizational
support. The positive correlation between OB and QoL contributes to occupational science providing extant evidence
on how occupations support health and well-being. Our findings have implications for developing programs that support hospital-based OTs during the pandemic period and beyond.
Keywords: occupational balance, quality of life, occupational therapists, hospital, COVID-19(Asian J Occup Ther 19: 161−168, 2023)

Introduction
The Coronavirus disease (COVID-19) pandemic
has affected the practice of different health industry
professionals and occupational therapists (OTs) are no
exception [1]. Among the different practice settings,
OTs working in hospitals were found to be especiallyvulnerable to the pandemic’s direct effects due to thehigher risk of exposure to COVID-19 and altered workroutines [2–4]. OTs faced work disruption and adoption
Received: 21 September 2021, Accepted: 14 April 2023
Corresponding to: Christopher Jeffrey Bernaldo Streegan, Departmentof Rehabilitation Medicine, Philippine General Hospital, Taft Avenue,
Manila, Philippines
e-mail: cbstreegan@up.edu.ph©2023 Japanese Association of Occupational Therapistsof new roles related to service delivery for both COVID
and non-COVID clients [3–5]. This shift in practice asa response to the pandemic has been reported to haveaffected the lives and well-being of OTs [6–9].
Occupational balance (OB) is defined as the subjective life experience of individuals in having the rightamount of occupations and variation between occupations that they want to, need to, or are expected to do[10, 11]. This has been measured in several populations
including OTs. Prior to the pandemic, there has been evidence that hospital employees and OTs have difficulty
achieving and maintaining OB [12, 13]. This may leadto OTs to consider new employment, or worse, leave
the profession altogether [13, 14]. Thus, ample OB may
contribute to the well-being of OTs.
Quality of life (QOL) refers to the “individuals’
perceptions of their position in life in the context of

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OCCUPATIONAL BALANCE AND QUALITY OF LIFE AMONG OCCUPATIONAL THERAPISTS

the culture and value systems in which they live andconcerning their goals, expectations, standards andconcerns” [15]. QOL entails looking beyond well-being
to include other domains of an individual’s life (i.e.,
physical health, psychological state, social relationships,
and environment) [16]. Prior to the pandemic, it has
been reported that OTs have adequate to good professional QOL, globally [17]. However, there is a dearth ofstudies on the current QOL among OTs during the timeof the pandemic, at the time this study was conducted.
Both OB and QOL can support an individual’s
health, well-being, and engagement in occupations [18,19]. Conceptually, they may be related to such functions.
Previous studies have been limited to studying theseconcepts in isolation. To the best of our knowledge,
the relationship between OB and QOL among hospitalbased OTs is at best, yet to be explored. Nevertheless,there is convincing evidence that OB and QOL are relat­
ed among other populations (i.e., nursing home residents,
older adults, adults, and adults with chronic diseases)[19–22].
Inquiry on the OB and QOL, and consequently
their relationship, among OTs are limited. Pandemic
effects may likely influence these outcomes among OTs,
especially those working in hospitals. Thus, this study
aimed to describe the OB, QOL, and their relationshipamong hospital-based OTs at the time of the COVID-19
pandemic.

Methodology
DesignThis study used a descriptive cross-sectional correlational research design.
Ethical Considerations
Ethical approval from the University of Santo
Tomas College of Nursing Ethics Review Committee
was initially sought. Participants’ informed consent wascollected electronically.
Participants and sampling
We used a purposive homogeneous conveniencesampling design to recruit n = 64 licensed Filipino
occupational therapists. Recruitment was accomplishedthrough social media, contact person coordination, andemail dissemination through the Philippine Academy ofOccupational Therapy, Inc. (PAOT, Inc.), the national
professional organization for occupational therapists.
Inclusion criteria for the participants were the following:(1) license to practice as an occupational therapist under
the Professional Regulation Commission, (2) performance of functions related to occupational therapy, and(3) employment in hospitals located in Metro Manila.
Based on the 2017 workforce survey by PAOT,
Inc., there may be a total of 121 members, which fit
the inclusion criteria [23]. The target sample size of thestudy was a minimum of 50% (n = 60) of the eligible
population to ensure adequate representation of thetarget population [24].
Research instruments
We used several instruments in this study, which
include a participant demographic questionnaire, Occupational Balance Questionnaire-11 (OBQ11), and World
Health Organization Quality of Life-BREF (WHOQOLBREF). The authors sought and were given permission
from the original authors to use the instruments prior todata collection.
OB was measured using the OBQ11, a tool thatmeasures different aspects of OB [25]. It is an 11-item
questionnaire with each item being rated from fourordered response categories (0 = strongly disagree, 1 =disagree, 2 = agree, 3 = strongly agree); a higher scoreindicates a higher OB. For the purposes of this research,the median score was used as the cut-off for high andlow OB [26, 27]. OBQ11 was found to have good reliability by a previous study [25]. Participants were asked
to accomplish an electronic form version of the OBQ11
and asked to think of their OB in the past two weeks.
The electronic version of the OBQ11 used in this study
had good internal consistency (α = 0.87).
QOL was measured using the WHOQOL-BREF, aculturally sensitive 26-item questionnaire that contains
two items (on QOL and health satisfaction) and 24 items
on each of the domains of QOL (i.e., physical health,psychological, social relationships, and environment)[15]. Each item is rated on a five-point scale (1 = very
dissatisfied, 2 = dissatisfied, 3 = neither satisfied nor
dissatisfied, 4 = satisfied, and 5 = very satisfied). Fourdomain scores are derived, with each score representing
the individual’s perceived QOL in each domain. Higherscores imply higher perceived QOL. The WHOQOLBREF was found to have good to excellent reliability
and validity [28]. Participants were asked to accomplish
an electronic form version of the WHOQOL-BREF and
asked to think of their QOL in the past two weeks. The
electronic version of the WHOQOL-BREF used in thisstudy had good internal consistency (α = 0.89).
Data collection
We developed comparable electronic versions of
the OBQ11 and WHOQOL-BREF using Google Forms.
Along with the consent form and participant demographic questionnaires, a survey link was sent to theparticipants. They were given one week to accomplish

Asian J Occup Ther 19: 161−168, 2023

Streegan CJB et al.

the survey, with reminders sent by the researchers forfollow-up. Participants were instructed to answer thesurvey within the past two weeks as context. The electronic survey was conducted within Metro Manila inMarch 2021, where national and local quarantine protocols were currently enforced.
Data analysis
Descriptive statistics (i.e., measures of central
tendency, standard deviation) were used to summarize
participant characteristic variables and scores on the
OBQ11 and WHOQOL-BREF. To compare QOL domainscores within-group, we used the Friedman test with apost-hoc pairwise Wilcoxon signed-rank test. In comparing subgroups, we used measures of differences (i.e.,
Independent t-test, Mann-Whitney Test). Correlation wasassessed using Spearman’s and Pearson’s correlation
coefficients. Quantitative data were analyzed statisticallyusing SPSS 23.0. The significance level was set at p <0.05.

Table 1 Participant Demographics
Variable
Age
21–25
26–30
31–35
46–40
41–45
Sex
FemaleMaleType of work done*
ClinicianManager
Researcher
Administrator
Others**Work Schedule
Full-timePart-timen

Percentage

18
35
6
3
2

28.13%
54.69%
9.38%
4.69%
3.13%

44
20

68.75%
31.35%

64
5
3
1
4

100%
7.81%
4.69%
1.56%
6.25%

45
19

70.31%
29.69%* OTs may perform more than one role in the hospital setting.
** Other identified roles include “clinical supervisor” and “educator.”

163

Results
We analyzed data from n = 64 hospital-based OTs
whose mean age was 28.05 ± 4.63 yr. There were more
females (68.75%) among the sampled participants whoare employed across 31 hospitals in Metro Manila, witha majority (60.94%) coming from government-owned
institutions. Table 1 summarizes other participant characteristics.
Occupational balance among hospital-based OTs
The range of the total OBQ11 score among theparticipants was between 6–32. The mean score is 18.86± 5.14 and the median score is 19. Given this cut-off
median score, 54.69% (n = 35) were classified to have
low OB. There was a significant difference in OB between the high OB group (M = 23.34, SD = 2.94) andthe low OB group (M = 15.14, SD = 3.22); t(62) = 10.55,
p ≤ 0.001). Table 2 shows the summary of the OBQ11
scores.
Quality of life among hospital-based OTs
The mean of the overall QOL scores was 3.59 ±0.68. The physical health domain (66.67 ± 11.41) had
the highest score, while the psychological domain (55.58± 15.60) was the lowest. The WHOQOL-BREF domainscores are summarized in Table 3. Given the sample size
and normality of our data, we computed for dependent
samples (n = 64) multivariate differences (QoL domains).
The results of the Friedman test indicate significant QoL
multivariate domain differences (χ2, p < 0.000). Followup Wilcoxon signed rank tests for paired univariatecomparisons are further summarized on Table 4.

Table 2 Descriptive Statistics of OBQ11 Scoresn
Mean Score
SD
95% CITotal

Low OBHigh OB

64
18.86
5.14
17.5–20.14

35
15.14
3.22
14.04–16.25

29
23.34
2.94
22.23–24.46

Table 3 Descriptive Statistics of QOL Domain Scores

Physical Health Domain
Psychological Domain
Social Relationships Domain
Environmental Domain

Mean Score

Standard Deviation

Mean Score (T-100)*

Standard Deviation (T-100)

95% CI

3.67
3.23
3.57
3.43

0.47
0.61
0.86
0.58

66.67
55.58
64.48
62.42

11.41
15.60
21.81
14.74

63.82–69.82
51.68–59.47
59.04–69.93
58.74–66.10* Mean score on a transformed-100 scale.

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OCCUPATIONAL BALANCE AND QUALITY OF LIFE AMONG OCCUPATIONAL THERAPISTS

Table 4 Friedman Test and Wilcoxon Signed-Rank Test of QoL Domains
Wilcoxon signed-rank test

Friedman Test
χ2
QOL
(D1–D4)*sig

29.775 < 0.000

D1-D2
Z

sig

−5.615 < 0.000

D1-D3

D1-D4

Z

Z

sig

−0.740 0.459

D2-D3

sig

Z

−2.294 0.022

sig−3.808 < 0.000

D2-D4

D3-D4

Z

Z

sig

−3.082 0.002

sig−0.924 0.355*Q OL refers to the multivariate Quality of Life dimensions (Dimensions 1–4) on the WHOQOL-Bref;
D1 = Physical dimension, D2 = Psychological dimension, D3 = Social dimension, D4 = Environmental dimension.

Table 5 OB and QOL Comparison Among Subgroups

Sex
Male (n = 20)
Female (n = 44)
Work Schedule
Part-time (n = 19)
Full-time (n = 45)
Hospital TypePrivate (n = 25)
Government-owned (n = 39)

Mean OB Score (SD)OB Sig.*Median QOL ScoreU

QOL Sig.*

18.65 (5.09)
18.95 (5.21)

0.83

4.00
4.00

412.000.64

19.16 (4.21)
18.73 (5.52)

0.77

4.00
4.00

403.000.68

18.48 (4.87)
19.10 (5.35)

0.24

4.00
4.00

456.000.62* All significance tests are 2-tailed.

Comparison of occupational balance and quality of life
among hospital-based OT Subgroups
We conducted several measurements of subgroup(i.e., sex, work schedule, type of hospital) differences for
OB and QOL. No significant statistical differences wereobserved. Table 5 summarizes the subgroup analysis.
Correlation between occupational balance and qualityof life among hospital-based OTs
This study discovered several significant correlations between OB and QOL among hospital-based
OTs (Table 6). There was significant moderate positive
correlation between OB and overall QOL, (r(62) = 0.56,
p < 0.001). We also found significant moderate to good
positive correlation between OB and the physical health
QOL domain, (r(62) = 0.66, p < 0.001); and OB and thepsychological QOL domain (r(62) = 0.61, p < 0.001).
A significant fair positive correlation between OB andthe social relationships QOL domain (r(62) = 0.29, p =0.022); OB and the environmental domain (r(62) = 0.35,
p = 0.005) was found as well.

Discussion
This study describes the OB, QOL, and their relationship among hospital-based OTs during the time of
the COVID-19 pandemic. There was low OB among
most of the sampled participants. Stability of OB and

Table 6 Correlations Between OB and QOL
Correlations

Correlation Coefficient (r)OB and overall QOL*
OB and Physical Health Domain*
OB and Psychological Domain*
OB and Social Relationships Domain**
OB and Environmental Domain**

0.56
0.66
0.61
0.29
0.35

* p < 0.001** p < 0.05

QOL was observed across subgroups. OB was significantly correlated with overall and domain-based QOL.
Among the sampled hospital-based OTs, 54.69%
exhibited low OB. This experience has varied resultscompared to research done prior to the pandemic.
The participants’ median score was 19 while Swedish
OTs had a median score of 13 (Lexen et al., 2020) andSwedish women had 12 (Magnussen et al., 2020). The
participants’ mean score of 18.86 ± 5.14 also had
comparable results to mothers of children with cerebral
palsy who averaged 16.88 ± 5.07 on the OBQ11 (Günal
et al., 2021) and adults with arthritis who averaged
15.89 ± 7.50. In other studies, OTs reported having difficulty managing their OB [29] and achieving OB [12].
Lack of time to accomplish their tasks in the workplace
was reported [30, 31]. These already existing working

Asian J Occup Ther 19: 161−168, 2023

conditions may have been exacerbated by pandemicrelated changes. In the Philippines, the implementationof national and local quarantine protocols has directly
affected the delivery of OT services. During the lockdown, telehealth emerged as a popular mode of service
delivery to reduce physical contact between therapists
and patients. This is despite the multiple hindrances to
its implementation in the country, such as slow internet
speed, limited acceptance, and lack of e-health policies[8]. Public transportation has also been limited by thenational government [32] which possibly affected thedaily schedule of OTs. Compliance with the proper
donning and doffing procedures of personal protective
equipment and the appropriate disinfection procedures[33] enforced by the national government may havecontributed to increased workload for OTs, especiallythose in understaffed hospitals. These findings resonate
with a survey wherein it was found that 41% of OTs
underwent work disruption and 25% adopted new roles
during the pandemic [3]. Given these changes and consequences, OTs may need to employ the same strategies
they teach their clients to achieve OB. This is an areaof research and clinical practice that will be interesting
to explore later. Nevertheless, adequate organizational
support towards hospital-based OTs is needed for themto transition and engage in new practice patterns [14].
On average, this study found that hospital-based
OTs view their overall QOL as moderate during the
pandemic. Previous research focused on the professional
QOL of OTs rather than their overall well-being [34].
While professional QOL may provide information on
the work-related well-being of OTs, it is a reductionist
point of view that fails to consider the variety of occupations individuals engage in. However, data is available
on other healthcare workers. Hospital staff in the same
subregion of Asia as our participants reported significantly higher mean scores across all domains prior to
the pandemic [35]. During the pandemic, healthcare
providers reported a similar overall QOL score as ourparticipants [36]. Filipino OTs are surmised to haveexperienced lower QOL given the ongoing public healthcrisis in the Philippines [37] and their increasing mental
health issues and worsened financial state [9].
This research provides a unique perspective on
how QOL may be viewed for OTs. The proximity of thescore to the midline at the time of the pandemic may indicate that the QOL among hospital-based OTs is at thecusp of marginal indication for support. This will needclinical and research attention later. Nonetheless, future
research on QOL among OTs may need to ground itself
on occupational science to inform its development andmethodologies.
Among the QOL domains, psychological QOL

Streegan CJB et al.

165

scored lowest among hospital-based OTs. This is supported by recent research which found increasing mental
health concerns among Filipino OTs at the time of the
COVID-19 pandemic [9]. The uncertainty of the current
contexts may likely cause psychological concerns [7].
Qualitative inquiry to support the findings in this study
may be needed in the future to further extrapolate information that can be used to develop programs aimed at
improving QOL among hospital-based OTs.
The physical health QOL domain had the highest
score. While previous authors have suggested that OTs
are prone to work-related pain [38] and have an increas­
ed risk of musculoskeletal disorders [39], the current
telehealth set-up adopted across hospitals may havelessened the commonly experienced physical fatigue
and risk of injury. Hospital-based OTs reduced theirtime of face-to-face patient care as shorter contact hours
have been recommended to reduce the risk of infection[40]. Nevertheless, this finding should not be taken in
isolation. QOL outcomes encompass a holistic approachand thus need to be interpreted along with the other
QOL domains.
The results from this present study showed a significant correlation between OB and overall QOL. Hospitalbased OTs with better OB also showed higher QOL.
This is further supported by evidence found on thecorrelation between OB and the different QOL domains.
To the best of our knowledge, no current studies havefocused on similar outcomes among hospital-based OTs.
The study’s findings are supported by literature despite differences in their population, methodologies, andcontext. A quantitative study among older adults foundthat OB was an independent variable that had an indirect
effect on QOL [21], while a mixed methods research on
individuals with chronic disease found a relationship between spirituality, health-related QoL, and OB [22]. OB
was also found to influence QOL, participation, health,and stress [19]. Although Langenberg [41] found no statistically significant relationship between QoL and OB,
their study presented a different interpretation of OB as
it defined OB based on time instead of perceived experience. This definition has been criticized as it overlooks
nuances in personal interpretation [42, 43]. Although
there was reported to be no significant difference in the
OB and QOL of different hospital-based OT subgroups,
the findings of the current study may be attributed tothe protocols set by the national government and institutions. This includes quarantine protocols, lockdowns,
use of personal protective equipment, and new service
delivery models.
The results of the study could be used as evidence
to support that achieving the right amount and variation
between occupations may ultimately lead to improved

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OCCUPATIONAL BALANCE AND QUALITY OF LIFE AMONG OCCUPATIONAL THERAPISTS

quality of life despite the imposed challenges, such as
the pandemic. The results affirm that OB reflects thecomplex and multidimensional nature of individuals.
This has implications for informing and guiding thedevelopment of strategies to ensure OB, during the
COVID-19 restrictions and even later in a post-pandemic
work scenario. Future research is recommended to test
this among complex interventions that address OB andQOL and its domains among OT.
Limitations and recommendations
There are several limitations in the conduct of
this study that need to be addressed in future research.
Our findings are limited to Filipino OTs practicing in
hospitals. There will be a need to determine the generalizability of our results to other practice areas in othercultures and contexts. The pandemic restricted us to use
electronic versions of the instruments. While this study
established good internal consistency of the electronic
versions, future research may be needed to validate thisadministration mode of the OBQ11 and WHOQOLBREF. The research was done during the pandemic
hence, results are not completely comparable to studies
done prior to the pandemic. Lastly, while we are able
to describe the OB and QOL of hospital-based OTs,
we recommended including qualitative information in
the future to further understand the depth, breadth, andmeaning of these quantitative data.
Conclusion and significance to the profession
During the period of the COVID-19 pandemic, most
hospital-based OTs had lower OB. On average, theiroverall QOL was moderate. The physical health QOL
domain ranked highest, while the psychological QOL
domain was last. This study provides supporting evidence on the relationship between OB and QOL. Our
results provide supporting evidence that the ability toorganize and participate in valued and meaningful occupations can support an individual’s overall QOL and its
domains. This has implications for developing strategies
and programs that support hospital-based OTs during theperiod of the pandemic and beyond.

Acknowledgments
The authors would like to thank the participants
who took the time to answer the survey.

Disclosure statement
The authors report no conflict of interest.

Funding
This research was not funded.

References[1] Hoel V, von Zweck C, Ledgerd R, World Federation of
Occupational Therapists. The impact of Covid-19 foroccupational therapy: Findings and recommendations ofa global survey. World Federation of Occup Ther Bull.
2021; 1–8.
[2] Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo CG,
Ma W, et al. Risk of COVID-19 among front-line healthcare workers and the general community: a prospective
cohort study. Lancet Public Health. 2020; 5(9): e475–83.
[3] Robinson, M, Esbrook, C, Jordan, K, et al. Occupational
therapy in hospital & inpatient care: responding to a pandemic. Paper presented at: COVID 19 & OT: an online
CE series. [Lecture] American Occupational Therapy
Association. 2020.
[4] Ran L, Chen X, Wang Y, Wu W, Zhang L, Tan X. Risk
factors of healthcare workers with coronavirus disease
2019: a retrospective cohort study in a designated hospital of Wuhan in China. Clin Infect Dis. 2020; 71(16):2218–21.
[5] American Occupational Therapy Association, Inc [online].
United States of America: The role of occupational therapy: Providing care in a pandemic [cited 2020 October29]. Available from: https://www.aota.org/AdvocacyPolicy/Federal-Reg-Affairs/News/2020/OT-Pandemic.
aspx.
[6] Shanafelt T, Ripp J, Trockel M. Understanding andaddressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. 2020;
323(21): 2133–4.
[7] Sy MP, Pineda RC, Yao DP, Guevara CA, Delos Reyes
RC, Castro IM. Shared voices of Filipino occupational
therapists during the COVID-19 pandemic: reflections
from an online forum. World Federation of Occup Ther
Bull. 2020; 76(1): 60–4.
[8] Leochico CF, Espiritu AI, Ignacio SD, Mojica JA.
Challenges to the emergence of telerehabilitation in adeveloping country: a systematic review. Front Neurol.
2020 Sep 8; 11: 1007.
[9] Delos Reyes, RC, Tolentino, KC, Sy, W. Impact of
COVID-19 pandemic in Filipino occupational therapy
practice across regions. Philipp J Allied Health Sci. 2021;
4(2): 22–8.
[10] Backman C. Measuring occupational performance:
supporting best practice in occupational therapy. In: Law,
M, Baum, C, Dunn, W, editors. Occupational balance:
Measuring time use and satisfaction across occupational
performance areas. New Jersey: Slack Incorporated;
2001; 203–13.
[11] Wagman P, Håkansson C, Björklund A. Occupational balance as used in occupational therapy: a concept analysis.

Asian J Occup Ther 19: 161−168, 2023

Scand J Occup Ther. 2011; 19(4): 322–7.
[12] Wagman, P, Lindmark, U, Rolander, B, et al. Occupational balance in health professionals in Sweden. Scand J
Occup Ther. 2016; 24(1): 18–23.
[13] Lexén A, Kåhlin I, Erlandsson LK, et al. Occupational
health among Swedish occupational therapists: a crosssectional study. Int J Environ Res Public Health. 2020;17(10): 3379.
[14] Clouston TJ. Whose occupational balance is it anyway?
The challenge of neoliberal capitalism and work–life
imbalance. Br J Occup Ther. 2014; 77(10): 507–15.
[15] WHOQOL Group. Development of the World Health Organization WHOQOL-BREF quality of life assessment.
Psychol Med. 1998; 28(3): 551–8.
[16] WHOQOL Group. Quality of life assessment: International perspectives. In: Orley, J, Kuyken, W, editors. The
development of the World Health Organization qualityof life assessment instrument (the WHOQOL). Berlin:
Springer; 1994; 41–57.
[17] Chen CC. Professional quality of life among occupational
therapy practitioners: an exploratory study of compassion
fatigue. Occup Ther Ment Health. 2020; 36(2): 162–75.
[18] Pizzi MA, Richards LG. Promoting health, well-being,and quality of life in occupational therapy: A commitment
to a paradigm shift for the next 100 years. Am J Occup
Ther. 2017; 71(4): 7104170010p1–7104170010p5.
[19] Park S, Park JH. Causal effects of occupational balance(OB) on participation, health, quality of life, and stresswith people in adulthood. Am J Occup Ther. 2019; 73(4_Supplement_1): 7311515290p1-7311515290p1.
[20] Aas MH, Austad VM, Lindstad MØ, et al. Occupationalbalance and quality of life in nursing home residents.
Phys Occup Ther Geriatr. 2020; 38(3): 302–14.
[21] Park S, Park JH, Lee HJ, et al. Effects of occupationalbalance (OB) on health, quality of life and related variables in community-dwelling older adults: structural
equation modeling. PLoS One. 2021; 16(2): 1–15.
[22] Parker Y. The relationship between spirituality, healthrelated quality of life and occupational balance among
adults with chronic diseases [master’s thesis]. South
Africa: University of the Western Cape; 2019.
[23] Carandang KA, Delos Reyes RC. Workforce survey
2017: working conditions and salary structure of occupational therapists working in the Philippines survey [Internet]. Philippines: Philippine Academy of Occupational
Therapists, Inc.; 2018. Available from: http://paot.org.ph/
pdf/other/Workforce%20Survey%202017%20Technical%20Report.pdf.
[24] National Heart, Lung and Blood Institute. Quality assessment tool for observational cohort and cross-sectional
studies [Internet]. USA: National Heart, Lung and Blood
Institute; 2018. Available from: https://www.nhlbi.nih.
gov/health-topics/study-quality-assessment-tools.
[25] Håkansson C, Wagman P, Hagell P. Construct validity ofa revised version of the occupational balance questionnaire. Scand J Occup Ther. 2019; 27(6): 441–9.
[26] Kassberg AC, Nyman A, Larsson Lund M. Perceived oc-

Streegan CJB et al.

167

cupational balance in people with stroke. Disabil Rehabil.
2019; 43(4): 553–8.
[27] Borgh M, Eek F, Wagman P, et al. Organisational factors
and occupational balance in working parents in Sweden.
Scand J Public Health. 2017; 46(3): 409–16.
[28] Skevington SM, Lotfy M, O’Connell KA. The World
Health Organization’s WHOQOL-BREF quality of life
assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group.
Quality Life Res. 2004; 13(2): 299–310.
[29] Lexén A, Kåhlin I, Erlandsson LK, Håkansson C. Occupational health among Swedish occupational therapists:a cross-sectional study. Int J Environ Res Public Health.
2020; 17(10): 3379.
[30] Wressle E, Samuelsson K. High job demands and lack oftime: a future challenge in occupational therapy. Scand J
Occup Ther. 2014; 21(6): 421–8.
[31] Wagner MN. Experiences of balance among novice
occupational therapists [master’s thesis]. Kentucky: University of Eastern Kentucky; 2018.
[32] Rappler. DOTr sets public transportation guidelines for‘NCR Plus’ lockdown [Internet]. Philippines: Rappler;
2021. Available from: https://www.rappler.com/nation/
dotr-public-transportation-guidelines-ncr-plus-ecq-march29-april-4-2021/.
[33] Department of Health. Workplace Handbook On COVID19 Management and Prevention [Internet]. Philippines:
Department of Health, 2021. Available from: https://doh.gov.ph/sites/default/files/publications/WorkplaceHandbook-Version-2-Sept-13-2021.pdf.
[34] Chen CC. Professional quality of life among occupational
therapy practitioners: An exploratory study of compassion
fatigue. Occup Ther Ment Health. 2020; 36(2): 162–75.
[35] Iqbal MS, Iqbal MZ, Khan SD, Saad EM, Kassab YW.
Evaluation of health-related quality of life among healthcare professionals–A cross-sectional study findings. Med
Sci. 2020; 24(106): 4471–6.
[36] Maqsood MB, Islam MA, Naqvi AA, Al Qarni A,
Al-Karasneh AF, Iffat W, Ghori SA, et al. Assessmentof quality of work life (QWL) among healthcare staff
of intensive care unit (ICU) and emergency unit during
COVID-19 outbreak using WHOQoL-BREF. Saudi
Pharm J. 2021; 29(11): 1348–54.
[37] The Lancet Regional Health – Western Pacific. COVID19: an ongoing public health crisis in the Philippines[Internet]. Western Pacific: The Lancet Regional Health- Western Pacific, 2021. Available from: https://www.
thelancet.com/action/showPdf?pii=S2666-6065%2821%
2900069-9.
[38] Campo M, Darragh AR. Impact of work-related pain
on physical therapists and occupational therapists. Phys
Ther. 2010; 90(6): 905–20.
[39] Darragh AR, Huddleston W, King P. Work-related musculoskeletal injuries and disorders among occupational
and physical therapists. Am J Occup Ther. 2009; 63(3):351–62.
[40] Dy LF, Rabajante JF. A COVID-19 infection risk model

168

OCCUPATIONAL BALANCE AND QUALITY OF LIFE AMONG OCCUPATIONAL THERAPISTS

for frontline health care workers. Netw Model Anal
Health Inform Bioinform. 2020; 9(1): 1–13.
[41] Langenberg JN. Occupational balance: A time use studyof industrial shift workers [thesis on the Internet]. New
York (USA): Ithaca College; 2012.
[42] Backman, CL. Occupational balance: Exploring the rela-tionships among daily occupations and their influence on
wellbeing. Can J Occupa Ther. 2004; 71(4): 202–9.
[43] Yazdani F, Harb A, Rassafiani M, Nobakht L, Yazdani
N. Occupational therapists’ perception of the concept ofoccupational balance. Scand J Occup Ther. 2018; 25(4):288–97.

■ORIGINAL ARTICLE

Relationship between Activities of Daily Living
and Psychological Aspects at Discharge
from a Convalescent Rehabilitation Ward
Sayaka Iwakami, Wataru Tominaga
Occupatoinal therapy, School of Health Sciences at Odawara, International University of Health and Welfare

Abstract: Discharge support currently focuses on the independence of activities of daily living (ADL) in the convalescent rehabilitation ward. However, understanding the psychological aspects is important for suitable discharge interventions. The objective of this study was to clarify the relationship between ADL independence level and psychologicalaspects when patients’ discharge from convalescent wards was confirmed. A cross-sectional survey was conducted with
80 patients in convalescent wards to examine the relationship between ADL independence level using functional independence measure (FIM) values and responses to eight questions about psychological aspects. The results revealed that
the ADL independence level is correlated with “mental preparation for discharge” and “consultation during hospitalization.” The details correlated with “mental preparation for discharge” differed depending on the disease. “Awarenessof ADL independence” was correlated in cerebrovascular diseases and “awareness of physical recovery” in motor diseases. The results suggest the importance of comprehending patients’ concerns during hospitalization and changing theperspective to providing psychological support according to disease.
Keywords: convalescent ward, discharge support, ADL support, psychological support(Asian J Occup Ther 19: 169−175, 2023)

1. Introduction
At least 20 years have passed since the convalescent rehabilitation ward (hereafter, convalescent ward)
was established in Japan. Currently, there are approximately 2,000 convalescent wards with 90,000 beds [1]and more than 6,000 occupational therapists [2]. This
corresponds to 10% of the members of the Japanese Association of Occupational Therapists. The convalescentward, where many occupational therapists work, is characterized that the purpose of hospitalization of patients,
such as improvement in activities of daily living (ADL),
prevention of becoming bedridden, and return to home[3]. Occupational therapists are required to provide
such as ADL training including eating meals, excretion,and bathing, and instrumental activities of daily living
Received: 8 April 2022, Accepted: 14 April 2023
Corresponding to: Sayaka Iwakami, occupational therapy, School of
Health Sciences at Odawara, International University of Health andWelfare, 1-2-25, Shiroyama, Odawara City, Kanagawa 250-8588, Japane-mail: sayaka168@iuhw.ac.jp©2023 Japanese Association of Occupational Therapists(IADL) training including housework, and outing [4].
Therefore, occupational therapists working in convalescent wards emphasize support for ADL independence.
A few studies have examined the relationship between
basic movement ability and ADL independence level [5]and investigated the ways to improve the independence
level by specifying ADL items such as toilet and dressing activities [6]. Many studies related to convalescentwards have reported on ADL independence, revealingthat sex, age, side of paralysis, balance ability, and walking ability affect functional recovery and independence[7]. However, occupational therapy aims to promote thehealth and well-being of patients through practice [8].
Therefore, it is important to support ADL independence
focusing not only on the restoration of physical function,
but also the psychological aspects. Approximately 25%of all patients in convalescent wards are depressed [9].
However, the severity of depression in patients does notnecessarily correlate with the severity of their diseases[10]. When people receive medical care, their minds are
involved not only with psychiatric diseases but also withphysical diseases [11]. Although there are few studies
on the psychological aspects of patients in convalescent

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RELATIONSHIP BETWEEN ADL AND PSYCHOLOGICAL ASPECTS

wards, there are surveys on anxiety at discharge, anxiety
of families, motivation and satisfaction, and quality oflife (QOL) [12–14]. A qualitative study by Kawai et al.
[15] has revealed that the anxiety felt by patients andtheir families before discharge from a convalescentward is mostly related to “patient’s ADL,” “nursing careability,” “nursing care services,” “outlook for diseases
and disabilities,” and “social participation of patients”.
The relationship between patients’ ADL independence and their psychological aspects in convalescentwards has not yet been clarified. There is significant
psychological stress on patients while performing occupational activities, including ADL [10]; therefore, it isimportant to ascertain whether they experience anxiety
as long as they are independent with ADL, and whether
they are satisfied upon discharge based on their independence level. In particular, interventions and psychological support considering individuality may be necessary
for patients at the time of discharge. The objective of
this study was to clarify the relationship between ADL
independence level and psychological aspects of patientsat the time of discharge from the convalescent ward.

2. Subjects and Methods
2.1 Ethics
This study was conducted with approval from the
Ethics Review Committee of the International University of Health and Welfare and each cooperating institution.
2.2 Study Design
This is a cross-sectional study using a questionnaire
for patients in convalescent wards.
2.3 Survey Target
Cooperation was requested, and consent received,from seven institutions registered as regular membersof the Kaifukuki Rehabilitation Ward Association as ofApril 2018. The subjects included occupational therapists and patients in convalescent wards who would bedischarged within one month. However, we excluded
patients with language disorders and cognitive impairment who had difficulty expressing their intentions andpatients who had previously been hospitalized in convalescent wards.
2.4 Survey Method
The survey lasted five months, from August 1 to
December 31, 2018. The author explained the study purpose to the occupational therapists of each cooperating
institution and requested them to conduct a questionnaire survey. The purpose of the study and the voluntary

nature of participation were explained to the patientsboth in writing and orally by the occupational therapists.
Responses were collected from the patients by the occupational therapists, from whom they were collected by
the author during and after the survey. The questionnaire
was so designed that the subjects could complete it
independently. Thus, the questionnaire content was notknown to others.
2.5 Survey Details
2.4.1 Objective patient information
To understand the patients’ condition, the occupational therapists were asked to enter the age, sex, diseasename, ADL independence level (functional independence measure value; hereafter, FIM value), duration of
hospitalization in the convalescent ward, and residence
after discharge.
2.4.2 Subjective patient information
A questionnaire survey was conducted to determine
how the patients accepted their conditions after theirdischarge had been decided. The questionnaire was prepared by selecting questions based on previous studies
and survey data on anxiety and psychological aspects atdischarge, and adding new questions. The questions on
subjective information included: (1) “Are you mentally
prepared for discharge?” (mental preparation); (2) “Do
you think you have recovered physically?” (awarenessof recovery); (3) “Can you handle your personal matters
independently?” (awareness of ADL independence);(4) “Do you have anxiety now?” (anxiety); (5) “Do you
understand your disease?” (understanding of disease);(6) “Have you acquired the skills necessary to cope withyour future life?” (future coping measures); (7) “Could
you consult about what you want to do in the futureduring hospitalization?” (consultation during hospitalization); and (8) “Do you think you can do what you
want to do, or do something worthwhile, in the future?”(worthy things). The patients were asked to respondusing a 7-point Likert scale ranging from “strongly disagree” to “strongly agree.”
2.6 Statistical Analysis
Descriptive statistics were performed to analyze
the objective and subjective information of the patients.
Spearman’s rank correlation coefficient was calculated
to examine the correlation between the FIM values andquestionnaire items to clarify the relationship between
ADL independence level and psychological aspects. The
same analysis was performed by dividing the analysis
target into cerebrovascular diseases and motor diseases
to clarify the characteristics by attribute. Furthermore,
Spearman’s rank correlation coefficient was calculated

Asian J Occup Ther 19: 169−175, 2023

Iwakami S et al.

Table 1 Patient attributes
Attribute (n = 80)

Mean (range)

Age (years)
Sex (%)
Male
FemaleDisease classification (%)
Cerebrovascular diseases
Motor diseases
Other
FIM value (point)
Durat ion of hospitalizat ion in a convalescentward (days)
Residence after discharge (%)
Home
Other

76.0 ± 12
42.5
57.5
50.0
42.5
7.5
107.0 ± 1475.0 ± 41
86.3
13.7

for the correlation between Question 1 “mental preparation” and the other seven questions, and analysis bydisease was performed to examine the psychologicalaspects toward discharge. IBM SPSS Statistics 25.0 wasused for statistical processing. The level of significancewas set at 5% for all the results.
2.7 Definitions of terms
In this study, the term “psychological aspects”
refers to the patients’ perception of their own conditions,
including their emotions.

3. Results
3.1 C ollection of questionnaire sheets and patients’attributes (Table 1)
A total of 81 patients participated in the survey,
and 80 patients completed all items. The mean age ofthe patients was 76 (± 12) years. The study included 34
men (42.5%) and 46 women (57.5%). The disease classification was as follows: cerebrovascular diseases in 40
patients (50%), motor diseases in 34 patients (42.5%),and others in six patients (7.5%), showing approximately 50% each for cerebrovascular diseases and motor
diseases. The mean FIM value was 107 (± 14), and themean duration of hospitalization in the convalescentward was 75 (± 41) days. Residence after discharge washome for 69 patients (86.3%) and others for 11 patients(13.7%).
3.2 Relationship between ADL independence level andpsychological aspects
A high percentage of patients chose in the questionnaire (strongly agree-agree) for “mental preparation,”“awareness of ADL independence,” and “understandingof disease”, indicating that their feelings about discharge

171

were balanced. However, responses for “anxiety,”“future coping measures,” and “consultation during hospitalization” were varied. A few patients chose strongly
disagree for “awareness of recovery” and “worthy
things,” indicating that there were patients who did not
feel that their condition was satisfactory. Figure 1 shows
the distribution of responses.
According to the results of the correlation analysis
to clarify the relationship between ADL independence
level and psychological aspects, a correlation was observed between the FIM value and “mental preparation”
at r = 0.409 ( p < .001), and between the FIM value and“consultation during hospitalization” at r = 0.416 ( p <.001). According to the results of analysis by disease, inpatients with cerebrovascular diseases, the correlation
was observed between the FIM value and “mental
preparation” at r = 0.509 ( p < .01), between the FIM
value and “awareness of ADL independence” at r =0.478 ( p < .01), and between the FIM value and “consultation during hospitalization” at r = 0.481 ( p < .01).
In contrast, in patients with motor diseases, a correlation
was observed between the FIM value and “consultation
during hospitalization” at r = 0.545 ( p < .01). The results are presented in Table 2.
3.3 Psychological aspects toward discharge“Mental preparation” was correlated with otherquestions regarding the correlation between questions in
the questionnaire. As a whole, the correlation coefficient
was the highest in “awareness of recovery” at r = 0.650( p < .001), followed by “awareness of ADL independence” at r = 0.647 ( p < .001), and “anxiety” at r = 0.622( p < .001). By disease, the correlation with “mental
preparation” in patients with cerebrovascular diseases
was the highest for “awareness of ADL independence”
at r = 0.726 ( p < .001), followed by “anxiety” at r = 0.648( p < .001), and “awareness of recovery” at r = 0.579 ( p< .001). In patients with motor diseases, the correlation
with “mental preparation” was the highest in “awarenessof recovery” at r = 0.737 ( p < .001), followed by “future
coping measures” at r = 0.721 ( p < .001), and “worthy
things” at r = 0.650 ( p < .001). The results are presented
in Table 3.

4. Discussion
4.1 Basic attributes of patients
According to the fact-finding survey by the Kaifukuki Rehabilitation Ward Association in 2015 [16],the mean age of patients in nationwide convalescentwards was 75.8 (± 13.3) years, and the sex ratio was
42.5% men and 57.5% women. In terms of diseaseclassification, cerebrovascular diseases accounted for

172

RELATIONSHIP BETWEEN ADL AND PSYCHOLOGICAL ASPECTS

worthy things

consulta�on during hospitaliza�on

future coping measures 2.5 5.0 5.0

18.8

understanding of disease

22.5

2.5 7.5

anxiety 3.7
8.6
1.2
awareness of ADL independence 1.2 3.7
2.5

mental prepara�on

36.3

30.0

46.3

21.3

18.8

19.8

34.6

23.5

1.3 11.3

34.6

27.2

19.8

14.8

18.5

27.2

29.6

11.1

22.5

28.8

17.5

11.1

awareness of recovery 1.2 4.9
1.2

33.3

21.0

23.5

9.9

6.2 2.53.7

21.0

29.6

27.2

12.3

3.7 6.2

1.3
strongly disagree

Slightly disagree

disaree

Neither agree nor disagree

agree

Slightly agreestrongly agree

Fig. 1. Distribution of answers to the questionnaire.

Table 2 Correlation between FIM values and questions

Overall FIM value
FIM value in cerebrovascular diseases
FIM value in motor diseases

Mentalpreparation

Awarenessof recovery

Awarenessof ADL
independence

Anxiety

Understandingof disease

Future coping
measures

Consultation
during hospitalization

Worthythings

0.409

0.159

0.249

0.302

0.172

0.207

0.416

0.300

0.509

0.208

0.478

0.354

0.321

0.276

0.481

0.410

0.409

0.338

0.176

0.359

0.238

0.330

0.545

0.426

Spearman’s rank correlation coefficient Bold p < .001 Standard p < .01 Italic n.s.
Table 3 Correlation between questions in the questionnaire

Overall mental preparation
Mental preparation in cerebrovasculardiseases
Mental preparation in motor diseases

Awarenessof recovery

Awarenessof ADL
independence

Anxiety

Understandingof disease

Future coping
measures

Consultation
duringhospitalization

Worthythings

0.650

0.647

0.622

0.412

0.602

0.517

0.585

0.579

0.726

0.648

0.285

0.478

0.552

0.526

0.737

0.557

0.605

0.601

0.721

0.484

0.650

Spearman’s rank correlation coefficient Bold p < .001 Standard p < .01 Italic n.s.

47.3%, motor diseases accounted for 44%, and disuse
syndrome and others accounted for 8.7%. The mean
FIM value was 91.1, and the mean duration of hospitalization in the convalescent ward was 71.4 (± 42.4)

days. Residences after discharge included home (69.3%),
home-based service facilities (9.6%), hospital transfer(8.2%), and rehabilitation facility for the elderly (7.5%).
With the exception of the FIM value and percentage

Asian J Occup Ther 19: 169−175, 2023

of residence after discharge, the basic attributes of thestudy subjects were similar to the national average forconvalescent wards. Therefore, they were consideredappropriate for the analysis. However, high mean FIM
value and large number of patients who were discharged
home are possibly influenced by the exclusion of patients with language disorders and cognitive impairment.
Cognitive impairment is considered a factor contributing
to ADL independence. The mean FIM value increased
because patients with severe cognitive impairment were
not included in the study. Accordingly, the percentageof patients discharged home was considered to haveincreased.
4.2 Relationship between ADL independence level andpsychological aspects
This study examined the relationship between ADL
independence and psychological aspects. The results
showed that FIM values, which indicate ADL independence, were correlated with “mental preparation” and“consultation during hospitalization.” Our results are
significant because no previous study has shown therelationship between ADL independence and psychological aspects related to discharge. Although a causal
relationship cannot be discussed, two hypotheses were
proposed based on the results. The first hypothesis wasthat there is a relationship between ADL independence
and mental preparation for discharge. Kajitani et al. [17]reported that patients and their families are sometimes
forced to decide about the place of care after discharge
without having sufficient images of recovery or recuperation. Even if the future state is vague, ADL independence enables them to easily imagine their living stateand mentally prepare for discharge. However, as theprevious studies shows, even patients and their families
with a clear idea about home care since the beginning of
hospitalization are often annoyed before discharge [18].
Thus, even if discharge is confirmed, it will be difficult
to imagine life after discharge and tough to be mentally
prepared for it without ADL independence.
The second hypothesis is that patients with ADL
independence are more likely to have consultations orthat patients with sufficient consultation are more likely
to be ADL independent. Kudo et al.[19] pointed outthat patients’ lives after discharge may not align withthe perspectives of therapists, who tend to focus on
physical functions. Patient who consult in detail about
matters that they, not the therapist, consider importantat the time of discharge, may receive ADL support
according to their individuality, thereby increasing their
independence level. In a study on the roles of nurses in
the convalescent ward, Sakugawa et al. [20] reported
that nurses tended to focus on care functions such as

Iwakami S et al.

173

ADL expansion toward return to home and were notaware of consultation services. Although all associatedprofessionals understand the importance of providing
consultation about patients’ and their families’ concerns
in the convalescent ward, consultation services are lacking in the current situation, which is an issue.
Therefore, it is important for occupational therapists to provide support aimed at the life of patients
after discharge. This raises patients’ ADL independence
level, which, in turn, facilitates their mental preparation
for discharge. This is consistent with the findings ofKamoto et al.[21] regarding a gap in life after discharge
experienced by patients with cerebrovascular diseases.
In occupational therapy in a convalescent ward, it isnecessary to provide interventions that match patients’specific life images from the time of admission, so thatthey can perform activities independently after discharge.
4.3 Psychological aspects toward discharge
The analysis exploring the psychological aspects
toward discharge showed that Question 1 on “mental
preparation” was correlated with all other seven questions. When patients’ information was analyzed according to their disease, it was hypothesized that among
patients with cerebrovascular diseases, those who arementally prepared for discharge tend to be aware of
their ADL independence and have no anxiety. According
to Sakai et al. [22], who analyzed the common experiences of patients with cerebrovascular diseases, patients
follow the following psychological course during theperiod from the onset to discharge: (1) perceiving theirsurvival, (2) becoming aware of their difficulties andrecovery, and (3) feeling glad to be alive. This psychological process for disease acceptance appears to beconsistent with the results of this study that analyzed
the psychological aspects at the time of discharge andshowed that patients were aware of their ADL independence and had no anxiety. Furthermore, regarding
the psychological process after discharge, Sakai et al.
reported that although patients face obstacles of real-life
hardship, they are supported by their experience of thejoy of living and can continue making efforts. Sakai
et al. pointed out the importance of providing support
for psychological recovery during hospitalization. In
this study, the analysis by disease revealed a correlation
between “mental preparation” and “awareness of ADL
independence” in patients with cerebrovascular diseases.
Therefore, to promote awareness of ADL independence,
support and oral encouragement that make patients feelthat they can perform activities necessary for them “bythemselves” can become helpful psychological supports.
On the other hand, it was hypothesized that among

174

RELATIONSHIP BETWEEN ADL AND PSYCHOLOGICAL ASPECTS

patients with motor disorders, those who are mentally
prepared for discharge tend to be aware of their physicalrecovery and think that they have acquired the ability
to apply future coping measures. Therefore, to makepatients with motor disorders believe they can feel “thisway enables me to do” teaching a specific way thatallow patients to perform the activities necessary forthem can become helpful psychological supports. Iida
et al. [23] reported that healthcare professionals are required to empathize with the patients’ wavering feelings
and support them in developing positive attitudes. In
the future, we will further analyze the data and like topropose specific methods of support based on diseasespecific approaches.
4.4 Limitations of the study
As this study was conducted only in cooperating
convalescent wards, its results cannot be generalized.
Additionally, the results could be biased because theoccupational therapists in each institution selected only
those patients who could communicate effectively;
those with communication problems were excluded.
Therefore, it may be necessary to re-examine the survey
method and selection of subjects. Additionally, while
responding to the questionnaire on the psychologicalaspects, patients’ subjectivity for the questions might
have impacted the quantitative analysis. Therefore, anadditional qualitative survey is necessary in the future.

5. Conclusion
We investigated the relationship between the ADL
independence level and psychological aspects after thedecision to discharge patients in convalescent wards.
The results suggested that “there is a relationship between ADL independence and mental preparation for
discharge” and that “patients with ADL independence
are more likely to have consultation or patients withenough consultation are more likely to be ADL independent.” Mental preparation for discharge differs according
to the disease. In patients with cerebrovascular diseases,“a patient with mental preparation for discharge tends
to be aware of ADL independence and has less anxiety,” whereas in patients with motor disease, “a patientwith mental preparation tends to be aware of physicalrecovery and feel that he/she has acquired future coping
measures.” Improvement areas for occupational therapy
include listening to patients’ concerns about life after
discharge and having the perspective to talking to patients according to disease so that they do are peacefulwhen discharged.

Acknowledgements
We express our gratitude to the patients who participated in this study and the staff who cooperated withdata collection.

Declaration of interest
The authors affirm that there were no conflicts ofinterest related to this study.

References[1] Kaifukuki Rehabilitation Word Association [on line].
National data on the number of hospital beds and wards(in Japanese) [cited 2021 April 15]. Available from http://
www.rehabili.jp/publications/sourcebook/graf/graf1.pdf.
[2] Japanese Association of Occupational Therapists [on line].
Statistics (in Japanese) [cited 2021 April 15] Available
from: https://www.jaot.or.jp/files/page/jimukyoku/kaiin
toukei2019.pdf.
[3] Takatsugu O, Seiichi A, Shigeru S, Ichiro M, Makoto I.
“Kaifukuki Rehabilitation Ward” in Japan. The Japanese
Journal of Rehabilitation Medicine. 2014; 51(10): 629–
33.
[4] Director-General of the Medical Policy Bureau, Ministryof Health, Labour and Welfare. Medical Policy Bulletin
No. 0430-1 [online] [cited 2021 April 22]. Available from:https://www.mhlw.go.jp/shingi/2010/05/dl/s0512-6h.pdf.
[5] Uskura K, Kamawa K, Sato A, Oshino S. The relationshipbetween basic movement and the degree of independencein activities of daily living (ADL) among patients withcerebrovascular disorder: Can basic movement be index
of ADL? (in Japanese) Japanese Journal of Occupational
Therapy Research. 2012; 14(2): 23–30.
[6] Mizutani S, Oonishi K, Kinosita S, Shimizu H, Hsegawa
R. Factors and cutoff values for cerebrovascular disease
patients to be unmonitored in the ward’s voiding activities (in Japanese). The Journal of Aichi OT. 2018; 26:
10–6.
[7] Cioncoloni D, Martini G, Piu P, Taddei S, Acampa M,
Guideri F, et al. Predictors of long-term recovery in complex activities of daily living before discharge from thestroke unit. 2013; 33: 217–23.
[8] World Federation of Occupational Therapists [on line].
Definition of occupational therapy [cited 2021April 22].
Available from: https://www.wfot.org/about/about-occupational-therapy.
[9] Yamakawa Y, Sato S, Sawa S, Isaji T, Ohse H, Ohnaka K,
et al. A preliminary study: The Impact of Depression on
QOL of the Patients with Post-Stoke State in a Rehabilitation-Specialized Hospital (in Japanese). The Publication
for studies in Ibaraki Prefectural University of Health
Sciences. 2004; 9: 189–95.
[10] Silverstone PH. Depression increases mortality andmorbidity in acute life-threatening medical illness. J Psy-

Asian J Occup Ther 19: 169−175, 2023

chosom Res. 1990; 34(6): 651–7.
[11] Konoshi N, Sakago T, Moritani T, Mekata T, Ujiie Y.
Considering Psychological Support in Healthcare (inJapanese). Japanese Journal of Clinical Psychology.
2006; 44(2): 16–9.
[12] Akiyaka K, Tsutui Y. Psychology of Patients’ Families
at the Time of Admission to a Rehabilitation Unit: A
Questionnaire Survey (in Japanese). Hamamatsudaigaku­
hoken­iryou­gakubu­kiyou. 2013; 4(1): 41–5.
[13] Yamamoto M, Nishimoto T, Takahashi S, Miyaguti T,
Yanagisawa T, Tanaka S, et al. Influence Factor Stroke
Patients Order to Discharge to Home and Thought ofDaily Living in Home (in Japanese). The Gunma Journalof Physical Therapy. 2006; 17: 7–12.
[14] Aikawa R, Yoshida H, Aoki M, Igari N, Nagase M,
Kashiwabara M. Patients anxiety at admission and at thetime of discharge decision in a convalescent care unit (inJapanese). The Japan Nursing Association Proceedings
Adult Nursing II. 2013; 43: 43–6.
[15] Kawai T, Andou Y. A Study on the Factors of Anxiety Felt
by Patients and Families before Discharge in a Rehabilitation Unit –Through Interview Surveys of Inpatients andTheir Families– (in Japanese). The Japan Nursing Association Proceedings Adult Nursing II. 2013; 43: 39–42.
[16] Kaifukuki Rehabilitation Ward Association. Survey
Report on the Current Situation and Issues in Kaifukuki
Rehabilitation (in Japanese). 2015: 26–36.
[17] Kajitani M, Futoyu Y. Psychological and relational analysis of male patients with sequelae of cerebrovasculardisease and their spouses (in Japanese). Family Nursing.

Iwakami S et al.

175

2004; 2(1): 134–9.
[18] Kajitani M, Futoyu Y, Shiraiwa Y. A Study of Psychological Process and Relationship Between Patients with (inJapanese). Japanese journal of research in family nursing.
2004; 10(1): 10–20. Cerebrovascular Accident and Main
Caregivers in the Family.
[19] Kudo H, Kouta M, Kisisita H, Ozaki K, Tanimoto C,
Ikeda J. How does the patient think the problem of community life: by considerated the medical record (in Japanese). Journal of physical therapy practice and research.
2011; 20: 45–9.
[20] Sakugawa M, Ohwan K, Kurechi S, Miyagi S. Role andawareness of nurses on recovery and rehabilitation wards
in supporting elders to return home (in Japanese). Journalof Okinawa Prefectural College of Nuesing. 2009; 10:
35–43.
[21] Kamoto Y, Miyamae T. Gaps in post-discharge life experienced by individuals with cerebrovascular disorder –Suggestions for occupational therapy for rehabilitation–(in Japanese). Journal of Rehabilitation Sciences. 2018;
14: 13–28.
[22] Sakai I, Kikuchi S. Common experiences in the recovery
process of people with cerebrovascular disorders (inJapanese). Bulletin of Kawasaki City College of Nursing.
2000; 5(1): 25–32.
[23] Iida T, Katou M, Shogenji M, Taniguchi Y. Nurses’ andtherapists’ perceptions of patients’ volition, and their support in a convalescent rehabilitation ward (in Japanese).
The Japanese journal of rehabilitation nursing. 2021;
11(1): 44–52.

■ORIGINAL ARTICLE

Occupational Therapists’ Perceptionsof Quality of Life Among Stroke Clients:
A Qualitative Descriptive Study
Junichiro Muranaka1, Satoshi Sasada2
1
2

Department of Occupational Therapy, Chigasaki Rehabilitation College
Graduate Course of Health and Social Services, Kanagawa University of Human Services Graduate School

Abstract: Background: Occupational therapists’ perceptions of the ‘quality of life’ of stroke clients are not uniform,
and therefore appropriate quality of life support is not always provided. The purpose of this study was to clarify occupational therapists’ perceptions of quality of life of stroke clients and to help develop a new disease-specific quality oflife scale and corresponding occupational therapy practice.
Method: The research design used was qualitative descriptive study. Inductive content analysis was used for the descriptive data obtained from the semi-structured interviews. The 12 participants included nine authorized by the Japan
Association of Occupational Therapists with experience in working with stroke clients and three quality of life expert
researchers.
Results: The qualitative analysis revealed that occupational therapists’ perceptions of stroke clients’ quality of life werebased on the concepts of ‘Adaptation to meaningful occupation’, ‘Good personal causation’, and ‘Family happiness andgood relationships’.
Conclusion: Occupational therapy researchers and clinicians can use the three concepts identified in this study to develop new quality of life measures and to develop occupational therapy practice to improve the quality of life of strokeclients.
Keywords: stroke, quality of life, occupational therapy, qualitative descriptive study(Asian J Occup Ther 19: 176−186, 2023)

Introduction
In the field of occupational therapy, research on
quality of life (QOL) has increased over the recent
decades [1]. Occupational therapy, as a profession that
promotes health and well-being, has significantly focus­
ed on enhancing QOL [2, 3].
The Occupational Therapy Practice Framework
Domains and Processes 4th Edition (OTPF-4th Edition)
explicitly places QOL and wellbeing alongside participation and work performance as desirable outcomesof the occupational therapy process [4]. There is also
Received: 2 August 2022, Accepted: 11 May 2023
Corresponding to: Junichiro Muranaka, Department of Occupational
Therapy, Chigasaki Rehabilitation College, 1-6-1 Nango, Chigasakishi, Kanagawa 253-0061, Japane-mail: ab695869@fb3.so-net.ne.jp©2023 Japanese Association of Occupational Therapists

a report that emphasises the importance of Patient Reported Outcomes (PROs) as outcomes of occupational
therapy, which are “reports of the patient’s health statusobtained directly from the patient, without interpretationof the patient’s response by the therapist or others” [4].
As PROs is a general term for patient-reported clinical
trial outcomes such as subjective symptoms, physicalfunctioning, health satisfaction and QOL [5], we can saythat QOL is one of the PROs of occupational therapy
outcomes.
In order for occupational therapy to become aleader in health care that promotes health, well-being,and QOL, Pizzi states that it must define itself not as arehabilitation specialist, but as an expert in QOL andwell-being [6]. This model is referred to as the environment-health-occupation-well-being (E-HOW) model,
which incorporates occupational participation, such as
occupational demands, roles and performance, environment, such as social, physical and cultural contexts,

Asian J Occup Ther 19: 176−186, 2023

and individual and group health as components of wellbeing and QOL framework [7, 8].
Therefore, if occupational therapy is to evolve as acontemporary and meaningful service, it must pay more
attention to QOL and well-being, which are important
for all human beings. In particular, we believe that thisshould be a priority for the continued development ofoccupational therapy for stroke clients, who are often
involved in the physical disability field.
However, a review of QOL research in occupational
therapy interventions states that QOL needs to be redefined and reevaluated from an occupational therapy perspective because of inconsistencies in the definition of
QOL and the scales used to measure it [9]. In addition,although limited to Japan, occupational therapy intervention studies using QOL as the main outcome foundthat the definition of QOL was not standardized, and furthermore, the QOL scale as an outcome of occupational
therapy was not unified among the 19 articles included[10]. Furthermore, in the only previous study that asked
rehabilitation professionals about the concept of QOL
and their perceptions of the profession, the differences
in QOL as perceived by physicians, physiotherapists andoccupational therapists were classified, but the detailsof the concept of QOL of stroke clients as perceived byoccupational therapists were not clarified [11]As described above, the concept of QOL has notbeen established as an important factor in occupational
therapy outcomes and the occupational therapy process,despite its special value for occupational therapy and thefact that specific models are being created. We believethat one of the reasons for this is that occupational therapists have different and not unified perceptions of the
QOL concept, i.e. the QOL as perceived by occupational
therapists has not been clarified.
By examining and analysing this issue, it will
be possible to have a more in-depth discussion about
the QOL of stroke clients in a common language withother professions. In addition, the results of this study,
together with developmental research on the concept
of QOL as perceived by stroke clients themselves, may
contribute to the development of a disease-specific QOL
scale that can be discussed with other professions, which
in turn may improve the QOL of stroke clients receiving
occupational therapy services.
Therefore, this study focused on the QOL of strokeclients, who are most frequently involved in the fieldof physical disability, and aimed to clarify the qualityof life of stroke clients as perceived by occupational
therapists and QOL specialists who have been deeply
involved with stroke clients.in addition The study was
conducted after approval by the Research Ethics Committee of A University.

Muranaka J et al.

177

Research Method
Identification of the research method
This study adopted a qualitative descriptive approach to elicit occupational therapists’ perceptions of
the complex concept of QOL among stroke clients andhelp them describe their perceptions [12]. To obtain awide range of codes, purposive sampling was used, witha target of approximately 10 ± 2 respondents, to ensure
individuality and diversity.
Data saturation method was employed to continue
the interviews using additional participants until no new
subcategories appeared. When no new subcategories
appeared, we included two or three additional interviewees to ensure the credibility and reliability of data
saturation. This qualitative descriptive study was basedon the 32-item checklist of the Consolidated Standards
for Reporting Qualitative Research [13].
Participants
Practitioners as study participants
Only Authorized Occupational Therapists (AOTs)
certified by the Japan Association of Occupational
Therapists participated in this study. This certification
assures that the practitioner has a specific level of competence in clinical practice, education, research, andthe administration of occupational therapy. To ensure
the reliability of the data, this definition was used to
select the target population, assuming that occupational
therapists with a specific level of competence in clinicalpractice would be the most reliable in recognising QOL.
The number of licensed occupational therapists in Japan
was approximately 100,000 as of 2021, of which 1,175
were AOTs and 54 were in X Prefecture (https://www.
jaot.or.jp/member/ninteiList/qualificate/).
Purposive sampling was conducted, and the AOTs
who fulfilled all the participation criteria were enrolled.
The inclusion criteria were as follows: each participantmust (1) work as an AOTs in a medical institution in X
prefecture, (2) have at least three years of experience
working in a rehabilitation ward as an occupational therapist, (3) agree with the purpose and main idea of thisstudy, and (4) be willing to participate in the study.
To confirm that the selected participants fulfilled
the above criteria, we consulted the AOTs list on thewebsite of the Japan Association of Occupational Therapists to identify the names and affiliations of AOTs in X
prefecture. The facilities with AOTs who had experience
working in recovery rehabilitation wards were invited
to participate. When obtaining consent for participation,
the principal investigator explained the purpose andintent of the study in writing, and the study was conducted after informed consent was obtained from both

178

OT’S PERCEPTIONS OF QOL AMONG STROKE CLIENTSTable 1 Interview guide (Questions)• H ow do you think about the QOL of clients with cerebrovascular disease?
• As an occupational therapist, what interventions have you performed for the QOL of cilents with cerebrovascular disorders?
• What is your most memorable experience of intervention for QOL?
• Do you think that there are cilents for whom it is easy to intervene in QOL and clients for whom it is difficult to intervene in QOL?
• What are the key words regarding the QOL of cilents with cerebrovascular disease?

the participants and their affiliated facilities. Specifically, we contacted 14 facilities in X prefecture via phoneor email to request their participation. The facilities that
did not provide consent were excluded. Therefore, AOTs
from these facilities were excluded, even if the individuals agreed to participate.
Experts as participants
To clarify the perceptions of occupational therapists
on QOL among stroke clients, we interviewed practitioners and QOL researchers (experts). This was to gain
broader and deeper insights into QOL among strokeclients by adding researchers’ (experts) perspectives tothose of practitioners.
We enrolled participants meeting the inclusion criteria for purposive sampling. The inclusion criteria forparticipants were as follows: (1) qualified occupational
therapist, (2) published at least three original papers
including QOL as a topic, (3) had conducted practiceor research on stroke victims, and (4) agreed with the
purpose and objectives of the study and were willing toparticipate.
The principal investigator contacted potential participants via email or phone to arrange an appointment
for each in the facility to which they belong. Whenobtaining consent for participation, the principal investigator explained the purpose and intent of the study inwriting, and proceeded only after obtaining consent.
Facilities that did not provide consent were excluded.
Data collection
Data were collected through semi-structured inter­views based on an interview guide developed by the researcher. The creation of the interview guide was basedon a framework [14], which included (1) the identification of the assumptions for the use of semi-structured
interviews. Therefore, It was decided that semi-structured
interviews would be appropriate for investigating
the perceptions of the complex and abstract concepts
of QOL. (2) Search for and use of prior knowledge:
Extensive literature research regarding occupational
therapy and QOL was conducted to identify what is
known and what is unknown. (3) Formulation of apreliminary semi-structured interview guide: To obtain
the richest possible data, the questions in the interview

guide involved broad questions regarding QOL among
stroke clients, and the questions were carefully designed
to be clear, straightforward, open-ended, and elicit
spontaneous and unique responses. (4) Pilot test of theinterview guide: A pilot test of the interview guide wasconducted by one of the participants, and it was concluded that the content of the guide was appropriate forthe research questions and that it was adequately comprehensive to answer the questions we intended to ask.
(5) Presentation of the completed semi-structured interview guide: From steps (1) through (4), we produced arelatively clear and complete interview guide for datacollection. The decision to complete the interview guide
was made following discussions with the collaborators.
Additionally, the interview guide was mailed to the participants before the interview so that they could respondpromptly (Table 1).
All the interviews were conducted online using
Zoom, and the interview content was recorded as notes
in a field notebook. The interviews were conducted overa period of approximately seven months, from 1 May
2021 to 4 December 2021.
Data analysis
The researcher conducted an inductive content
analysis to explore occupational therapists’ perceptionsof QOL among clients with cerebrovascular disease[15]. The interviews were recorded using the Zoom, an
online video conferencing platform, and the recordings
were transcribed verbatim. When preparing the verbatim
transcripts, the researcher checked for discrepancies
between the recorded content and the transcripts. Data
collection and analysis were carried out simultaneously,with data analysis commencing immediately after eachsubject was interviewed.
Open coding of the qualitative content analysis
process was followed. The first step involved conceptualising the content of the data in short sentences, whichwere intercepted in several chunks. The second step
involved grouping and defining the emerging concepts,
combining similar ones. The third step involved developing the grouped categories and organising them into ahierarchical structure of subcategories, main categories,
and core categories to build a coding frame [16]. Thismethod has been shown to increase the reliability of theAsian J Occup Ther 19: 176−186, 2023

Muranaka J et al.

179

Table 2-1 Overview of the research participants (Practiciners)
ID

Sex

OT Experience(Years)Stroke intervention
experience

Interview time
(Min, Sec)Engaged Stroke Phase

Cliant Age Group

Degree

A
B
C
D
E
F
G
H
I

Male
FemaleMale
Male
FemaleFemale
Male
Male
Male

15
16
16
10
36
30
14
16
14

10
5
3.5
9
3.5
15
11
10
9

49`49
85`15
83`9
56`30
35`52
64`42
59`24
53`27
102`41

RecoveryRecovery
Acute/Recovery
Recovery
Acute/Recovery
Acute/Recovery
RecoveryRecoveryRecoveryelderlyelderlyelderlyelderlyelderlyelderlyelderlyelderlyelderly

MasterDoctorate
Doctorate
Advanced special
MasterDoctorate
Doctorate
Doctorate
MasterTable 2-2 Overview of the research participants (Researchers)
ID

Sex

OT Experience(Years)Experience in
QOL research(Years)Interview time
(Min, sec)

Number of peerreviewed articles on
QOL (eds.)

Total citations

Areas of work

Degree

J
K
L

Male
Male
Male

16
22
21

10
17
14

52`50
70`40
45`15

8
14
10

3
4
3

Training school teachers
Training school teachers
Training school teachers

Doctorate
Doctorate
Doctorate

coding process. It also determines the frame of classification, thereby allowing others to analyse the data
similarly [16, 17].
To ensure the reliability of the analysis, coding
was conducted together with the co-researchers anddiscussed to the satisfaction of the researchers. Additionally, the results were re-communicated to the participants for member checking, and the analyses of codes,
subcategories, main categories, and core categories wererepeatedly revised until consensus was reached, thereby
ensuring the validity of the analyses. From open coding
to the creation of coding frames, NVivo (USACO
Corporation) was used as an adjunct to qualitative data
analysis software.
Data saturation
Throughout the course of the analysis, 18 subcategories were generated at the end of the discussion involving the ninth subject. After completing discussions
with the tenth participant, we confirmed that the datatended to fit into the existing subcategories and there
was no need to generate new categories. Therefore,
two additional participants were included in the study,
and as it was confirmed that there were no additions to
the existing coding frame and the data were consideredsaturated.

Findings
Overview of the participants
There were 12 study participants: nine AOTs aspractitioners (ID: A-I) and three quality of life researchers as QOL experts (ID: J-L). Nine participants weremale and three were female. The average interview
time for all participants was 62.75 minutes. The average
years of experience of the participants as occupational
therapists was 18.8 ± 7.4 years. The degrees held by theparticipants were eight doctoral degrees, three master’s
degrees and one advanced professional degree.
The average number of years of occupational therapy practice with stroke clients for AOTs as practitioners
was 8.4 ± 3.8 years. The participants’ main stage ofstroke involvement was recovery, with three participants
indicating that they also had experience in the acutephase of stroke; the ages of the stroke clients with whom
the AOTs were primarily involved were all elderly (Table
2-1).
The average years of experience of researchers
on QOL was 13.6 ± 3.5 years, and the number of peerreviewed articles on the subject of QOL was 8 (total
citation 3) for J, 14 (total citation 4) for K and 10 (total
citation 3) for L in the study, which The inclusion criteria for being a QOL expert (researcher) in this study
were judged to be met (Table 2-2).
Occupational therapists’ perceptions of QOL among
stroke clients
Qualitative content analysis revealed 125 codes,
18 subcategories, six main categories, and three core
categories. Occupational therapists’ perceptions of QOL
among stroke clients extracted from these coding frames
were divided into three core categories: adaptation to180

OT’S PERCEPTIONS OF QOL AMONG STROKE CLIENTS

meaningful occupation, good personal causation, andfamily happiness and good relationships. These threecore categories are described below (Table 3).
(1) Adaptation to meaningful occupation
The two main categories were as follows ‘To beable to live the life you want’ and ‘being able to engage
in the role’. These core categories have one thing incommon: they are based on what the client wants andwhat the client (stroke victim) can do to adapt to theirprevious role.
In the main category, ‘To be able to live the life
you want’, participants described stroke ‘ QOL as anexperience of life shaped by their wants, values andneeds. They also tended to perceive QOL as being
about returning home and regaining control over one’s
lifestyle, rather than QOL when a person is hospitalisedor admitted after a stroke. In addition, opinions about
the ability to perform activities of daily living (ADLs),such as “I do not think that improving ADLs leads toimproved QOL” and “Honestly, I did not feel clinicallythat ADLs support improved QOL”, were not the mainconcepts of QOL.
In the other main category of ‘being able to engage
in the role’, it was recognised that it is vital for stroke
victims to engage in the roles of a stay-at-home spouse,e.g., cooking, cleaning, and performing other tasks thatare required by their family and relatives. They also
recognised that engaging in leisure activities and hobbies was important for enhancing QOL among stroke
victims.
Based on these two main categories, we extracted
core categories, such as ‘adaptation to meaningful occupation’.
(2) Good personal causation
The two main categories associated with this core
category were as follows: ‘have an accurate perceptionof life and abilities’, and ‘have a sense of self-efficacy
regarding their future life’.
‘Have an accurate perception of life and abilities’reflects that many of the participants indicated it was
imperative to continue their pre-stroke lifestyle, more
realistic perception of their functional impairment anddisability caused by the stroke was crucial to their QOL.
They also emphasised that it is important for strokeclients and their families, supporters, and stakeholders
to correctly understand their abilities.
In addition, two participants stated that ‘have asense of self-efficacy regarding their future life’ had asignificant impact on their quality of life, suggestingthat self-efficacy is one of the aspects needed to improvestroke patients’ QOL.

From these two categories, the concept of quality oflife was extracted as ‘Good personal causation’, whichindicates a state of high self-efficacy and a correct perception of the loss of function and ability due to stroke.
(3) Family happiness and good relationships
The two main categories—good personal relationships and a sense of happiness in the family—had one
concept in common: family happiness and good relation­
ships. The participants recognised that good relationships,
especially among family members, are crucial to enhancing QOL. For example, when a daughter was thestroke patient’s key person, some of the participants
asserted that they ensured the daughter and the stroke
patient did not get on badly and they supported the pairthrough occupational therapy aimed at maintaining theirrelationship.
In the category: a sense of happiness in the family,
three participants perceived happiness and satisfaction
within the family and by the stroke victim as indicationsof good QOL. One participant asserted that it was
imperative to consider the security and happiness offamily members, especially in the case of severe stroke
victims who could not talk. Additionally, this participant
argued that QOL is an interactive process, whereby thehappiness of the caregiver (family) and that of the stroke
victim must be harmonised.
The core category: family happiness and good relationships, describes a state of satisfactory interactions
and happiness among stroke victims and their family
members.

Discussion
This qualitative descriptive study aimed to identify
the way in which occupational therapists perceive QOL
among stroke clients. The results enabled the development of a novel disease-specific QOL scale for strokeclients and the identification of six main categories andthree core categories that may be useful in enhancing
QOL among stroke clients.
The first category of QOL among stroke clientsas perceived by occupational therapists was the core
category ‘adaptation to meaningful occupation’, which
was generated from the main categories ‘To be able
to live the life you want’ and ‘being able to engage inthe role’. This core category reflects the overall aimof occupational therapy, which is to enable clients to‘do’ what they want or what they must [18]. The aims
of occupational therapy can be considered similar to
those aimed at improving clients’ QOL. At first glance,
this finding may seem obvious. However, clinicians
may assume that because occupational therapists areAsian J Occup Ther 19: 176−186, 2023

Muranaka J et al.

181

Table 3 Occupational therapists' perceptions of the quality of life of stroke clients

The happiness of living the life you want• The part about what he wants to do or what he wants to do next is important.
• It’s about getting them closer to the life that they want, the life that they want to lead.
• It’s about what they were doing before the illness, what they want to do, what they want their life to be like.
• How they want to live their life.
• I think it’s about how you want to live a good life, how you want to live a rich life.
• How have you lived? What do you want to do, what are your characteristics?
• I think it’s important to make it possible for the patient to do what they want to do, what they wish to do.
• If the patient feels good or happy, I think we are getting closer to QOL.
• Not only in daily life, but also in what you want to do and what makes you happy, I think this will lead to QOL.
• When the patient said he wanted to play futsal and drive, we did exactly that.
• I think goals are very important.
• First of all, what the patient thinks is the most important thing.
• How does the person feel? It is a self-perception of one’s life.
• Quality of life is basically a subjective perception of the person’s own life.
• It’s the person’s sense of well-being. Whether the person feels happy or not.
• QOL is mainly subjective, what do you want to do, what makes you happy?
• I think that QOL is created by being able to achieve what you want to do.
• I think OT is the only person who can do what he wants to do, what makes him happy and how he can communicate.

Doing the daily activities you want after leaving hospitalCode• Think about life after discharge from hospital from the point of view of what kind of life is desirable for this person.
• We think about how the patient is living at home. We think about the person’s life after discharge.
• The OT manages the patient’s life, such as how we want the patient to live one year from now, and how we want thepatient to spend their time at home.
• We want to do this by focusing on their life after they go home.
• I don’t know if QOL will improve during hospitalization, but I think it will lead to QOL after returning home.
• I think it would be easier to approach QOL after the recovery period is over and the patient is discharged from thehospital, when they become independent.
• Not only in the recovery ward, but also after returning home, it is important to look at QOL in a linear manner rather
than in terms of points.
• I think it is better to call the patient after the recovery period, or to have tea with him/her after a few years, and to see
how his/her QOL is in the end.
• I think it is better to see how the patient feels about life after returning home. That’s what we are here to support.
• In the recovery stage, we need to know what the patient will be like when they return home one month after discharge.
• I think it will be a little while before we can see the results of QOL, so I think the results of the support in the recovery
phase will be seen three months after discharge.
• There was a patient who had to go back to Okinawa, so I asked him about his home situation in detail, and thought
about what I could do to help him stay in Okinawa. I asked him about his home and how he could spend his time in
Okinawa.

Wanting more than just ADLs; to live a full lifeSub
category• Are you able to see what the patient is satisfied with, other than the ADL items? I don’t think it’s recognized that much.
• In the first place, improving ADL is a matter of course in the recovery stage, and I don’t think it is a goal to be given to
individuals.
• It is the mission of the recovery ward to improve ADL, so what are you saying that that is the goal? I think you have to
set a goal based on what you want to do with the person’s life.
• There are people who say, “We have to improve ADLs,” but since this is a ward like that, we should aim for more thanthat, don’t we?
• I thought it would be better to use theories such as the human work model to support the QOL of patients who are
relatively independent in their ADL.
• I don’t think that improving ADL will lead to better QOL.
• I think that raising ADL in order to get a performance index is itself harmful, and I think it may cause QOL to decline in
the future.
• To be honest, I didn’t feel clinically that the ADL support was improving QOL.
• If all you want is to be able to eat or change your clothes, or if you just want to be able to do things without any help
from us, then in the true sense of the word, QOL is not about improving ADL first.
• It’s not just about raising ADLs, that’s what I’m saying.
• If it’s a kind of uniform ADL training in the training room, well, as an occupational therapist, I think it’s probably not
QOL just to intervene there.
• I’m just saying that you don’t necessarily need a foundation of ADLs to improve QOL.

Identify what arises
from need and valueMain
category

To be able to live the life you want

Adaptation to meaningful occupationCore
category• Quality of life depends on each person’s sense of value, and while quality of life may be valuable to one person, it may
be of no value to another.
• It is important to think about the value of the work and the value of the person.
• When we think about QOL, we think about the value of the person and the achievement of the person’s work.
• I think it’s important to uncover the latent needs of the client.
• I think it’s important to uncover the latent needs of the client.
• It’s been a bit difficult to provide quality of life support to people who have difficulty in eliciting their needs.

Be yourself in the way
you live• Quality of life is about how to live a life that is rich, how to be happy, how to be yourself. I think it’s about how you canlive your life, how you can be happy, how you can be yourself.
• I think it’s about the future, or rather, looking at a person’s life in the future, and supporting them in their own way, theirown identity, and their own happiness.
• I would like to place importance on the person’s own identity and happiness.
• Indicators to help people and their families to live their own lives• Personality, or the way of life of the person.
• What is the meaning of life for the person?
• It means that the person walks on his or her own feet, in his or her own way.

Be able to carry out the role

• By consciously assessing what the person needs to do, I think I naturally picked up on what the person wants to do.
• There are roles and habits and things like that, so I think that’s a very good part of the cost of interviewing and setting
up these situations, as a skill for us.
• The QOL was to regain the roles in the family and things like that.
• There are many women who feel that they are the last housewife in the family, so we think that focusing on their own
role will improve their QOL.
• I think it’s important to acknowledge the value of the client’s existence, and to interact with them in such a way thatthey can maintain their role, even if only a little.
• It is important to recognize the value of the client’s existence.
• When I thought about QOL, I thought that we should work towards regaining the role of the family and social
participation.
• To be able to participate in meaningful occupation.

To do the important
occupation that isrequiredCode• Being able to do the work that is important to the person, and thinking about why it is important, is linked to QOL.
• I think that this will lead to the identity of the OT and the QOL of the patient.
• A high quality of life is achieved when a person is satisfied with the work that they consider important.
• What does the client want to do? Thinking about what are the important tasks, and being able to do them.

To take up a role as a hobbyist

Being able to engage in the role
Have an accurate perception of life and abilities

Adaptation to meaningful occupation
Good personal causationSub
category• The higher the leisure activities and hobbies of the client, the better the QOL.
• It was concluded that intervening in leisure activities improved the QOL of the patient, and also created a positive cycle
for the caregivers.
• One of the ways to support QOL was to enable and expand hobby activities.
• She was a person who participated in volunteer work and knitting circles at home, so it was good to enable her to dothat.
• I think that patients should have hobbies and other activities at the same time.
• I think that providing activities based on hobbies and the like can be useful for QOL.
• The approach to leisure activities and productive activities is also an approach to QOL.
• OT is the only person who can intervene to make people feel that they can have a fulfilling life so that they can enjoy
their favourite hobbies.

Rediscovering your lifeMain
category
To be able to live the life
you wantCore
category

OT’S PERCEPTIONS OF QOL AMONG STROKE CLIENTS• When I was practising taking the washing in and out of the washing machine on the ward, she pulled out the washingwith her back to me and said, “This is how I used to live”.
• I was thinking about how I used to live my life, and how OT helps me to focus on that.
• I thought it could help me to remember what I have been doing since I came back home, and what kind of life I havebeen leading.
• In the end, it becomes “this is my life”, and this process has a depth that supports QOL.
• If you don’t feel that you have got your life back, you should be happy with the hospital, you should be happy with this
hospital.

Being awareness as a sick client

182• I think that we need to improve the quality of life of the sick people, even if they don’t approve of the fact that they
have a disease and it is natural that they can’t do some things because of their disease.
• Before we can move on to the next stage, we need to recognize that we have become ill and that there are parts of us
that cannot be cured.
• I think it’s because he doesn’t have the approval. I don’t know who I can rely on, and I have to do it by myself, so I
have to do it by myself .
• First of all, it is important to accept the fact that we are approving you, and to make sure that you fulfil your role as a
hospital.
• I think that the sick should be sick because they are in a part of the hospital called the recovery rehabilitation ward. If
we don’t make them sick first, they won’t be able to achieve what they want to achieve.
• If you think that being independent as a sick person will improve your QOL, if you are not approved, your QOL will not
improve in the long run.

Asian J Occup Ther 19: 176−186, 2023

Have a disability awarenessdue to stroke• If you can’t accept your disability, you can’t be happy yet, or maybe you can’t get the real QOL.
• You have to understand your current situation, and you have to understand what will happen when you go home in amonth.
• It’s not for us to teach them to understand their current situation, but for them to recognize that this is who they are andthis is what they want to be.
• I would like to make it important to create opportunities for the person to understand their own situation, their own
existence, their own characteristics, and to express themselves.
• I want them to be able to understand themselves, to be able to live with the disability, to think about their own health inorder to take the next step.
• The client has to be the sick person. It is only after that that the QOL of the next life can be achieved.

Family understanding of
disability• It was more about being as involved as possible with the family. It was more about getting the family to understand thedisability.
• When it comes to quality of life, people who are easy to intervene with and people who are difficult to intervene withare the ones who can listen to their families. It is important to be able to listen to the family’s perception.
• When we were assessing the attention disorder of higher brain functions, we asked the family to see as much as
possible. I would tell them that this is an attention disorder, and that it could affect their lives in this way.

Confidence in what
they want to do• From a comprehensive point of view, it is important to keep looking at the person and thinking about them, and not toforget their thoughts and feelings.
• We use the MAL (Motor Activity Log). Well, the subjective confidence of the patient may be important.
• I think QOL is the most important subjective QOL of the patient, and I think it is very necessary to do rehabilitation
based on the patient’s thoughts.
• I think that in order to support QOL, we should not focus on subjectivity, such as “I feel like I can do it”.
• It is the subjectivity that is evaluated, such as the feeling that one can do something, or the feeling that one wants to dosomething.

Awareness of what
they feel they can do• There is a relationship between self-efficacy and quality of life, and it can be linked to the development of occupational
therapy to provide success experiences and to encourage the person to experience success in meaningful occupation.
• An assessment method that reflects the feeling of being able to do something and the feeling of wanting to do something
may be a QOL outcome in recovery.
• If you can make people feel that they can do it, I think that is a wonderful perspective for occupational therapists in therecovery period.
• In terms of QOL, I think that raising self-efficacy is one of the missions of OTs in the recovery phase.
• How much the patient can do, and how satisfied they are with it.

With family• I think it is important to think about the relationship between the family and the patient, now and later.
• If the mother is in hospital and there is a devoted daughter, when the daughter comes to visit the mother and daughter, it
is important to have a friendly relationship with the mother and daughter so that they can meet and make small talk.
• In the case of a severe patient, rather than thinking about the QOL of the patient, we think about the amount of care thefamily needs, and not only about the QOL of the patient, but also about the family.
• I think the needs of the family and the needs of the patient are both important, so I like to provide QOL support that
supports both.
• We also checked with the father that the electric wheelchair would work well at home and that he would be able to getaround.
• I think a lot of people focus on whether they can do something with their family, so I thought it was very important.
• I didn’t want to bother my wife, so I practiced so that I could do it by myself. I think that was another way of supporting
my QOL.
• I think that supporting parent-child relationships, marital relationships and family connections can also be QOL support.

With others

Code• What we need to focus on in the recovery period is social interaction with others. I think it is important to create social
interaction after the patient returns home.
• When I think about it in the recovery period, I also think that building relationships between therapists, nurses and otherstaff and clients is also a quality of life.

Family feeling secureand satisfiedSub
category183• Isn’t it important for recovery rehabilitation to make the family feel at ease?
• I think that raising the satisfaction level of the family, as I did in the section on family satisfaction, is one form of QOL.
• I don’t know what the QOL of the patient is, but the family’s QOL, the satisfaction of the family, can be improved, so
we did transfer practice, family guidance, and wheelchair adjustment for about five months.
• Regardless of what the patient thinks, it is the family that ultimately receives the treatment, so we have to make surethat we meet the family’s needs.
• The family should be able to feel at ease through the relationship.
• For the families of patients who cannot talk about it, their trust in the hospital or rehabilitation will be determined by
how the patient is treated.

Carer’shappiness

Good personal relationships

Have a sense of self-efficacy regarding
their future life

Have an accurate perception of life and abilities

Main
category

A sense of happiness in the family

Family happiness and good relationships

Good personal causationCore
category

Muranaka J et al.

• If the patient is not happy, the caregivers will not be happy either.
• If the patient is not happy, the caregivers are not happy either.
• We paid attention to the family’s sense of well-being, QOL, and the improvement of their quality of life.
• The joy of the family may not be the same as the joy of the patient, but if we could support the joy of the family, it
would be QOL support.

184

OT’S PERCEPTIONS OF QOL AMONG STROKE CLIENTS

concern­ed primarily with the welfare, health, and wellbeing of their clients, they must use well-known measures associated with the broad concept of QOL [11]and that the widespread use of the term QOL is because
there is general agreement regarding what it represents[19]. In other words, currently, there is no evidence
showing that the stated and universally accepted aim ofoccupational therapy is improving and supporting clients’ QOL. However, this may be a common assumption
routinely found and reported.
Therefore, the concept of ‘adaptation to meaningful
occupation’ as one of the occupational therapists’ perceptions of QOL among stroke clients, which was identified in this study, can be considered synonymous withachieving the aims of occupational therapy, including
the improvement of clients’ QOL. This concept supports
occupational therapists’ perceptions that objectives ofoccupational therapy are closely related to QOL.
The second perception of QOL involves the core
category ‘good personal causation’, which is generated
from the following main categories: ‘having an accurate
perception of life and abilities’ and ‘having a sense of
self-efficacy regarding future life’. The perception ofability and self-efficacy fall under the personal causationin the will, as described in the Model of Human Occupation [20]. The aftereffects of stroke are complex andinclude motor, sensory, and higher brain dysfunction. It
is also argued that the negative consequences of illness
create a perception that one is not in control [21]. On theother hand, those who think they can do well will seek
opportunities, use feedback to modify their performance,and keep attempting to achieve their goals [22].
The results of this study indicate that occupational
therapists perceive their clients’ ‘good personal causation’as satisfactory QOL. This may be because occupational
therapists understand that even if a client suffers fromvarious impairments owing to stroke, if they have a ‘good
personal causation’, they will not become lethargic but
will have a proper understanding of their current abilities
and can challenge themselves through setting appropriate goals according to their abilities. Previous research
has also shown that the ability to improve QOL depends
on whether an individual can live the life they want
while paying attention to their abilities [6, 8]; and the
QOL of people with physical disabilities is not higher
among those with minimal disability and not lower
among those with complete paralysis [23, 24]. Some
reports suggest that the disability status and QOL are
not related. In other words, QOL among stroke clients,
as perceived by occupational therapists, is not based on
the actual degree of functional impairment or disability
caused by stroke, thereby suggesting that the degree of
personal causation attribution may be a crucial factor for

determining clients’ QOL.
The last core category: family happiness and good
relationships is generated from the following maincategories: good personal relationships and a sense ofhappiness in the family. It was established that occupational therapists perceived good personal relationships
with family and caregivers and a sense of happinessamong family and caregivers as stroke clients’ QOL.
Many previous studies on QOL and the relationships
between family members and others have shown that
QOL is influenced by the relationships between people
and the help they receive as a result of these relationships[25,26]. In a study on QOL among clients, patientreports mentioned that family problems influence theperception of QOL. This is because occupational therapists know that QOL among stroke clients is closely
related to the QOL of their family members. Therefore,
focusing on the family’s well-being may also be a vital
factor affecting the enhancement of QOL among strokeclients. ‘Family happiness and good relationships’, oneof the QOL concepts for stroke clients, can be generated
through the interaction of good relationships between
family and caregivers and the happiness of stroke clientsand their family and caregivers.
The main reason for the identification of these threecore categories may be that the main area of stroke
involved by the study participants was the recovery
phase. Recovery phase has an institutional function ofrestoring physical function, life skills and returninghome [27]. However, stroke recovery is said to be a time
when clients experience a separation of social roles andforms and switch to a new image of life, living with thedisabilities caused by the effects of stroke [28, 29].
Skilled AOTs are likely to be highly aware of theimportance of re-establishing social roles, disability perceptions and family presence necessary for reintegrationback into the home by working deeply with stroke client
during stroke recovery, and recognise that these concepts
are closely related to the wellbeing and quality of life of
the stroke client.
Therefore, the categories of ‘adaptation to meaning­
ful occupation’, which focuses on re-establishing roles
to improve stroke survivors’ QOL, ‘good personal caus­
ation’, which indicates self-efficacy and self-perceptionof appropriate competence, and ‘family happiness andgood relationships’, which indicates family relationships
necessary for returning home, are considered to havebeen extracted.
Finally, we would like to discuss the differences
between existing QOL measures and the QOL concepts
extracted in this study. Typical QOL measures usedby occupational therapists include the SF-36 and the
WHOQOL-BREF [30]. However, the SF-36 does notAsian J Occup Ther 19: 176−186, 2023

include content related to environmental and personal
factors other than health and functioning [31], and the
WHOQOL-BREF does not have enough items related tohuman environments and personal factors. Additionally,
the Stroke-specific QOL scale has sub-items for vision,
upper limb function, language function, mood, and ener­gy, but it does not contain sufficient content related tothe human, social, environmental, and personal factors.
There seems to be a significant difference between
the results of this study and the QOL concepts of existing measures. The WHOQOL-BREF and the SF-36
are comprehensive QOL scales that are not limited to
stroke. Comprehensive QOL scales are said to be superior in assessing general health status, mental status andcomparison with healthy subjects. In other words, they
do not address disease-specific aspects of stroke, which
may be a reason for the differences between the resultsof this study and those of the present study.
In addition, the WHOQOL-BREF and SF-36 arescales developed by a wide range of subjects around theworld, and cultural aspects of a limited number of subjects in a limited geographical area, as in this study, may
have a significant impact on the results and be a factor
in the differences in the concept of QOL.
However, our study aimed to identify concepts thatwere missing from traditional QOL indicators and had
not been considered in the literature. In particular, we
believe that the concept of QOL, which includes thephilosophical background and identity of occupational
therapy, is essential for the future development of occupational therapy.
Therefore, we believe that the novelty of the results
obtained through this study involves the extraction ofconcepts that reflect the philosophy of occupational therapy, including ‘adaptation to meaningful occupation’,‘good personal causation’, and ‘family happiness andgood relationships’, which are not included in the existing QOL scales. The results of this study, combined withfurther research on the concept of QOL, as perceived
by stroke clients, will contribute to the development ofnovel disease-specific QOL indicators among strokeclients and, ultimately, occupational therapy practices
for improving QOL among stroke clients.
Limitations and directions for future researchThis study has three limitations. First, the participants were occupational therapists, and the QOL among
stroke clients cannot be determined by this alone. To
clarify the concepts, future studies comparing and integrating stroke clients research participants are necessary.
Additionally, further research based on the Consensusbased Standards for the selection of health Measurement
Instruments (COSMIN) is necessary for future scale de-Muranaka J et al.

185velopment. Second, this study clarified the perceptionsof occupational therapists regarding the concept of QOL
among stroke clients. The differences in QOL regarding
other symptoms and diseases remain unclear. In futurestudies, comparisons with other diseases will be necessary. Finally, it is possible that social acceptance bias
existed among some of the study participants. All participants were asked for their accurate and honest opinions
prior to the interview, and sufficient member checking
was conducted on their responses. However, it cannot becompletely ruled out that some of the participants may
have given answers that represented untrue intentions,but rather, those that were considered desirable by the
public.

Conclusions
This study investigated occupational therapists’perceptions of QOL among stroke clients. The results
revealed that ‘adaptation to meaningful occupation’,‘good personal causation’, and ‘family happiness andgood relationships’ were the three major concepts
contributing to QOL. These findings can be used by occupational therapy clinicians and researchers to address
QOL among stroke clients and are vital for ensuring thedevelopment of QOL assessment scales and occupational therapy services.

Conflict of interest
There are no conflict of interest related issues to bedisclosed in relation to this paper.

References[1] Van Hecke N, Claes C, Vanderplasschen W, De Maeyer
J, De Witte N, Vandevelde S. Conceptualisation andmeasurement of quality of life based on Schalock andVerdugo’s model: A cross-disciplinary review of the literature. Social Indicators Research. 2018; 137(1): 335–51.
[2] Backman C. Outcomes and outcome measures: Measuring what matters is in the eye of the beholder. Canadian
Journal of Occupational Therapy. 2012; 72: 259–64.
[3] Cusick A, Lawler R, Swain M. Chemotherapy, cancer,
and the quality of life-An occupational therapy approach.
Australian Occupational Therapy Journal. 1987; 34(3):105–13.
[4] American Occupational Therapy Association. Occupational therapy practice framework: Domain and process(4th ed.). American Journal of Occupational Therapy.
2020; 74(Supplement 2): 17–68.
[5] Brettschneider C, Lühmann D, Raspe H. Informativevalue of patient reported outcomes (PRO) in healthtechnology assessment (HTA). GMS Health Technology

186

OT’S PERCEPTIONS OF QOL AMONG STROKE CLIENTSAssessment. 2011; 7: 1–5.
[6] Pizzi MA,Richards LG. Promoting health, well-being,and quality of life in occupational therapy: A commitment
to a paradigm shift for the next 100 years. The American
Journal of Occupational Therapy. 2017; 71(4): 1–5.
[7] Pizzi MA. Childhood obesity and the Environment–
Health–Occupation–Well-being (E–HOW) Model. Paper
presented at Ono College, Tel Aviv, Israel.
[8] Pizzi MA. Promoting health and well-being at the end oflife through client-centered care. Scandinavian Journal of
Occupational Therapy. 2015; 22(6): 442–9.
[9] Haley B, Natalie H, Samantha S. Understanding qualityof life within occupational therapy intervention research:
A scoping review. Australian Occupational Therapy Journal. 2019; 66(4): 417–27.
[10] Junichiro M, Satoshi S, Masatoshi G, Takeru M, Yuko S.
A Literature review of the definition and measurement ofquality of life in Japan occupational therapy intervention
studies (in Japanese). Japanese Journal of Occupational
Therapy Research. 2021; 24(1): 47–53.
[11] McKevitt C, Redfern J, LaPlaca V, Wolfe CD. Defining
and using quality of life: a survey of health care professionals. Clinical Rehabilitation. 2003; 17(8): 865–70.
[12] Sandelowski M. What’s in a name? Qualitative description revisited. Research in nursing & health. 2010; 33(1):77–84.
[13] Tong A, Sainsbury P, Craig J. Consolidated criteria
for reporting qualitative research (COREQ): a 32-item
checklist for interviews and focus groups. International
Journal for Quality in Health Care. 2007; 19(6): 349–57.
[14] Kallio H, Pietilä AM, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework
for a qualitative semi-structured interview guide. Journalof Advanced Nursing. 2016; 72(12): 2954–65.
[15] Elo S, Kyngäs H. The qualitative content analysis process. Journal of Advanced Nursing. 2008; 62(1): 107–115.
[16] Stemler S. An overview of content analysis. Practical
ASSESSMENT, RESEARCH, and Evaluation. 2000;
7(1): 17.
[17] Mayring PH. Qualitative Content Analysis (Forum Qualitative Sozialforschung). German Qualitative Psychology.
2000; 1(2): Article 20.
[18] Law M, Baptiste S, McColl M, Opzoomer A, Polatajko
H, Pollock N. The Canadian occupational performancemeasure: an outcome measure for occupational therapy.
Canadian Journal of Occupational Therapy. 1990; 57(2):82–7.
[19] Post MW, de Witte LP, Schrijvers AJ. Quality of life andthe ICIDH: towards an integrated conceptual model forrehabilitation outcomes research. Clinical Rehabilitation.
1999; 13(1): 5–15.
[20] Taylor RR. (Ed.). Kielhofner’s model of human occupation: theory and application. Wolters Kluwer. 2017; pp.
38–56.
[21] Burish, T. G. (1983). Coping with Chronic Disease; Research and Applications. New York, NY: Academic Press.
[22] Burke JP. A clinical perspective on motivation: pawn
versus origin. American Journal of Occupational Therapy,
1977; 31: 254–8.
[23] Hammell KW. Exploring quality of life following highspinal cord injury: A review and critique. Spinal Cord.
2014; 42(9): 491–502.
[24] Kemp BJ. Quality of Life, Coping and Depression. Aging
With a Disability. Baltimore: Johns Hopkins University
Press, 2014; pp. 48–67.
[25] Berkman LF, Syme SL. Social networks, host resistance,and mortality: A nine-year follow-up study of Alameda
County residents. American Journal of Epidemiology.
1979; 109(2): 186–204.
[26] House JS, Landis KR, Umberson D. Social relationships
and health. Science. 1988; 241(4865): 540–5.
[27] Association of kaifukuki rehabilitation wards: guidelines
for Kaifukuki rehabilitation wards (in Japanese). http://
rehabili.jp/organization/links/point_vol-1.pdf (Ref:20234-10)[28] Glass TA, Maddox GL. The quality and quantity of social
support:Stroke recovery as psychosocial transition. Soc
Sci Med. 1992; 34(11): 1249–61.
[29] Van Gennep A. The rites of passage Second edition. University of Chicago Press, Chicago. 1960, pp.1189.
[30] Baron H, Hawrylyshyn N, Hunt SS, McDougall J. Understanding quality of life within occupational therapy
intervention research: A scoping review. Australian Occupational Therapy Journal. 2019; 66(4): 417–27.
[31] Fayed N, Kerr E, Rosenbaum P, Dubey A. Generic patientreported outcomes in child health research: a review ofconceptual content using World Health Organization
definitions. Developmental Medicine & Child Neurology.
2012; 54(12): 1085–95.

■ORIGINAL ARTICLE

A Novel Developed Nine-Hole Pegboard
to Assess Peg Travel and Reach Times
Kensuke Tochio1, 2, Daisuke Kimura3, Hiroshi Kinoshita4,
Ryuhei Okuno5, Takeshi Fukui6
1

 aster’s Program in Rehabilitation, Graduate School of Health Science and Technology, Kawasaki University of Medical
M
Welfare, Kurashiki, Japan2
Department of Rehabilitation Center, Kawasaki Medical School Hospital, Kurashiki, Japan3
Department of Physical Therapy, Kawasaki University of Medical Welfare, Kurashiki, Japan
4
Department of Health and Nutrition, Osaka Aoyama University, Mino, Japan
5
Department of Science and Engineering, Setsunan University, Neyagawa, Japan
6
Department of Occupational Therapy, Kawasaki University of Medical Welfare, Kurashiki, Japan

Abstract: Objective: The aim of this study was to develop a personal computer (PC)-coupled nine-hole peg test (NHPT)
incorporating an engineering device that could accurately measure the travel time of individual pegs and use it to provide standard data in healthy young women for future reference.
Methods: We produced a nine-hole pegboard consisting of a container with an accelerometer, a small photo reflector,
and an amplifier. Four temporal variables were calculated using software developed by the researcher. NHPTs were performed by 37 healthy right-handed young women with dominant and non-dominant hands. The hand used, the distancefrom the container to the peg hole (index of difficulty; ID), task (container to the board and board to the container), andphase (peg movement time, reaching time) were used as independent variables.
Results: The developed pegboard was found to accurately measure the time in each of the assumed phases. The total
performance time with the dominant hand was significantly shorter than that of the non-dominant hand (P < 0.001).
Time to move the peg from the container to the board accounted for approximately 54% of the total performance time
for both the left and right hands. The peg movement time increased performance time as the task difficulty increased(P < 0.001).
Conclusions: Our pegboard accurately measures movement times with individual pegs and the time to reach pegs without stopwatch assessments in young women. Baseline data on the right- and left-hand peg travel times and reach times
for healthy young women were provided for future reference.
Keywords: nine-hole peg test, hand dexterity, rehabilitation, Fitts’ law, functional assessment(Asian J Occup Ther 19: 187−194, 2023)

1. Introduction
The nine-hole peg test (NHPT) was developed in
1971, and its protocol, reliability, and validity were confirmed in 1985 [1, 2]. The National Institutes of HealthToolbox for Assessment of Neurological and Behavioral
Function, a simple assessment tool for researchers andReceived: 19 January 2023, Accepted: 11 May 2023
Corresponding to: Daisuke Kimura, Department of Physical Therapy,
Faculty of Rehabilitation, Kawasaki University of Medical Welfare,
288, Matsushima, Kurashiki, Okayama, 701-0193, Japane-mail: kimura.d@mw.kawasaki-m.ac.jp©2023 Japanese Association of Occupational Therapists

clinicians, was created in 2006 and recommended NHPT
for assessing hand dexterity [3]. The NHPT consists ofa container with nine pegs and a board with nine holes.
The user must lift one peg at a time from the container,
insert the peg into a hole in the board, and after all thepegs are inserted, return the pegs to the container one byone. The total time from the moment the finger touchesa peg in the container to the moment that the last peg is
moved back to the container is recorded.
The kinematic parameters measured by NHPT
allow for the detection of early motor deficits, typical ofsome pathologies [4]. The NHPT has also been used inrecent studies as an outcome measure for characterizing
diseases, to determine the severity of disability and188

NEWLY DEVELOPED NINE-HOLE PEGBOARD

whether it can be self-managed, and to estimate the likelihood of improvements [5].
The advantages of the NHPT include simplicity,
low cost, portability, short measurement time, and easeof application to all age groups. However, there areseveral disadvantages to the traditional testing method.
First, although there have been attempts, the NHPT has
not been technologically improved since 1971. Second,
the test result is based solely on the total time, whichcannot evaluate each patient’s particular difficulty (e.g.,in picking up the peg, transferring the peg, putting thepeg in a hole, or putting a peg back in the container).
Third, the difficulty of NHPT varies with the task
(removing or inserting a peg) and distance (location ofpeg holes); thus, without evaluating the movement of
individual pegs, the variation in the difficulty of NHPT
is hard to evaluate in detail. The difficulty of the NHPT
is determined by Fitts’ law [6], which has been used asa quantitative definition of difficulty in various studies
involving clinicians [7], healthy individuals [8], andtwo- and three-dimensional movements [9]. Fitts’ law
predicts that the operation time increases linearly withthe task’s index of difficulty (ID).
There were two aims in the present study; the firstwas to develop a new NHPT to accurately measure thetravel time of individual pegs, and the second was topresent future reference data in healthy adults using the
newly developed NHPT. Regarding the developmentof new pegboards, we developed a method whereby anelectro-optical device is fitted to detect the in and out
movement of individual pegs, and a connected personal
computer (PC) is used to acquire and analyze accurate
time information. This method measures the time taken
to move individual pegs, the time taken to reach the next
peg to be moved, and the difference in distance to theposition of the hole in the pegboard. Additionally, no
measurements include the examiner’s time measurement
error, thus ensuring accurate data. Regarding the second
aim, we provided detailed baseline data on peg movement times and reach times in healthy young women.
Previous studies have reported gender differences inupper limb dexterity [2]. Therefore, in this study, subjects were limited to females to eliminate the influenceof gender.

2. Methods
2.1. ParticipantsThis study included 37 young, healthy female
participants (mean age ± standard deviation [SD] = 24.6
± 2.5 years old). The dominant hand was investigatedusing the Edinburgh Handedness Inventory [10]. All
participants were determined to be right-handed (meanlaterality quotient ± SD = 89.78 ± 10.36). No participants had a history of hand injuries. Each participant
provided informed consent. This study was approvedby the ethics committee at the Kawasaki University of
Medical Welfare (No.17-104) and conformed to the
Declaration of Helsinki.
2.2. Pegboard development
A wooden nine-hole pegboard box (length × width× height = 340 × 145 × 60 mm) with a round lightweight
shallow plastic peg container (diameter = 105 mm) was
built with reference to the size and depth of the holes
and hole-to-hole distance of a commercially available
Rolyan nine-hole pegboard (Model A8515, Sammons
Preston Co., USA) (Fig. 1a). A miniature photo-reflector(RPR-220, Rohm Semiconductor Co., Japan) was fixedat the bottom of each hole to detect the light reflected bya small, lightweight wooden peg (weight = 0.5 g, diameter = 7 mm, length = 32 mm) (Fig. 1b). Self-built analog
amplifiers for photo-reflector signal amplification werealso placed inside the pegboard box (Fig. 1c). A miniature 3-D accelerometer (ADXL-335, Analog Device
Co., USA) was attached to the back side of the container
to detect the vibration caused by the participant touching a peg. The distances from the hole and container
centers were 110 mm for the first column, 142 mm forthe second, and 174 mm for the third. Electrical signals
from the photo-reflector and the accelerometer were
A/D-converted (250 Hz/channel) and stored on a PC.
2.3. Experimental procedures
The experiment was conducted in a quiet clinicalroom. Each participant was briefed about the experimental task to be performed after receiving a demonstrationof the task by one of the researchers. The participant
then sat on a chair, faced the test table on which thepegboard was placed, and performed practice trials until
they felt comfortable performing the task. The first task
was to move the pegs from the container, one by one,and place them into the holes on the board as quickly
as possible (“Task A”). The second task was performed
without pause, consisting of removing the pegs from theboard, one by one, and returning them to the container
as quickly as possible (“Task B”) (Fig. 2). The experimenter said “start” to initiate the task. When using theright hand, the container was located on the right side of
the board, while for left hand movements the container
was located on the left side of the board. Pegs werealways inserted and removed from the holes in the frontline to the third line, from the first column to the thirdcolumn for the right hand, and from the third column tothe first column for the left hand. For the experimental
data collection, each participant performed the task

Asian J Occup Ther 19: 187−194, 2023

Tochio K et al.

189

Fig. 1. PC-connected nine-hole pegboard.
A. A nine-hole pegboard with sensors was developed. B. The electrical circuits installed inside the pegboard C. One of the photoreflectors and operational amplifiers.

Fig. 2. Procedural operation.
Task A. The task is to take the peg from the container and put it in the hole, then reach for another peg in the container. Task B.
The task is to return the peg inserted in the hole to the container and then reach the peg inserted in the hole.

twice for each hand. Adequate breaks were provided between trials to minimize fatigue. Failure to grasp a peg
or dropping the peg in the middle of the task resulted inretesting.
2.4. Data analysis
A MATLAB (MathWorks, version 9.12)-based
program was developed by the authors to determine themoments of accelerometer signal onset for finger-peg
contact on the container and the peg drop in the container. The photo-reflectors onset and offset moments represented the insertion of a peg into the hole and removalof a peg from the board (Fig. 3). Another MATLAB
program was used to compute four temporal variables
for each of the nine pegs for the subsequent statisticalanalysis. The temporal variables included durations
from the finger-peg contact to the hole insertion (Fig.

3a) and from the hole insertion to the next peg contact
on the container (Fig. 3b) during Task A, as well as
durations from the removal of the peg from the board to
the container (Fig. 3c) and from the drop into the container to the removal of the next peg on the board (Fig.
3d) during Task B. Durations depicted in Figs. 3a and 3b
were the durations needed to move the pegs, which wetermed “peg movement times.” The durations depicted
in Figs. 3c and 3d involved the movement of the handto reach the next peg to be moved, which we termed the“reaching times.”
The total performance time was determined fromthe initial finger-peg contact moment to the final peg
drop in the container moment. The total time in Tasks A
and B was the sum of peg movement and reaching times
for the nine pegs. The time for the inter-task interval
was also computed by subtracting the total times of the

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NEWLY DEVELOPED NINE-HOLE PEGBOARD

Fig. 3. Signal output from the sensor pegboard and the examined temporal variables.
a. Peg movement time during the container-to-board task; b. reaching time during the board-to-container task; c. peg movement
time during the board-to-container task; d. reaching time during the container-to-board task.

container-to-board and board-to-container tasks from thetotal performance time.
2.5. Statistical analysis
Statistical analysis was performed with IBM SPSS
(Statistical Packages for Social Sciences, 21.0) witha chosen significance level of 0.05. Depending on the
purpose of the comparison, a paired samples t-test or
two-way analysis of variance (ANOVA) with repeatedmeasures was used. When performing the two-way
repeated measures ANOVA, the independent variables
used were the task (Tasks A and B), phase (peg movement and reaching times), hand used (right or left), andcolumn (first, second, and third columns). Post hoc multiple comparisons were performed using a Bonferroni
method when necessary.
2.6. Application of Fitts’ law to the nine-hole pegboard
performance
Fitts studied the relationship between the size ofan object, the distance to a target, and its associatedmotion time from a tapping task with a metal stylus andexpressed these relationships in the following equation:
MT = a + b ´ ID
Movement time (MT) is the movement time to thetarget, “a” and “b” are constants, and ID is the difficultyof the movement, which is expressed by the following
equation:

ID = log 2( 2WA )

where “A” is distance and “W ” is width.

3. Results
3.1. Total performance time
The mean values of the total performance, peg
movement, reaching, and inter-interval times for allparticipants for each hand and task are summarized inTable 1. The peg movement times for Task A accounted
for 54.1% of the total performance time for the righthand and 55.2% of that of the left hand. For Task B, thepeg movement times were 15% of the total performancetime for the right hand and 14.7% of that for the left
hand. The reaching and task interval times for both tasks
were approximately 14% and 2% of the total performance time for both hands, respectively. The results ofthe paired t-test are also presented in Table 1. For bothtasks, the total performance, peg movement, and reaching times were significantly lower with the right handthan with the left hand.
To investigate whether the differences in time fortasks were due to differences in the tasks performed (Task
A or B) and phase (peg movement time, reaching time),
we performed ANOVA of the two corresponding factors,
with task and phase as independent variables and timeas the dependent variable. There was an interaction oftask × phase (F (1, 72) = 3,572.984, P < 0.001). There
was a main effect in both task (F (1, 72) = 4,227.638,

Asian J Occup Ther 19: 187−194, 2023

Tochio K et al.

191

Table 1 Mean total performance, peg movement, and reaching times for the Task A and Task B with right and left hand.
Total perfomance time

Task A

Task BPeg movement time

Reaching time

Peg movement time

Reaching time

Task interval timeright hand (sec)left hand (sec)

15.78 (1.21)
17.48 (1.33)

8.53 (0.71)
9.65 (0.83)

2.31 (0.24)
2.51 (0.34)

2.37 (0.26)
2.56 (0.23)

2.22 (0.33)
2.39 (0.34)

0.35 (0.05)
0.37 (0.09)

t-test t-value−8.15***−7.52***−4.45***−5.65**−2.98**N.S

The values in parenthesis are the standard deviation. ** p < 0.01, *** P < 0.001.

P < 0.001) and phase (F (1, 72) = 3,926.839, P < 0.001).
Peg movement time in Task A was approximately 3.6
times higher than that in Task B (9.1 vs. 2.5 s; P < 0.001).
Reaching time in Task A was greater than that in Task
B (2.41 vs. 2.31 s; P = 0.013). Peg movement time wasgreater than the reaching time for both Tasks A and B(P < 0.001).
3.2. Index of difficulty of the NHPTThe difficulty in Task A in a descending order ofthe distance between the column and the contender was
as follows: first column ID, 7.6 bits; second column ID,
8.1 bits; and third column ID, 8.4 bits. In contrast, thedifficulty in Task B was as follows: first column ID, 1.0
bits; second column ID, 1.5 bits; and third column ID,
1.8 bits.
3.3. Peg movement time in Task A
To investigate whether the differences in peg movement time in Task A were due to differences in the handused (right or left) and distance (first, second, or thirdcolumn), we performed an ANOVA of these two factors,
with hand and distance as independent variables andtime as the dependent variable. The results showed that
there was no interaction of hand × distance (F (2, 72) =0.710, P = 0.495), but the main effects of hand (F (1, 36)= 53.063, P < 0.001) and distance (F (2, 72) = 87.597, P< 0.001) were significant (Fig. 4). Task A took approximately 3.6-times longer than Task B. Multiple comparisons using the Bonferroni method showed that the firstcolumn was the faster and the third column the slowest.
The left hand required more time than the right, and thethird column required more time than the first.
3.4. Reaching time in Task A
There was no hand × distance interaction for thereaching time in Task A (F (2, 72) = 1.015, P = 0.368),
but there were main effects of hand (F (1, 36) = 11.967,
P = 0.001) and distance (F (2, 72) = 12.505, P < 0.001)(Fig. 5). The results of multiple comparisons using the
Bonferroni method showed a significant difference between the mean times for the second and third columns
for the right hand (P = 0.011). There was a significant

difference between the mean times for the first and thirdcolumns for both left and right hands (right hand: P =0.001, left hand: P = 0.038).
3.5. Peg movement time in Task B
Regarding peg movement times in Task B, there
was an interaction of hand (right or left) × distance (first,
second, or third column) (F (2, 72) = 3.929, P = 0.021).
There was a main effect of hand (F (1, 36) = 30.079, P <0.001) and distance (F (2, 72) = 183.598, P < 0.001) (Fig.
4). Multiple comparisons using the Bonferroni method
showed the first column was the faster and the third theslowest.
3.6. Reaching time in Task B
There was no interaction between hand and distance(F (2, 72) = 0.730, P = 0.485). Further, there was no main
effect of distance (F (2, 72) = 1.868, P = 0.162), although
there was a main effect of hand (F (1, 36) = 7.029, P =0.012) (Fig. 5).

4. Discussion
4.1. A newly developed NHPTIn the frequently used NHPTs, an examiner witha stopwatch signals the beginning of the test to theindividual, starts the measurement by visually judging
the start of the individual’s movement, and stops it upon
visual confirmation of the last peg being moved to thecontainer. The measured results are always influenced
by the examiner’s judgment and stopwatch operation
errors. Moreover, the only time information available
from these tests is the total task execution time, andno detailed movement time information related to the
manipulation of the pegs can be obtained. To overcome
these challenges, we developed a prototype NHPT that
can identify peg travel times using electro-optical technology. The results showed that the novel NHPT could
measure the travel time of individual pegs between thecontainer and the board and the peg arrival time of thehand in milliseconds. The importance of separating
the peg transfer from the container to the board in thefirst half (Task A) and from the board to the container

192

NEWLY DEVELOPED NINE-HOLE PEGBOARD

Fig. 4. Peg movement times for each distance with the right and left hands.
As the distance increased, it took longer to complete the task with both the left and right hands. ** P < 0.01, *** P < 0.001.

Fig. 5. Reaching time with the right and left hands.
The 1st column represents the holes close to the container, the 2nd column represents the holes in the middle of the pegboard, andthe 3rd column represents the holes far from the container. In Task A, the reaching time increased as the distance increased. In
Task B, reaching took more time at closer distances than at farther distances. *** P < 0.001.

in the second half (Task B) was also demonstrated.
Furthermore, the differences between peg transfer timeand hand reaching time to the peg were also clarified,allowing a more detailed assessment of the individual’s
dexterity function with more time variables. Incorporating a system for wireless data capture to mobile phones
and software for an immediate evaluation of results canimprove the usefulness of this new device.
4.2. Task differences
Regarding peg movement times, it became evident
that the peg manipulation time became longer as ID
increased in both Tasks A and B. The peg movement
time of Task A accounted for approximately 55% of

the total performance time with both the left and righthands, clearly showing that Task A required longer tomove pegs than Task B. The IDs of the peg movementof Tasks A and B were 7.6–8.4 bits and 1.0–1.8 bits,
respectively. The peg movement time in Task A wasapproximately 3.6 times longer than that in Task B. The
peg movement time for both Tasks A and B tended toincrease as the ID increased, which supported the resultsof previous studies [11]. The time required for the left
and right hands increased as task difficulty increased,
as indicated by the difference between the left and righthands (191 ms for Task B and 1,129 ms for Task A).
In Task A, the movement times became longer
as the distances to the object increased. These resultsAsian J Occup Ther 19: 187−194, 2023

supported a previous study on online feedback and trajectories in pointing tasks in which the time required forreaching increased as the distance to an object increased[12, 13]. However, in Task B, which showed no significant differences, there was a reverse trend in which the
movement time was shorter for the third column thanthat for the first column. To clarify the cause of theseresults, we filmed several participants performing thetest. Throwing the peg into the container was frequently
observed as the peg movement distance became longer.
This reversal may have occurred because the reaching
distance became shorter than the actual distance because
participants were throwing the peg.
Taken together, the NHPT is an evaluation methodthat includes two types of tasks that differ in difficulty:
grasping and manipulating an object and reaching for
it. The results for peg movement and reaching times in
Tasks A and B suggested that the degree of difficulty ofeach task differs. Even for peg manipulation, inserting a
peg in Task A and removing it in Task B have different
characteristics. To perform the NHPT correctly, it may
be necessary to instruct the participants to place the pegs
in the container and prevent them from throwing thepegs during Task B.
The concept of task difficulty may help assess theupper extremity. In the context of specific upper extremity functional assessments, such as the NHPT, Purdue
Pegboard Test [14], and O’Connor Finger Dexterity Test[15], the task difficulty differs owing to changes in thetransmission distance. Nevertheless, the index for theseassessments is the total time required to perform thetask. We suppose that their task difficulty was quantified
in the same way as in this study. In that case, it might bepossible to identify patient problems, develop training
content and new treatment methods, linking assessment
to rehabilitation.
4.3. Baseline data
Detailed baseline data on the NHPT of 37 healthy
young women were provided. Cross-group studies ofdexterity using the pegboard test have often identified
that women perform better than men [2]. A recent study
has found that women are significantly more dexterous
than men, even when hand size is considered [16].
Thus, in the present study, only women were included,
considering the differences in dexterity between men
and women. The total performance time was shorter forthe dominant right hand (15.78 ± 1.21 s) than that for
the nondominant left hand (17.48 ± 1.33 s), and significant differences in the interval time required to switch
between tasks were found. The right hand had shorter
execution times in Task A, Task B, and each of the fourphases. The results of this study were consistent withTochio K et al.

193

previous studies [17], which showed that the dominant
hand elaborates and shortens the motor time more than
the nondominant hand.
4.4. Limitations
This study has some limitations. Healthy youngright-handed women with their normative values were
included, and data on men, healthy individuals of awider age range, left-handed individuals, and patientswith hand dexterity problems were not included, which
is an issue that needs to be addressed in the future.
Furthermore, the board was prototyped using a commercially available NHPT as a model, and the data obtained
were analyzed using dedicated software developed by
the researchers. For use in clinics and other facilities, itis necessary to develop general-purpose software thatallows data to be easily processed and calculated on a
PC or a mobile phone.

5. Summary and conclusions
This study introduced a newly developed PCconnected NHPT that automatically measures peg insertion and peg lifting, dividing it into two tasks and fourphases. Moreover, detailed baseline data on peg movement times and reaching times were obtained in the left
and right hands of 37 healthy young women, showingthat a longer time was required for the left hand than for
the right hand in all four phases and with the increasing
ID of the NHPT.

Acknowledgements
We are grateful to the staffs and participants of our
hospital for their support.

Disclosure statement
No potential conflicts of interest were reported by
the authors.

References[1] Kellor M, Frost J, Silberberg N, Iversen I, Cummings
R. Hand strength and dexterity. Am J Occup Ther. 1971;
25(2): 77–83.
[2] Mathiowetz V, Weber K, Kashman N, Volland G. Adult
norms for the nine hole peg test of finger dexterity. Occup
Ther J Res. 1985; 5(1): 24–38.
[3] Gershon RC, Wagster MV, Hendrie HC, Fox NA, Cook
KF, Nowinski CJ. NIH toolbox for assessment of neurological and behavioral function. Neurology. 2013; 80(11Suppl 3): S2–6.

194

NEWLY DEVELOPED NINE-HOLE PEGBOARD[4] Paquin K, Ali S, Carr K, Crawley J, McGowan C, Horton
S. Effectiveness of commercial video gaming on fine
motor control in chronic stroke within community-level
rehabilitation. Disabil Rehabil. 2015; 37(23): 2184–91.
[5] Johansson GM, Häger CK. A modified standardized ninehole peg test for valid and reliable kinematic assessmentof dexterity post-stroke. J Neuroeng Rehabil. 2019;16(1): 8.
[6] Fitts PM. The information capacity of the human motor
system in controlling the amplitude of movement. J Exp
Psychol Gen. 1992; 121(3): 262–9.
[7] Temprado JJ, Sleimen-Malkoun R, Lemaire P, ReyRobert B, Retornaz F, Berton E. Aging of sensorimotor
processes: a systematic study in Fitts’ task. Exp Brain
Res. 2013; 228(1): 105–16.
[8] Mottet D, Bootsma RJ. The dynamics of rhythmical
aiming in 2D task space: relation between geometry andkinematics under examination. Hum Mov Sci. 2001;
20(3): 213–41.
[9] Verros S, Lucassen K, Hekman EEG, Bergsma A, Verkerke GJ, Koopman BFJM. Evaluation of intuitive trunkand non-intuitive leg sEMG control interfaces as command input for a 2-D Fitts’s law style task. PLoS One.
2019; 14(4): e0214645.
[10] Oldfield RC. The assessment and analysis of handedness:

the Edinburgh inventory. Neuropsychologia. 1971; 9(1):97–113.
[11] Saunders JA, Knill DC. Humans use continuous visualfeedback from the hand to control both the direction anddistance of pointing movements. Exp Brain Res. 2005;
162(4): 458–73.
[12] Thompson SG, McConnell DS, Slocum JS, Bohan M.
Kinematic analysis of multiple constraints on a pointing
task. Hum Mov Sci. 2007; 26(1): 11–26.
[13] Tiffin J, Asher EJ. The Purdue pegboard; norms andstudies of reliability and validity. J Appl Psychol. 1948;
32(3): 234–47.
[14] Berger MAM, Krul AJ, Daanen HAM. Task specificity offinger dexterity tests. Appl Ergon. 2009; 40(1): 145–7.
[15] Tiffin J. Purdue Pegboard: Examiner Manual; London
House: Rosemont, IL, USA, 1968
[16] Bardo A, Town K, Kivell TL, Donati G, Ballieux H,
Stamate C, Edington T, Forrester GS. The precision of
the human hand: variability in pinch strength and manual
dexterity. Symmetry. 2022; 14(1): 1–21, doi:10.3390/sym
14010071.
[17] Goble DJ, Brown SH. The biological and behavioral basis
of upper limb asymmetries in sensorimotor performance.
Neurosci Biobehav Rev. 2008; 32(3): 598-610.

■ORIGINAL ARTICLE

Variation in Lifestyle and Readiness of Participantsof a Return to Work Program According to Depressive
State by a Mixed Design Method
Aiko Hoshino1, Ichiro Kutsuna1, 2, Ami Usui3, Yukari Mori3, Mami Suwa3
1

Physical and occupational therapy,Graduate school of medicine,Nagoya University
Kusunoki Mental Hospital, Specified Medical Corporation Kusunokikai
3
Mental Clinic Anser, Medical Corporation Seiseikai
2

Abstract: Background: Mental health problems in the workplace are an important issue globally, and return-to-work(RTW) programs for people on sick leave because of mental health problems are being developed. However, participants’ situations and states are various and there are few assessment tools.
Objectives: We aimed to reveal the clinical picture of participants of an RTW program according to depressive statewith mixed method research to help occupational therapists plan client-centered rehabilitation programs.
Methods: We used a conversion mixed methods research design. We collected basic information and administered theBeck Depression Inventory (BDI) in the quantitative arm, and used written rehabilitation plans based on interviews
conducted in the initial stage assessments of participants in an RTW program as the qualitative arm. Data from thequantitative arm were divided into three groups according to severity of depressive symptoms based on BDI cut-off
points. Qualitative data were analyzed by creating codes and categories following the grounded theory approach. Bothtypes of data were merged by calculating the frequencies of occurrence of codes for each depression severity group.
Results: Our results showed that participants’ clinical pictures were different depending on their depressive state. Participants with a severe state had difficulty waking up early, disordered eating habits and appetite, and difficulty withselfdisclosure. Participants with a lighter depressive state had a stable lifestyle and were able to perform high-level cognitive activities like studying or exercise.
Conclusions: Our results will help occupational therapists assess participants in the initial stage RTW programs, andcontribute to effective interventions.
Keywords: depression, return to work, assessment, mixed design(Asian J Occup Ther 19: 195−204, 2023)

Introduction
Mental health problems in the work place are oneof the most important issues globally. For these problems, prolonged absence or separation from work is
one of the issues that needs to be resolved [1]. Support
and appropriate assessments for the people absencefrom work by mental health problems is one of thecentral role of occupational therapists.
Received: 17 December 2021, Accepted: 29 May 2023
Corresponding to: Aiko Hoshino, Physical and occupational therapy,
Graduate school of medicine, Nagoya University, 1-1-20 Daiko-Minami, Higashi-ku, Nagoya City, Aichi Prefecture
e-mail: hoshino@met.nagoya-u.ac.jp©2023 Japanese Association of Occupational Therapists

Various interventions have been conducted andreported on in the literature. For example, Nieuwenhuijsen et al. [2] reported that the combination of awork-directed intervention and clinical intervention
reduced the number of sick leave days. Stronger
evidence was also found for cognitive behavioral therapy-based stress management [3]. The effectivenessof occupational therapy for depressive symptoms isalready supported by strong evidence, and various occupational therapy practices also have been shown to
improve clients’ daily lives and work performance, andincrease participation in the workforce [4]. In returnto-work programs, occupational therapists reported
possibility of playing a role with intervention focusedon cognitive functions [5]In Japan, similarly, absence from work and196

VARIATION IN LIFESTYLE AND READINESS OF PARTICIPANTS OF A RETURN TO WORK PROGRAM ACCORDING TO DEPRESSIVE STATE BY A MIXED DESIGN METHOD

retirement due to mental health problems have constituted a significant issue. The number of employeeson administrative leave has increased rapidly, and thenumber of cases of mental health issues recognized as
being work-related in 2019 was the highest ever. Investigations of employees who returned to work after
leaving due to depression also showed that 47.1% ofthem took administrative leave again, and the second
period of leave was 1.5 times longer than the first [6-8].
Moreover, Endo’s report from an information technology company showed that there was a steep increase
in recurrent rates the first two years after RTW [9]. To
resolve this situation, in Japan, return-to-work (RTW)
programs under the direction of psychiatric doctors
in mental health clinics have been implemented sincethe 2000s, and were reported the effectiveness in
depressive state, social anxiety and parasympathetic
activity [10, 11]. Many occupational therapists havebecome involved in various programs and taken on
the central role of conducting the programs. Support
for RTW programs in Japanese society has since been
growing [12]. However, the problems in daily living
and concrete disabilities experienced by RTW users inJapan have not yet been clarified because there havebeen few reports on the matter.
In RTW programs in Japan, generally, various
interventions based on group therapy are conducted,
for example, cognitive behavioral therapy, psychoeducation, and assertive training [13]. In Japan, a
psychiatrist or industrial doctor is responsible forthe occupational therapists conducting RTW programs, and the entry qualification for RTW programs
primarily consists of only the taking of a leave ofabsence from work at the point of starting the RTW
program. As a result, the client’s situations, withrespect to things such as depressive state, period ofleave, motivation, relationships with their co-workers
and family, and activities outside of work, are varied.
Initial assessments in RTW programs tend to be basedon a medical model and, as mentioned above, are quite
uniform, despite being graded according to the client’s
depressive state. In other words, the clinical picture in
the initial stage of RTW is not evaluated thoroughly
enough. Therefore, although occupational therapists’focus is client-centered, there tend to be few interventions in individualized settings [4]. This situation too
might be caused by the structure of RTW programs inJapan, which are packaged, uniform, and group based;
however, this is not an issue unique to Japan, and is
one of the common challenges faced worldwide in therelatively new field of occupational therapy in RTW.
For client-centered interventions in RTW, we first needto reveal the full variety of clinical pictures of clientsin the initial stage of RTW.
On the other hand, we generally only have few
and limited tools for initial assessments, such as theBeck Depression Inventory (BDI) [14], The Center
for Epidemiologic Studies Depression Scale [15], orthe Psychiatric Rework Readiness Scale (PRRS) [16].
Therefore, in order to develop more effective RTWinterventions, we need further investigations to help
assess clients based on evidence in the initial stage andto set attainable goals.
The purpose of this study was to clarify RTW
program participants’ clinical pictures in the initialstage according to their depressive state through mixed
method research. The results are expected to enableoccupational therapists to play an important role inplanning precise RTW rehabilitation programs andallow for more effective client-centered interventions.

Materials/Subjects
We used a mixed method design for the purposesof this study, which aimed to clarify RTW program
participants’ clinical pictures in the initial stage according to their depressive state. We used interview
data from staff to develop initial rehabilitation plans as
qualitative data for grasping participants’ clinical pictures. We also used BDI scores as quantitative data toassess participants’ depressive state. BDI was the main
assessment tool in previous studies, and thus enables
us to compare our results with those of previous studies, and to verify the position of our results in this area.
Therefore, we adopted BDI scores as quantitative datafor producing a quantitative standard. After collecting
both the qualitative and quantitative data, we merged
them. This method enabled us to explore multiple
perspectives based on both qualitative and quantitative
factors, and reveal relationships spanning multiple
research questions such as RTW participants’ clinicalpictures, depressive state, and readiness for work [17].
Participants in both the quantitative arm andqualitative arm
Participants were users of an RTW program. The
RTW program was conducted at one clinic in Aichi
Prefecture in Japan. The conditions for participationin this RTW program were absence from work due tomental health problems, depression, adjustment disorder, or bipolar disorder. The aim of the RTW program
was to ensure a smooth return to work for RTW users
by gradually increasing their level of activity aiming
toward an eventual return to work. The program wasconducted 5 days a week, and was combined withcognitive behavioral therapy, desk work, self-help

Asian J Occup Ther 19: 195−204, 2023

meetings, communication training, and exercise.
Professional staff including occupational therapists
assessed participants and conducted the RTW program
based on the assessment. The general usage periodof RTW programs in this institute was about 4 to 5
months. The contents of the RTW program conductedin this institute are standard in Japan, and the programis registered by the Japan Association of Rework for
Depression [18], which plays a central role in publicawareness in Japan.
The inclusion criteria for participants in this study
were as follows: (a) started using the RTW program at
the participating facility from 2017-2020, (b) absencefrom work at the start of the program, (c) diagnosis ofmajor depression or an adjustment disorder according
to the Diagnostic and Statistical Manual of Mental
Disorders 5th edition (DSM-5), and (d) consented toparticipation in this study. The exclusion criteria were:(a) diagnosis of bipolar disorder or a developmental
disorder according to the DSM-5 and (b) quitting workat the start of the program. We recruited the participants at the end of their RTW program taking into
consideration their depressive state and mental healthburden. We gave them information on our research andrequested their participation and use of their data. All
the participants provided written and verbal informed
consent to participate. All procedures were approvedby the Research Ethics Committee of the Graduate
School of Medicine, Nagoya University, Japan (authorization number: 2018-0149) in 2018, and followed all
ethical standards laid out in the Declaration of Helsinki.

Methods
Instruments
Background information and measurement:
Quantitative arm
We collected the following data as backgroundinformation: age, sex, years of education, numberof leaves of absence from work, kind of work, work
position, length of current service, and number ofjob changes. We also conducted the BDI, which is aself-administered questionnaire used to assess individuals’ depressive state in the preceding 2 weeks.
Higher scores indicate depressive symptoms as being
more severe. The cut-off scores are as follows: 0-13
(minimal), 14-19 (mild), 20-28 (moderate), and 29-63(severe). The validity and reliability of the Japaneseversion of the BDI have been confirmed [19]. The
BDI assesses depressive state for preceding 2 weeks.
Hence, in this study, in order to assess the depressive
state on the starting day of the RTW program, partici-

Hoshino A et al.

197

pants answered the BDI between the first and 14th dayof the RTW program.
Rehabilitation plan: Qualitative arm
We collected documents of rehabilitation plans
written based on initial interviews for assessments andgoal setting at the initial stage of the RTW program.
In the documents, results of interviews included
free-writing text, and we used that text data in thisstudy. The initial interview was a semi-structured
interview that lasted from 40 minutes to 1 hour, andwas conducted during the same period as the BDI.
Contents of interviews were constructed based on theparticipant’s needs and assessment items were extracted from the PRRS [16]. The PRRS is an observational
assessment for readiness of actual work in the last 2
weeks and consists of the following eight items: living
condition, symptoms, basic social skills, support, relationship with the participant’s company, work ability,
readiness of actual work, and health management.
Data analyses
Data from the quantitative arm were divided
into three groups according to severity of depressive
symptoms based on the cut-off points of the BDI. Eachbackground data item was compared among threegroups: severe (BDI: 21-40), light (BDI: 11-20), andminimal (BDI: 0-10).
Data from the qualitative arm were analyzed insteps. Firstly, we conducted incident-by-incident initialcoding following the Grounded Theory Approach [20]for one participant. After that, we conducted focus
coding depending on the contents of the initial code.
Finally, we divided the focus codes into categories.
After analyzing the data in both arms, we merged
the quantitative data and qualitative data, and calculated the frequencies of occurrence of focus codesin the severe depression group based on BDI scores.
Namely, we calculated the occurrence rate as follows
in each depressive state group: number of initial codesin the same focus code in each group per number ofparticipants included in each group. According to theoccurrence rate, we reviewed the characteristics of theparticipants.

Results
Participants
94 individuals used an RTW program in this research period, and 27 participated in this research. 24
males and three females participated, and the average
age was 40.7±9.95 years. Table 1 shows detailed sociodemographic data of the study participants.

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VARIATION IN LIFESTYLE AND READINESS OF PARTICIPANTS OF A RETURN TO WORK PROGRAM ACCORDING TO DEPRESSIVE STATE BY A MIXED DESIGN METHOD

Table 1 Demographics of participants
All participants(n=27)

Severe group(n=8)

Light group(n=13)

Minimal group(n=6)

P value †Average age, years (SD)40.7
(9.95)

41.3(8.73)

38.0(10.7)

46.1(8.86)

0.28

Average BDI(SD)17.9(9.53)

29.5(5.26)

16.6(3.12)

5.33(1.21)<.001
MG < LG <SG**

Sex (Male/Female)

24/3

7/1

11/2

6/0

0.61

Complication (with/without)

14/13

3/5

11/2

0/6

0.18

Number of leaves of absence,
1
2
3
4

14
5
6
2

1
3
2
2

9
2
2
0

4
0
2
0

1
8
13

1
2
4

0
5
5

0
1
4

2
1
2

0
1
0

2
0
1

0
0
1

11
16

3
5

5
8

3
3

17.2
(10.8)

17.5
(3.5)

15.1
(11.4)

21.3(11.3)

Number of job changes,
0
1
2

22
2
3

5
1
2

12
1
0

5
0
1

Education level,
Less than high school
High school graduate
College graduate or more

1
12
14

0
3
5

0
9
4

1
0
5

Occupation,
Sales work
Clerical work
Engineering or technicalwork
Medical work
Public official
OthersPosition
Higher than manager
General
Average years of incumbent
employment (SD)

0.07

0.36

0.87

0.49
0.37

0.016

Note.MG = Minimal group, LG = Light group, SG = Severe group, SD = standard deviation, BDI: Beck Depression Inventory, IQR: interquartile range.9.53†Scores between the three groups were compared using One way ANOVA and t-test for age, BDI, years of incumbent employment. Scores
between the three groups were compared using Pearson’s chi-square test for sex, complication, number of leaves of absence, occupation,
position, number of jobs change and education level.

Quantitative arm
The mean BDI of all participants was 17.9±9.53.
Participants were divided into three groups based on
BDI score: minimal group (six participants), lightgroup (13 participants), and severe group (eight participants). The mean BDI in each group was as follows:
minimal group (5.33±1.21), light group (16.6±3.12),
and severe group (29.5±5.26). Background information in each group is also shown in Table 1. In only
education level, although it showed different trends

between the minimal group and light group significantly, we were unable to conduct further analysis due tothe limitation of the small number of participants. Allother factors were not significantly different among thethree groups.
Qualitative arm
We identified 570 initial codes based on our
procedure, and after the next stage, we developed 124
focus codes. Finally, we created 13 categories. The
names of the categories were as follows (the number

Asian J Occup Ther 19: 195−204, 2023

Hoshino A et al.

199

Table 2 Developed focus codes and categories
Category (number of focus codes-initial codes)

Examples of focus codes

Lifestyle (15-98)

Have three meals a day
Going to bed later than usual on work days
Drinking habit; once a day

Sleep (15-69)

Difficulty getting to sleep
Have interrupted sleep
Have hypersomnia

Taking medicine (3-28)

Missing doses
Only take medicine as needed

Activity(12-66)

Housework
Exercise
Watching TV

People, interpersonal relations and social scenes that participants don’t like (17-73)

People who put themselves under high pressure or are angry
Shy of strangers
Feeling others can’t understand me

Psychiatric symptoms when in a bad condition (14-46)

Feeling something is wrong with mentality
Being pessimistic
Decreased concentration

Somatic symptoms when in a bad condition (14-33)

Headache
Palpitation
Abdominal pains/diarrhea

Current relationships with people at work (5-24)

Little contact with people at work
Regularly contact with people at work
Want to transfer

The relationships with family or doctor (2-3)

Wanting to transfer a different hospital

Purposes of RTW program (27-132)

Already decided the period of returning to work
Participating in the program without absence
Reinforcement of interpersonal skill
Finding my own pace for life

RTW: return-to-workof included focus codes-the number of included initialcodes): Lifestyle (15-98), Sleep (15-69), Taking medicine (3-28), Activity (12-66), People, Interpersonal
relations and social scenes that participants do not
like (17-73), Psychiatric symptoms when in a bad
condition (14-46), Somatic symptoms when in a bad
condition (14-33), Current relationships with people atwork (5-24), Relationships with family or doctor (2-3),
and Purposes of the RTW program (27-132). Table 2
shows examples of the focus codes.

Merge of quantitative data and qualitative data
We extracted, in each group, focus codes withfrequencies of occurrence of over 50%. We showed
the frequencies Table 3.
As a result, the following five focus codes showedfrequencies of over 50% in all groups: Difficulty ingetting to sleep, Housework, People who put themselves under high pressure or are angry, No missing
doses, and Already having decided the period of
returning to work. In the severe group only, Waking

1 (12.5)

Studying (5)Purposes of RTW program

3 (37.5)

Exercise (10)Activity

3 (37.5)
1 (12.5)
1 (12.5)

Understanding the contents of the program (6)Reinforcement of interpersonal skills (8)Working as usual (7)2 (25.0)

Feeling something is wrong with mentality (12)Psychiatric symptoms in bad condition

3 (37.5)

Have three meals a day (17)Only minimalgroup

3 (37.5)

4 (50.0)

Have an appetite (14)Shy of strangers (15)People, interpersonal relations and social
scenes that participants don’t like

4 (50.0)

Lifestyle

Skipping meals (11)Life style

4 (50.0)

Participating in the program without absence (10)

4 (50.0)

6 (75.0)

4 (50.0)

Already having decided the period of returning to work (22)

Purposes of RTW program

8 (100)Finding my own pace for life (9)No missing doses (23)

Taking medicine

6 (75.0)

Purposes of RTW program

People who put themselves under high pressure or are angry (20)People, interpersonal relations and social
scenes that participants don’t like

4 (50.0)

Wake up later than you should for work (10)Housework (20)

Activity

5 (62.5)

LifestyleDifficulty getting to sleep (18)Sleep

Severe group(n=8)

2 (15.3)

3 (23.0)

0 (0)

0 (0)

3 (23.0)

6 (46.1)

8 (61.5)

7 (53.8)

9 (69.2)

7 (53.8)

6 (46.1)

5 (38.4)

4 (30.7)

11(84.6)

11 (84.6)

10 (76.9)

11 (84.6)

10 (76.9)

Light group(n=13)

4 66.6)4 (66.6)

3 (50.0)

4 (66.6)

4 (66.6)

4 (66.6)

6 (100)4 (66.6)

2 (33.3)

0 (0)

0 (0)

0 (0)

2(33.3)5 (83.3)

4 (66.6)

4 (66.6)

5 (83.3)

3 (50.0)

Minimal group(n=6)

Number of included initial codes(Percentage of frequency :%)Light groupand minimal
group

Severe groupand light group

Only severegroup

All threegroups incommonName of category

Name of focus code
(number of included initial codes)

Table 3 Frequencies of occurrence of focus code

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up later than needed to for work, Finding one’s own
pace for life, and Participating in the program withoutabsences showed frequencies of over 50%. Also, Skipping meals and Shy of strangers showed frequenciesof over 50% in the severe group and the light group.
On the other hand, in the light group and minimalgroup, Having an appetite and Having three meals a
day had high frequency focus codes. Additionally, we
revealed the following six focus codes as having over
50% frequency in the minimal group only: Feelingthere is something wrong with own mentality, Exercise,
Studying, Understanding the contents of the program,
Reinforcement of interpersonal skills, and Working as
usual.

Discussion
The aim of this study was to reveal RTW participants’ concrete clinical pictures in initial stage
according to their depressive state. We focused on
characteristic categories, and discussed our resultsfrom the following three points: variation in attitudes
towards participation in the RTW program according
to depressive state; clinical picture in daily life; andcharacteristics in interpersonal activities.
Variation in attitudes of participation in the RTW
program according to depressive state
Already having decided the period of returning
to work was revealed to have a high frequency inall groups, which showed that participants had highmotivation for the RTW program. Additionally, in allgroups, No missing doses showed a high frequency,
which showed that participants had high treatmentcompliance. In Japan, generally, re-work programs are
optional programs provided in addition to outpatientcare; therefore, participants choosing to participate inan RTW program of their own volition suggests it ispossible that they agree with their own diagnoses andthus take their medication as directed.
However, Participating in the program withoutabsence and Finding one’s own pace for life showeda high frequency in the severe group only. This result
suggests that participants with a severe depressive
state had little confidence about participating in the
RTW program and being able to reconstruct their
daily lives thorough the program. Therefore, based on
those results, we focused on wake-up time as a factor
causing absence in the program, and participants inthe severe group, at high frequency, woke up later
than usual (Waking up later than needed to for work).
Previous studies reported that depression caused
insomnia [21], and patients with depression tended to

Hoshino A et al.

201

have difficulty waking up because of sleeping disorders or diurnal variation [22]. Similarly, in this study,
participants with a severe depressive state seemed toshow this code at a high frequency. On the other hand,
our results showed Difficulty in getting to sleep wascommon in all stages of depression. A previous study
showed continuity of this symptom [23] over all recovery stages of depression, and our results supported theresults of this previous research. Therefore, our results
suggested the necessity of focusing on regulation ofparticipants with severe depressive state for participation in RTW programs. Occupational therapists, inother words, should pay attention to clients’ wake-up
time and promote regulation in their lives, in addition
to interventions for continuous difficulties based on
insomnia as generally seen in clients with depression.
Actually, in some previous reports of rehabilitation forthe clients with depression [24, 25], regulation of theirlife or time management was suggested as the first stepof rehabilitation or occupational therapy.
Generally, is it recommended for clients to haveachieved a certain recovery stage at the start of an
RTW program because they are required to participate
in activities through the program. Based on this, however, we suggest that occupational therapists should
focus on participants in a severe depressive state whoare experiencing difficulties that occur more easily
in the initial recovery stage, and conduct appropriate
interventions for them.
In the minimal group, additionally, in accordancewith the purpose of the RTW program we revealed
focus codes such as Understanding the contents ofthe program and Reinforcement of interpersonal
skills, which were above simple participation, andconstituted the more advanced purposes of the RTW
program. Moreover, participants were able to notice
their minor psychiatric symptoms (Feeling there issomething wrong with one’s own mentality). Occupational therapists tend to think that understanding of
the purpose of the program and the participants’ own
states develops after the middle stage of the rehabilitation period, namely the stage when some recovery
has been achieved; however, our results showed thatparticipants with a very low depressive state could
understand those purposes and understand themselves
even in the initial stage of the RTW program. Suchunderstanding can promote participants’ motivation,and therefore, in order to put it to use in the RTW
program, occupational therapists will need to select anappropriate intervention without being biased by thestage of the program.

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VARIATION IN LIFESTYLE AND READINESS OF PARTICIPANTS OF A RETURN TO WORK PROGRAM ACCORDING TO DEPRESSIVE STATE BY A MIXED DESIGN METHOD

Daily activities participants performed
When we focused on the participants’ lifestyles,
skipping meals was common in the severe and lightgroups. In addition, some participants in the lightand minimal groups indicated they had an appetiteand had three meals a day. This result indicates thatparticipants’ appetites in the initial stage of rehabilitation might be an indicator of depressive state. In
the DSM-5 [26], decreased or increased appetite withsignificant weight loss are common symptoms ofdepression. Moreover, Papadimitriou [27] mentioned
the co-occurrence of disturbed sleep and appetite loss,
and some reports have suggested appetite and thesleep/wake cycle were the most sensitive biologicalrhythms. In this study, similarly, delayed wake-up
time co-occurred with decreased appetite in the severegroup. Occupational therapists tend to focus only on
factors directly related to work performance; therefore,
it is easy to overlook participants’ appetite. However,these results suggest that the degree of a participant’s
appetite is an important indicator in RTW programs.
We also discussed the activities the participants
performed. Housework was conducted by participantsin all groups. Generally, housework includes activities
that require high-level cognitive functions, like cooking or child-rearing. Otherwise, housework can also
include easy and short-duration activities like taking
out the garbage or simple cleaning. In other words,
housework can be thought to require several kindsof cognitive functions. As such, most participants indifferent depressive states might be able to perform
housework.
On the other hand, studying and exercise werecharacteristic activities in participants in the minimalgroup. Generally, studying is a desktop activity that
requires high-level cognitive functions such as attention and memory. In our results, participants in theminimal group seemed to be able to perform activities
like studying using cognitive functions that improvedin accordance with their recovery from depressive
symptoms. Previous studies suggested that impairment
of attention, executive functioning, and verbal memory
continued in patients after remission, and also thatthose cognitive dysfunctions were influenced by theremaining depressive symptoms [28, 29]. Additionally, the severity of cognitive functioning impairment
was said to be one of the independent indicators of
psychosocial aspects [30]; therefore, focusing on cognitive functioning through activities the participants
performed was important from the viewpoint of the
RTW program, in order to assess participants’ state in
the initial stage of rehabilitation.
Exercise was also one of the characteristic ac-

tivities in the minimal group. Previous studies havealso shown physical activity and depression to beconsistently inversely associated [31]. Based on thosereports, similarly, the amount of physical activity inparticipants in the minimal group seemed to be higher
than those in other groups with a more severe depressive state. Focusing on participants’ activities is essential in occupational therapy, and based on our results
we believe that occupational therapists can investigate,as part of the initial assessment, whether clients perform activities requiring high-level cognitive functions
or actions like exercise or desktop activities, as indicators.
Characteristics in interpersonal activities
In interpersonal activities, participants in allgroups showed unpleasant feelings towards people
who put themselves under high pressure or were angry.
Many previous reports [32] mentioned high sensitivity
for interpersonal factors in interpersonal conflicts inpeople with depression, and the Interpersonal Sensitivity Scale (IPSM) [33] was used in many of thosereports. The IPSM consists of five underlying components: interpersonal awareness, separation anxiety,timidity, fragile inner self, and need for approval. Discussed from the viewpoint of those five components,
unpleasant feelings towards individuals who put themselves under high pressure or are angry in our results
seemed to be related to sensitivity of “interpersonalawareness” and “timidity”. Further, participants in thesevere group and light group mentioned they were “shyof strangers”, potentially indicating a “fragile innerself” as described in the IPSM. Moreover, Luty et al.
reported not only that the total IPSM score was strongly correlated with depressive state, but “fragile innerself” was also the only significantly correlated factor
with depression in the five sub-axes in the IPSM [34].
From these considerations, it can be said that interpersonal problems revealed in this study were expressedat the appropriate point, indicating high interpersonalsensitivity in those with depression.
Clinical Implications
We revealed a variety of depressive states andclinical pictures among users in the initial stage of an
RTW. Sleeping disorders and degree of appetite areappropriate considerations for the assessment of RTW
users’ state. Moreover, the contents of the activities
they performed were varied, and might have changed
according to depressive state. As a clinical implication, carefully listening to information about users’
daily lives based on the specialty of occupational
therapists is suggested to be important. These points

Asian J Occup Ther 19: 195−204, 2023

are self-evident for occupational therapists; however,
RTW programs tend to follow a medical model, andwe cannot deny that we tend to overlook these aspects
in our practice. We believe that we should develop ourinterventions based on those results. In this study, we
did not collect detailed data regarding participants’occupations in the interviews, such as information
about the meaning of their occupation, because we
focused on users’ clinical pictures in the initial stage of
the RTW program, in which their condition is usually
severe and it is difficult for them to develop rapport
with others. If we conduct those assessments in the
middle stage of the RTW, interventions could potentially be more effective and client-centered.

LimitationsFirst, we should note that our results are based ondata from only one clinic. There is thus the possibilityof bias in both participants and staff participating in
our research. Additionally, participants were skewed
toward being male. Therefore, it might be difficult togeneralize our results, although they did reveal important perspectives. In order to generalize and make ourresults relevant to clinical practice, we need to conduct
further research in the future.
Second, qualitative data were collected from interviews based on the PRRS. The PRRS is an assessment
specific to RTW, and it was matched with the participants and purpose of this study. However, by using the
PRRS, we could not focus on other characteristics or
clinical pictures not included in it. In a future study, tocompensate for this problem, we need to acquire more
information about participants through observation or
unstructured interviews.
Third, we set depressive state (as determinedby BDI score) as a factor influencing participants’lifestyles and clinical pictures, and divided qualitative
data based on BDI score. However, factors besides
depressive state can influence sick leave, including
developmental disorders, economic state, and sex [35].
Moreover, the degree to which these factors influence
the clinical picture is unclear. In order to clarify this,
we hope to analyze qualitative data based on otheraspects. It is also important to clarify the degree towhich those factors influence participants’ daily lives.

Summary and Conclusions
We investigated the clinical pictures of participants of an RTW program according to depressive
state in a cross-sectional study with a mixed method
design. Our results showed that participants’ clinical

Hoshino A et al.

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pictures differed substantially depending on theirdepressive states. Participants with a severe state had
difficulty waking up early, had disordered eating habits
and appetites, and they seemed to be unable to use the
RTW program properly. Additionally, they tended tofeel difficulty with self-disclosure. On the other hand,participants with a lighter depressive state had stable
lifestyles, and they could perform high-level cognitive
activities like studying or exercise. They also could
use the RTW program and understand its contents.

Acknowledgements
The authors are deeply grateful to all the participants for taking part in this study.

Declaration of Conflicting Interests
The authors confirm that there is no conflict ofinterest.

Funding
This work was supported by JSPS KAKENHI
Grant Number JP18K17716.

References[1] Doki S, Sasahara S, Matsuzaki I. Psychological approach of occupational health service to sick leave due
to mental problems: a systematic review and meta-analysis. Int Arch Occup Environ Health. 2015;88(6):659–
67.
[2] Nieuwenhuijsen K, Faber B, Verbeek JH, Neumeyer-Gromen A, Hees HL, Verhoeven AC, et al. Interventions to improve return to work in depressed people.
Cochrane Database of Syst Rev. 2014; Dec 3(12).
[3] Joyce S, Modini M, Christensen H, Mykletun A, Bryant
R, Mitchell PB, et al. Workplace interventions forcommon mental disorders: a systematic meta-review.
Psychol Med. 2016;46(4):683–97.
[4] Christie L, Inman J, Davys D, Cook PA. A systematic
review into the effectiveness of occupational therapy
for improving function and participation in activities ofeveryday life in adults with a diagnosis of depression. J
Affect Disord. 2021;282:962–73.
[5] Wisenthal A, Krupa T. Cognitive work hardening: areturn-to-work intervention for people with depression.
Work. 2013;45(4):423–30.
[6] Japan Local Government Employee Safety & Health
Association. Overview of the current status of healthof local public officers [online]. 2019 [cited 2021 Nov
10]. Available from: http://www.jalsha.or.jp/wordpress/
wp-content/uploads/2021/12/R3 ★地方公務員健康状
況等の現況の概要 .pdf (Japanese)

204

VARIATION IN LIFESTYLE AND READINESS OF PARTICIPANTS OF A RETURN TO WORK PROGRAM ACCORDING TO DEPRESSIVE STATE BY A MIXED DESIGN METHOD[7] Ministry of Health L and W of J. Status of Workers’
Compensation for Brain and Heart Diseases and Mental
Disorders in 2009 [online]. [cited 2021 Nov 10]. Available from: https://www.mhlw.go.jp/houdou/2009/06/dl/
h0608-1b.pdf[8] Kazuhito Y. Clinical Research Grant for Occupational
Diseases Summary Report: Research on the proposalof effective methods for cooperation between attending
physicians and industrial physicians [online]. 2015
[cited 2021 Nov 10]. Available from: https://www.
mhlw.go.jp/seisakunitsuite/bunya/koyou_roudou/
roudoukijun/rousai/hojokin/dl/27_14010101-02.pdf[9] Endo M, Haruyama Y, Muto T, Yuhara M, Asada K,
Kato R. Recurrence of sickness absence due to depression after returning to work at a Japanese IT company.
Industrial Health. 2013;51(2):165–71.
[10] Hattori S. A return to work program improves parasympathetic activity and psychiatric symptoms in workers
on sick leave due to depression. Heliyon.2019;5(7):e02151[11] Okamoto Y. Improvement in social anxiety following
a return-to-work intervention for patients with depression.Medicine.2022;101(7):e28845[12] Ohki Y, Igarashi Y, Yamauchi K. Re-work Program inJapan—Overview and Outcome of the Program. Front
Psychiatry. 2020;11:616223.
[13] Hattori S, Kishida I, Suda A, Kawanishi C, Miyauchi M,
Shiraishi Y, et al. A return to work program improvesparasympathetic activity and psychiatric symptoms
in workers on sick leave due to depression. Heliyon.
2019;5(7):e02151.
[14] Wang Y-P, Gorenstein C. Psychometric properties of the
Beck Depression Inventory-II: a comprehensive review.
Brazilian J Psychiatry. 2013;35(4):416–31.
[15] Van Dam NT, Earleywine M. Validation of the Center
for Epidemiologic Studies Depression Scale--Revised(CESD-R): pragmatic depression assessment in the general population. Psychiatry Res. 2011;186(1):128–32.
[16] Sakai Y. Inter-rater reliability, internal consistency andpredictive validity of Psychiatric Rework Readiness
Scale. Japanese Journal of Psychiatric Treatment.
2012;27(5):655–67. (Japanese)[17] Fetters MD. The Mixed Methods Research Workbook:
Activities for Designing, Implementing, and Publishing
Projects (Mixed Methods Research Series). California:
SAGE Publications Inc.; 2019. 122–143.
[18] Japanese Association of Rework for Depression[online]. [cited 2021 May 10]. Available from: https://www.utsu-rework.org/list/certified.html[19] Kojima M, Furukawa TA, Takahashi H, Kawai M,
Nagaya T, Tokudome S. Cross-cultural validation of the
Beck Depression Inventory-II in Japan. Psychiatry Res.
2002;110(3):291–9.
[20] Charmaz K, Nukui N, editor. Constructing Grounded
Theory: A Practical Guide through Qualitative Analysis.
Tokyo: Nakanishiya; 2008. 51–67.
[21] Alvaro PK, Roberts RM, Harris JK. A systematic review

assessing bidirectionality between sleep disturbances,anxiety, and depression. Sleep. 2013;36(7):1059–68.
[22] Germain A, Kupfer DJ. Circadian rhythm disturbances in depression. Hum Psychopharmacol Clin Exp.
2008;23(7):571–85.
[23] Baglioni C, Battagliese G, Feige B, SpiegelhalderK, Nissen C, Voderholzer U, et al. Insomnia as apredictor of depression: a meta-analytic evaluation of
longitudinal epidemiological studies. J Affect Disord.
2011;135(1–3):10–9.
[24] Chen YL, Pan AW, Hsiung PC, Chung L, Lai JS, ShurFen Gau S, et al. Life Adaptation Skills Training (LAST)
for persons with depression: a randomized controlled
study. J Affect Disord. 2015;185:108–14.
[25] Chen Y-L, Pan A-W, Hsiung P-C, Chung L. Qualityof life enhancement programme for individuals withmood disorder: a randomized controlled pilot study.
2015;25:23–31.
[26] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5) [online].
[cited 2021 May 10]. Available from: https://www.
psychiatry.org/psychiatrists/practice/dsm[27] Papadimitriou GN, Dikeos DG, Daskalopoulou EG,
Soldatos CR. Co-occurrence of disturbed sleep andappetite loss differentiates between unipolar and bipolar
depressive episodes. Prog Neuro-Psychopharmacology
Biol Psychiatry. 2002;26(6):1041–5.
[28] Rock PL, Roiser JP, Riedel WJ, Blackwell AD. Cognitive impairment in depression: a systematic review andmeta-analysis. Psychol Med. 2014;44(10):2029–40.
[29] Woo YS, Rosenblat JD, Kakar R, Bahk W-M, McIntyre
RS. Cognitive deficits as a mediator of poor occupational function in remitted major depressive disorderpatients. Clin Psychopharmacol Neurosci. 2016;14(1):1.
[30] McDermott LM, Ebmeier KP. A meta-analysis ofdepression severity and cognitive function. J Affect
Disord. 2009;119(1–3):1–8.
[31] Teychenne M, Ball K, Salmon J. Physical activity andlikelihood of depression in adults: a review. Prev Med(Baltim). 2008;46(5):397–411.
[32] Gadassi R, Rafaeli E. Interpersonal perception as a mediator of the depression–interpersonal difficulties link: areview. Pers Individ Dif. 2015;87:1–7.
[33] Wilhelm K, Boyce P, Brownhill S. The relationshipbetween interpersonal sensitivity, anxiety disorders andmajor depression. J Affect Disord. 2004;79(1–3):33–41.
[34] Luty SE, Joyce PR, Mulder RT, F. Sullivan P, McKenzie JM. The interpersonal sensitivity measure in depression: associations with temperament and character. J
Affect Disord. 2002;70(3):307–12.
[35] Gragnano A, Negrini A, Miglioretti M, Corbière M.
Common Psychosocial factors predicting return towork after common mental disorders, cardiovasculardiseases, and cancers: a review of reviews supporting across-disease approach. J Occup Rehabil. 2018;28:215–
31.

■ORIGINAL ARTICLE

The Effects of Cognitive Rehabilitation Targeting
Frontal Lobe Executive Functionin Mild Cognitive Impairment
Yuri Matsuzaki1, Hidetoshi Omiya2, Takayuki Hisakura2,
Hiroki Tanii3, Maki Miyajima4
1

Takarazuka university of medical and health care
Sapporo Gakuin University
3
Tomikawa Gloria Home Inc4
Department of health sciences, Hokkaido University
2

Abstract: Background: Mild Cognitive Impairment (MCI) are known to revert to normal cognition, so early intervention during the MCI stage is required. MCI is reported to be associated with a reduction in frontal lobe volume, blood
flow, and metabolism; dysfunction of the frontal lobes has also been reported to increase the risk of progressing to dementia. This study verifies the effects of cognitive rehabilitation targeting frontal lobe executive function in MCI.
Method: MCI patients aged over 65 were divided into a group taking part in the Frontal/Executive Program (FEP
Group), and the Control Group. Ten FEP Group patients took part in the FEP, and nine Control Group patients took partin the Group Exercise Program, 22 times each. Cognitive function was evaluated with MoCA-J, BACS-J, and WCST.
Results: The FEP Group showed significant improvements over the Control Group in verbal memory, working memory, executive function, conversion of sets, and persistent wrong answers. A dramatic effect was also seen in the FEPGroup before and after intervention in verbal memory, working memory, verbal fluency, executive function, conversionof sets, and persistent wrong answers. These effects on verbal memory, verbal fluency, and conversion of sets weremaintained for a period of three months. In addition, 60.0% of the patients in the FEP Group reverted to and maintained
normal cognition for three months.
Conclusion: Improvements were seen in the target function due to cognitive rehabilitation targeting frontal lobe executive function. A high rate of reversion was also seen from MCI to normal cognition.
Keywords: cognitive rehabilitation, dementia, executive function, frontal lobe, mild cognitive impairment(Asian J Occup Ther 19: 205−212, 2023)

Introduction
Mild Cognitive Impairment (MCI) is a condition
mid-way between normal cognitive changes caused byaging and dementia. The patients are in a state in which,despite a decline in cognitive functions, their daily life
activities are successfully maintained. MCI cannot be
considered as necessarily being the first manifestationof an underlying neurodegenerative process, as it canReceived: 24 May 2022, Accepted: 14 June 2023
Corresponding to: Maki Miyajima, Department of Rehabilitation
Sciences, Faculty of Health Sciences, Hokkaido University, North 12
West 5, Kitaku, Sapporo 060-0812, Japane-mail: mmiyajima@pop.med.hokudai.ac.jp©2023 Japanese Association of Occupational Therapists

be caused by transient and reversible conditions (e.g.
nutritional deficits, affective disorders, cerebrovascular
events, physical frailty, sleep disorders, and social
issues). Therefore, MCI is an unstable and fluctuating
condition, with subjects actually experiencing a reversion to normal cognition over time. While between 20
and 25% MCI patients reverts to normal cognition [1, 2],
the rate of MCI progressing to dementia has beenreported to be between 10 and 32.5% annually [3–5].
Early detection and early intervention in the MCI stage
are therefore important.
Researchers have reported that MCI is caused
by a reduction in the volume of the subregional basal
forebrain’s cholinergic system, and a reduction in thevolume of gray matter in the frontal and temporal lobes[6, 7]. In MCI, similar to the lowered perfusion seen in206

COGNITIVE REHABILITATION FOR FRONTAL LOBE EXECUTIVE FUNCTION IN MCI

mild Alzheimer’s dementia (AD), blood flow decreases
in various areas of the brain, such as the medial temporal lobe and the temporal/parietal cortices, posterior
cingulate cortex, and the anterior prefrontal cortex[8–10]. In addition, 79% of multiple-domain MCI arereported to show decreased frontal metabolism in combination [11]. Amnestic MCI multiple domains have ahigh risk of progressing to AD. This risk is reported tobe especially high if psychomotor speed and executivefunctions have declined [12]. We also know that MCI inindividuals whose cortex in the prefrontal, temporal, andparietal regions is thin are at high risk of progressing todementia, and that both amnesia MCI and non-amnesia
MCI cases have a high risk of progressing to dementia ifthey are accompanied by frontal executive dysfunction[13, 14]. It can be said, therefore, that, a reduction in
frontal lobe gray matter and blood flow, as well as frontal lobe dysfunction, are characteristic of MCI, and thatsuch dysfunction elevates the risk of MCI progressing todementia.
Based on the neurological findings described above,
pharmacotherapy and non-pharmacotherapies is used.
For example, among non-pharmacotherapies in interventions using aerobic exercise, functional improvements
are reported in general cognition, working or immediate
memory, language ability, multitasking, cognitive
flexibility, information processing speed, and selective
attention [15, 16]. Studies investigating the effects ofcognitive rehabilitation using computer programs hasreported functional improvements in language learning,memory, focused attention, processing speed, and conversion of attention [17, 18]. Interventional studies thatcombined aerobic exercise and cognitive rehabilitation,
meanwhile, have reported improvements in working
memory, executive function, Mini-Mental State Examination scores, and logical memory, as well as reduced
atrophy of the left medial temporal lobe [19, 20].
As seen from the above, the risk of transition todementia is high when dysfunction of the frontal lobe ispresent in MCI, therefore improvement of dysfunctionof the frontal lobe and prevention of functional decline
are important therapeutic targets. Prompted by the lackof conclusive results of interventions that directly target
dysfunction of the frontal lobes, which are seen in a
majority of MCI cases, we carried out this study toinvestigate whether there are improvements in MCI’s
cognitive impairment as a result of cognitive rehabilitation that targets the frontal lobe executive functions
and to identify conversion rates of MCI to dementia andreversion rates to normal cognition.

Methods
Subjects
We used community bulletin boards at three sites in
Hidaka-cho, Hokkaido, to display a leaflet that described
the significance and purpose of this study, the content
of the program to be implemented, and conditions forparticipation. People aged 65 and older with concerns
about their cognitive function were stated to be eligible
for participation. We also called for participation in the
study by distributing similar leaflets at a nursing careprevention class held at one location in the town. We explained the content and purpose of the study orally, andobtained the participants’ consent. In a private room, atherapist individually performed the Japanese-language
edition of the Montreal Cognitive Assessment (MoCA-J)[21] on the 23 individuals who had been recruited as
described above. Of these, 19 who were suspected ofhaving MCI based on MoCA-J were used as the subjectsof this study after eliminating 4 individuals with normal
cognition (MoCA-J ≥ 26). Next, the 19 individuals who
were adopted as the study’s subjects took part in basepoint evaluation, and 10 subjects who requested to participate in the cognitive remediation program. were assigned to the FEP Group (four males, six females, mean
age: 79.5 ± 5.5 years), and the remaining nine to theControl Group (one male, eight females, mean age: 76.3
± 5.4 years) (Fig. 1). All study participants (23 subjects)
provided informed consent, and this study was carriedout on receiving approval by the A University Graduate
School of Clinical Psychology Research Ethical Committee.
Content of the intervention
Frontal/Executive Program
The subjects in the FEP Group took part in a onehour per session cognitive function improvement therapy once or twice a week for a total of 22 sessions. The
cognitive function improvement therapy used a Frontal/
Executive Program (FEP) [22] that was formulated byfocusing on the frontal lobe/executive function, and implemented on a one-on-one basis with an occupational
therapists or nurses inside a quiet, private room. An FEP
normally comprises 44 sessions. For this study, however,
we used a program that consisted of 22 sessions, An FEP
normally comprises 44 sessions. For this study, however, we used a program that consisted of 22 sessions,with the number of sessions in each module halved in
the first half, in consideration of the subject’s physicalfitness. The FEP comprises three modules: Cognitive
Flexibility, Working Memory, and Planning. Cognitive
flexibility module is intended to enhance flexibility inattention and cognition. Working memory module aims

Asian J Occup Ther 19: 205−212, 2023

Fig. 1.

Matsuzaki Y et al.

207

Subject flow diagram from initial contact through study completion.

at manipulating maximum of 8 sets of information. The
task focuses on attention, sequence, multiple tasks, andworking memory. Planning module is intended to attention skills, organizing information, applying reasoning,setting lower goals, sequence, working memory, andcontrolling processes required to work on multitasks
within same modality or between modalities. The content of the tasks becomes more complex as the program
progresses.
Physical exercise
The subjects in the Control Group took part in theGroup Exercise Program once or twice a week for a
total of 22 sessions. Group exercises were carried out
targeting 25 to 30 participants and were led by one
occupational therapist and one caregiver for two hours
each time inside an area spacious enough to allow theparticipants to move around without constraint. The
Group Exercise Program featured strength training suchas bending and stretching the lower and upper limbs,
as well as rotating the trunk, using Theraband training
tubes for 1 hour, and aerobic exercises such as boxercise
for 1 hour.
Treatment fidelity
The implementers of FEP were certified nurses
or occupational therapists. They confirmed the implementation methods prior to starting each session, andcompared/checked the content at least once a month.
The Group Exercise Program was provided by the same
occupational therapist and caregiver each time.
Evaluations
The following cognitive functions were evaluated at
the base point and the end point and, for the FEP Group,at the follow-up point, three months after the end of theintervention.

MoCA-J [21] is a cognitive screening test for
detecting MCI, consisting of visuospatial/executivefunction, naming, memory, attention, language, abstraction, delayed recall, and orientation. A score of 26 points
on the MoCA-J out of a perfect score of 30 points wasmade the cutoff point. Our study employed this test
to diagnose MCI and evaluate the rate of reversion tonormal cognition.
The Brief Assessment of Cognition in Schizophrenia, Japanese version (BACS-J) [23], is a scale forassessing cognitive function. It consists of a test that
evaluates six subscales: verbal memory, working
memory, motor function, attention and information processing speed, verbal fluency, and executive function.
Our study used as a reference the average values ofhealthy males or females aged 70–79 [24]. We made ourassessments using Z-values, whereby the score is linearly converted such that the average and SD become 0 and
1, respectively.
Wisconsin Card Sorting Test (WCST) [25] is atest of abstract behavior and “set shifting.” Our study
assessed three items: The number of categories that had
been achieved, the number of perseverative errors ofMilner (PEM), and the number of perseverative errorsof Nelson (PEN). The number of categories achieved
indicates the number of categories answered correctlyfor six consecutive questions. The scores ranged from 0
to 7, with larger numbers indicating better results.
Statistical analysis
A total of 19 subjects, ten in the FEP Group andnine in the Control Group, were targets of analysis. A
χ2-test was performed for sex and a non-paired t-test
for age, the number of years of education received, andMoCA-J. Likewise, a non-paired t-test was performed
on a two-group comparison of pre-intervention cognitive function and on a comparison of various functional

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COGNITIVE REHABILITATION FOR FRONTAL LOBE EXECUTIVE FUNCTION IN MCI

evaluations between before and after the interventions.
To investigate the efficacy of FEP and continuation of
the effects in the FEP Group, we performed the Holmmethod three times in nine FEP Group subjects: before
intervention, after intervention, and as a follow-up. We
used JASP 0.11.1.0 for statistical analysis, and set thelevel of significance at 5%. GPower 3.1 was used toanalyze statistical power.

Results
Subjects’ demographic information
Table 1 shows the demographic information of thesubjects in each group. No significant inter-group differences were seen in the subjects’ age (P = .282), numberof years of education received (P = .44), percentage ofmales (P = .153), and MoCA-J scores (P = .236).
Comparison of base point cognitive function between
the two groups
Table 2 shows the cognitive function at the basepoint of the 19 subjects in the FEP and Control Group in
this study. The Control Group had significantly higher

Table 1. Clinical characteristics of participants at Base point.

scores in the BACS-J’s Composite Score (P = .01) and
Verbal Memory (P = .049), and in the WCST’s Categories (P = .033).
Comparison of changes in cognitive functions before
and after intervention
Table 3 compares the changes in cognitive functionin the two groups before and after intervention. With
BACS-J, the FEP Group showed a more significant improvement than the Control Group in Composite Score(P < .001) and Verbal Memory (P = .02), Digit Sequencing (P = .024), and the Tower of London (P = .005),
and, with WCST, in Categories (P = .002) and PEN (P =.03). In other words, in these subordinate test items, the
FEP Group showed a larger increase in scores after intervention and greater changes than the Control Group.
Comparison of the effect size of the FEP Group at threetimes
Table 4 shows the results on BACS-J and WCST of
the nine subjects in the FEP Group at three time points,
namely, base point, end point, and follow-up. As a resultof comparing base point and end point, the end point
was significantly higher and a larger effect size wasobserved with BACS-J’s composite score (P <. 001; d =2.28), Verbal memory (P = .009; d = 1.30), Verbal fluency (P = .028; d = 1.13), WCST’s category (P = .002;
d = 1.79), and PEN (P = .037; d = 1.07). In addition,
no significant difference was found as a result of multiple comparison, but a large effect size was observed
before and after the intervention with BACS-J’s Digit
Sequencing (P = .060; d = .97) and Tower of London (P= .078; d = .91). As a result of comparing base point andfollow-up, the follow-up was significantly higher and alarger effect size was observed with BACS-J’s compos-

Table 2. Cognitive function at Base point.

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Table 3. Change of cognitive function Base point and End point.

ite score (P = .005; d = 1.44), Verbal Memory (P = .009;
d = 1.39) and WCST’s category (P = .016; d = 1.17). In
addition, no significant difference was found as a resultof multiple comparison, but a large effect size was observed base point and follow-up with BACS-J’s Verbal
Fluency (P = .086; d = .80).
Implementing FEP yielded a large effect size inverbal memory, working memory, verbal fluency, executive function, conversion of sets, and persistent wrong
answers. With verbal memory, verbal fluency, andconversion of sets, moreover, the effects lasted for threemonths.
The rate of reversion to normal cognition in the FEPGroup
Of the 19 MCI patients who were subjects in thisstudy, six in the FEP Group (ten subjects) and two in
the Control Group (nine subjects) reverted from MCI
to normal cognition (MoCA-J ≥ 26). In short, reversion
from MCI to normal cognition occurred in 60.0% of thesubjects in the FEP Group, and 22.2% in the Control
Group. At the follow-up, moreover, of the six subjects
in the FEP Group who had reverted to normal cognitionat the end point, one had dropped out and five had maintained normal cognition (Fig. 2).

Discussion
The first purpose of this study was to verify theeffects of cognitive rehabilitation targeting frontal lobe
executive dysfunction, which can increase the risk ofprogressing to dementia, especially in individuals with
MCI. We used a program that activates the frontal lobes/
executive function in stages and in a comprehensive
manner. The results showed more significant improvements in verbal memory, working memory, executivefunction, conversion of sets, and persistent wrong
answers in the FEP Group than Control Group, which
received motor interventions instead (Table 3). In ourstudy, the subjects in the Control Group also showed
improvements on several subscales of the BACS-J.
On the other hand, the results suggest that the group
undergoing cognitive rehabilitation focusing on frontal
executive function showed even greater cognitive function improvement effects than did the Control Group,
which engaged in aerobic exercise. Two points may beconsidered regarding the cause of improved cognitive
function through FEP. First is verbalization, which isa requirement in the FEP. FEP requires participants
to repeatedly verbalize their understanding of a task
and their plans/strategies to tackle it. This might have
led to the improvement of functions such as verbal

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COGNITIVE REHABILITATION FOR FRONTAL LOBE EXECUTIVE FUNCTION IN MCI

Table 4. Change of cognitive function at Base point, End point and Follow-up.

memory and fluency, as well as the improvement ofexecutive function in the form of establishing strategic
thought processes. The second factor is that in addition
to cognitive flexibility modules that target subordinate
cognitive areas module sessions in the FEP are designed
to improve the two cognitive areas of working memory
and planning. In other words, improvements in working
memory and executive function may have occurred
through emphasis on frontal lobe functions related toworking memory and executive function, and because of
the relationships with the subscales of cognitive function
assessments that were conducted on this occasion. On
the other hand, there is a possibility of ceiling effects in
the Control Group’s results because the Control Group
had significantly higher scores than the FEP Group at

the base point on Multiple sub items. Moreover, insteadof randomly dividing the participants into two groups,
in the study design we included in the FEP Group
individuals who had provided consent for intervention.
This resulted in differences in the subjects’ treatment
motivations between the two groups, so the possibilityof greater effects in the FEP Group cannot be dismissed.
Second, comparison of the FEP Group between
before and after the intervention found a large effectsize in verbal memory, working memory, verbal fluency,
executive function, conversion of sets, and persistentwrong answers. Improvement effects had also continued, even at the follow-up point three months after theend of intervention in verbal memory, verbal fluency,
and conversion of sets (Table 4). It appears possible

Asian J Occup Ther 19: 205−212, 2023

Fig. 2. Cognitive function at Base point, End point and Follow-up.
Changes in MCI to normal cognition in the FEPGroup and the Control Group at three time points:base point, end point, and follow-up.

that, through interventions that targeted the frontal lobe,
the subjects experienced increased motivation throughactivation of the frontal area and acquired a sense ofachievement and confidence in having completed theprogram, which in turn helped increase the volume ofactivity in their daily lives. Studies have reported that
increases in daily activity lower the risk of progressing
to dementia [26]; in our study also, it is likely thatcognitive function was maintained, not only due to theeffects of cognitive rehabilitation itself but also to theresultant increase in daily activity. Our study only evaluated cognitive function; thus, mental functions including
will/motivation as well as life functions such as activity
volume remain a matter of speculation. In the future,
therefore, there is a need to evaluate not only the aspectsof cognitive function but also those related to mental
and life functions.
The second purpose of our study was to identify
conversion rates of MCI to dementia and reversion rates
to normal cognition. In this study, no progression from
MCI to dementia was seen in either group. Reversion
from MCI to normal cognition occurred in 60.0% of thesubjects in the FEP Group, and 22.2% in the Control
Group (Fig. 2). Previous studies reported that one outof four or five MCI subjects reverts to normal cognition[1, 2]. The Control Group rate of reversion to normal

Matsuzaki Y et al.

211

cognition by motor intervention alone was not high, no
progression to dementia was seen, indicating that the
subjects in aerobic exercise able to maintain their functions. On the other hand, in the FEP Group, suggestingthat the interventions made in this study had caused
the MCI patients to revert to normal cognition. In thefollow-up to the FEP Group, suggest that all the individuals had maintained normal cognition (Fig. 2), andthat the effects of the interventions in this study wereretained for three months. In other words, the effects ofcognitive rehabilitation that targeted frontal lobe executive function which appear to confer a high risk of MCI
progressing to dementia, had greater potential to raise
the rate of reversion to normal cognition and contributeto a reduced risk of progressing to dementia than aerobic
exercise. Thus, there is a need to investigate the continuity of even longer-term effects of interventions while
taking into consideration the natural decline in cognitive
function due to aging.
In this study, by conducting cognitive rehabilitationthat targeted the frontal executive function, we saw improvements in verbal memory, working memory, verbal
fluidity, and executive functions. The rate of reversion
from MCI to normal cognition, moreover, was a high60%, and normal cognition was maintained for threemonths. In the future, while it is hoped that the program
can be applied to MCI patients who show a decline infrontal executive function, there is a need to establish arandomized, double-blind framework and interventional
designs to investigate the effects of long-term interventions that take into consideration the natural decline incognitive function that is caused by aging.

References[1] Canevelli M, Grande G, Lacorte E, Quarchioni E, Cesari
M, Mariani C, et al. Spontaneous Reversion of Mild Cognitive Impairment to Normal Cognition: A Systematic
Review of Literature and Meta-Analysis. J Am Med Dir
Assoc. 2016; 17(10): 943–8.
[2] Malek-Ahmadi M. Reversion from Mild Cognitive
Impairment to Normal Cognition: A Meta-Analysis. Alzheimer Dis Assoc Disord. 2016; 30(4): 324–30.
[3] Petersen RC, Thomas RG, Grundman M, Bennett D,
Doody R, Ferris S, et al. Vitamin E and Donepezil for theTreatment of Mild Cognitive Impairment. N Engl J Med.
2005; 352(23): 2379–88.
[4] Sobów T, Fendler W, Magierski R. Body mass index andmild cognitive impairment-to-dementia progression in 24
months: A prospective study. Eur J Clin Nutr. 2014; 68:
1216–19.
[5] Yaffe K, Petersen RC, Lindquist K, Kramer J, Miller B.
Subtype of mild cognitive impairment and progression todementia and death. Dement Geriatr Cogn Disord. 2006;

212

COGNITIVE REHABILITATION FOR FRONTAL LOBE EXECUTIVE FUNCTION IN MCI

22(4): 312–9.
[6] Kilimann I, Grothe M, Heinsen H, Alho EJ, Grinberg L,
Amaro E Jr, et al. Subregional basal forebrain atrophy inalzheimer’s disease: A multicenter study. J Alzheimer’s
Dis. 2014; 40(3): 687–700.
[7] Duarte A, Hayasaka S, Du A, Schuff N, Jahng GH,
Kramer J, et al. Volumetric correlates of memory andexecutive function in normal elderly, mild cognitive impairment and Alzheimer’s disease. Neurosci Lett. 2006;
406(1–2): 60–5.
[8] Alegret M, Cuberas-Borrós G, Vinyes-Junqué G, Espinosa A, Valero S, Hernández I, et al. A two-year follow-up
of cognitive deficits and brain perfusion in mild cognitive
impairment and mild alzheimer’s disease. J Alzheimer’s
Dis. 2012; 30(1): 109–20.
[9] Hirao K, Ohnishi T, Hirata Y, Yamashita F, Mori T,
Moriguchi Y, et al. The prediction of rapid conversion to
Alzheimer’s disease in mild cognitive impairment using
regional cerebral blood flow SPECT. Neuroimage. 2005;
28(4): 1014–21.
[10] Nobili F, De Carli F, Frisoni GB, Portet F, Verhey F,
Rodriguez G, et al. SPECT predictors of cognitive decline
and alzheimer’s disease in mild cognitive impairment. J
Alzheimer’s Dis. 2009; 17(4): 761–72.
[11] Mosconi L, Tsui WH, Herholz K, Pupi A, Drzezga A,
Lucignani G, et al. Multicenter standardized 18F-FDG
PET diagnosis of mild cognitive impairment, Alzheimer’s
disease, and other dementias. J Nucl Med. 2008; 49(3):390–8.
[12] Tabert MH, Manly JJ, Liu X, Pelton GH, Rosenblum
S, Jacobs M, et al. Neuropsychological prediction of
conversion to alzheimer disease in patients with mild
cognitive impairment. Arch Gen Psychiatry. 2006; 63(8):916–24.
[13] Jung YH, Park S, Jang H, Cho SH, Kim SJ, Kim JP, et al.
Frontal-executive dysfunction affects dementia conversion in patients with amnestic mild cognitive impairment.
Sci Rep. 2020; 10(1): 772.
[14] Lee JS, Cho SK, Kim HJ, Kim YJ, Park KC, Lockhart
SN, et al. Prediction Models of Cognitive Trajectories inPatients with Nonamnestic Mild Cognitive Impairment.
Sci Rep. 2018; 8(1): 10468.
[15] Suzuki T, Shimada H, Makizako H, Doi T, Yoshida D, Ito
K, et al. Effects of multicomponent exercise on cognitive
function in older adults with amnestic mild cognitive
impairment: a randomized controlled trial. BMC Neurol.
2012; 12: 128.
[16] Baker LD, Frank LL, Foster-Schubert K, Green PS,

Wilkinson CW, McTiernan A, et al. Effects of aerobic
exercise on mild cognitive impairment: A controlled trial.
Arch Neurol. 2010; 67(1): 71–9.
[17] Barnes DE, Yaffe K, Belfor N, Jagust WJ, DeCarli C,
Reed BR, et al. Computer-based cognitive training for
mild cognitive impairment: Results from a pilot randomized, controlled trial. Alzheimer Dis Assoc Disord. 2009;23(3): 205–10.
[18] Gagnon LG, Belleville S. Training of attentional control
in mild cognitive impairment with executive deficits:
Results from a double-blind randomised controlled study.
Neuropsychol Rehabil. 2012; 22(6): 809–35.
[19] Park H, Park JH, Na HR, Hiroyuki S, Kim GM, Jung
MK, et al. Combined Intervention of Physical Activity,
Aerobic Exercise, and Cognitive Exercise Intervention toPrevent Cognitive Decline for Patients with Mild Cognitive Impairment: A Randomized Controlled ClinicalStudy. J Clin Med. 2019; 8(7): 940.
[20] Shimada H, Makizako H, Doi T, Park H, Tsutsumimoto K,
Verghese J, et al. Effects of Combined Physical and Cognitive Exercises on Cognition and Mobility in Patients
With Mild Cognitive Impairment: A Randomized Clinical
Trial. J Am Med Dir Assoc. 2018; 19(7): 584–91.
[21] Fujiwara Y, Suzuki H, Yasunaga M, Sugiyama M, Ijuin M,
Sakuma N, et al. Brief screening tool for mild cognitive
impairment in older Japanese: Validation of the Japaneseversion of the Montreal Cognitive Assessment. Geriatr
Gerontol Int. 2010; 10(3): 225–32.
[22] Delahunty A, Morice R. Frontal/executive program: aneurocognitive rehabilitation program for schizophrenia.
(Matsui M, Shibat T, Shosaku T. Trans.). Tokyo: Shinko
igaku shuppansya; 2015.
[23] Kaneda Y, Sumiyoshi T, Keefe R, Ishimoto Y, Numata S,
Ohmori T. Brief Assessment of Cognition in Schizophrenia: Validation of the Japanese version. Psychiatry Clin
Neurosci. 2007; 61(6): 602–9.
[24] Keefe RS, Harvey PD, Goldberg TE, Gold JM, Walker
TM, Kennel C, et al. Norms and standardization of theBrief Assessment of Cognition in Schizophrenia (BACS).
Schizophr Res. 2008; 102(1–3): 108–15.
[25] Heaton R, Chelune G, Talley J, Kay G, Curtiss G. Wisconsin Card Sorting Test Manual. Revised and Expanded.
Florida: Psychological Assessment Resources; 1993.
[26] Verghese J, Lipton RB, Katz MJ, Hall CB, Derby CA,
Kuslansky G, et al. Leisure Activities and the Risk of
Dementia in the Elderly. N Engl J Med. 2003; 348(25):2508–16.

■ORIGINAL ARTICLES

Effects of Functional Electrical Stimulation on
Attentional Function: A Study on
Healthy Young Participants
Nao Yoshihiro1, 2, Kazu Amimoto3, Shinpei Osaki4, Junpei Tanabe5
1Department of Occupational Therapy, Faculty of Health Sciences, Kansai University of Health Sciences
Department of Physical Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan University
3
Department of Physical Therapy, Faculty of Rehabilitation, Sendai Seiyo Gakuin College
4
Department of Rehabilitation, Kansai Electric Power Hospital
5
Department of Physical Therapy, Faculty of Health Sciences, Hiroshima Cosmopolitan University
2

Abstract: Background: Functional electrical stimulation (FES) improves unilateral spatial neglect (USN). However,
only few studies have reported on the relationship between FES and cognitive function. Therefore, this study aimed toinvestigate the effects of FES on attentional function in healthy participants using the Posner task, which is generally
used to assess patients with USN.
Methods: In this interventional study, we conducted experiments on healthy participants to obtain fundamental knowledge before investigating effective ways of adapting FES to patients with USN as our final purpose. A total of 28
right-handed healthy young participants were assigned to the online-effect group or after-effect group and underwent
FES simultaneously with or immediately before the Posner task, respectively. FES was applied to the extensor musclesof the left forearm to induce involuntary movement.
Results: A significant difference was observed in the effects of FES in the Posner task between the online-effect groupor after-effect group in the left-valid conditions (online-effect, 26.7 ms delay; after-effect, -0.4 ms [reduction]; p = 0.01).
No interaction was noted between the groups and the type of target of the Posner task presentation condition. The effects of FES differed between the online- and after-effect condition groups.
Conclusion: Performing the attention task after FES may enhance attention compared with performing the task with
FES simultaneously.
Keywords: Functional electrical stimulation, attention, Posner task, unilateral spatial neglect(Asian J Occup Ther 19: 213−222, 2023)

1. Introduction
Unilateral spatial neglect (USN) is a common
disorder that occurs after stroke and is defined as thefailure to orient to, respond to, or detect stimulationon the affected side [1]. Left USN, which occurs afterright-hemisphere damage, is more frequent (43%) thanright USN (19%), which occurs after left-hemispheredamage [2–4]. Therefore, the right hemisphere, particReceived: 25 August 2022, Accepted: 29 May 2023
Corresponding to: Kazu Amimoto, Department of Physical Therapy,
Faculty of Rehabilitation, Sendai Seiyo Gakuin College, 4-3-55, Nagamachi, Taihaku-ku, Sendai-shi, Miyagi, 982-0011, Japane-mail: amimoto@tmu.ac.jp©2023 Japanese Association of Occupational Therapists

ularly the frontal and parietal lobes, may be involvedin the amelioration of USN symptoms. Patients with
USN encounter numerous problems in their dailyliving, such as missing food and meeting with crashes
during walking. This is because USN prevents thedetection of objects on their desk and in their way[5]. Several interventions to improve USN, including
visual scanning training, prism adaptation, and limb
activation, have been reported previously [6].
Robertson and North [7] reported that the active
movement of the paretic limb in the neglected spacesignificantly improves the symptoms of neglect onletter cancelation and reading tests. They concluded
that only the active movement of the affected limb in
the affected space improves USN. However, Làdavas
et al. [8] demonstrated that even involuntary limb

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EFFECTS OF FUNCTIONAL ELECTRICAL STIMULATION ON ATTENTION

movement on the affected side improves USN basedon results of a naming test, in which a patient isrequired to name all the projected target stimuli (i.e.,line drawings of objects). Moreover, involuntary limb
activation is considered beneficial because it can beused regardless of the severity of motor paralysis.
Functional electrical stimulation (FES) is used toinduce involuntary limb movements. FES is a rehabilitation technique in which high-frequency electricalpulses are administered to the nerves or directly tothe muscle belly for inducing muscle contraction
and improving motor function in the paralyzed limb
after a central nervous system injury, such as stroke[9]. Moreover, Eskes et al. [10] reported that visualscanning tasks (i.e., reading letters and numbers)
performed simultaneously with FES-induced involuntary wrist extension improves USN. Some previous
studies on FES intervention for USN have reported on
the effects of this intervention on attentional function
upon conducting attention tasks simultaneously with
FES [10,11,12], whereas others have reported on theseeffects on attentional function after FES [13]. However, to the best of our knowledge, no studies havedirectly compared the online-effect and after-effect.
Comparing the online- and after-effect of FES may
provide insights into effective intervention methods
for USN. For example, if the online-effect is operational, researchers should implement a combination of
attentional function training or activities of daily living(ADL) movements and FES. If the after-effect is operational, researchers should recommend introducing
ADL movement training after FES.
Paper-and-pencil tests help in effective identification of various USN pathologies; however, the results
may incorrectly reflect the behavior of patients with
USN in daily activities. This finding appears to bepartially attributed to diverse symptoms, such as “internal representation” of space, “spatial attention,” and“spatial frame of reference,” in patients with USN [14].
For example, patients should switch their attention
instantly during movement to avoid people or objects.
Paper-and-pencil tests cannot assess this behavioral
trait, thus necessitating a method to evaluate the reaction time (RT) of patients with USN to switch theirattention instantly.
The Posner task is a computerized method thathelps evaluate spatial attention by measuring the RT(in ms) [14]. In a previous study, participants were
instructed to press the response key swiftly after atarget appeared on the computer screen. The following
two types of targets appeared: 1) targets that appearedon the side indicated by a cue (valid condition) and2) targets that appeared on the opposite side (invalid

condition). The valid condition is associated with voluntary attention, and the invalid condition is associatedwith the reorientation of attention [15].
USN can occur in the horizontal (left-right) andvertical (upper-lower) spaces [16,17]. However, theconventional “paper and pencil tests” for USN and
the Posner task are unsuitable for detecting verticalneglect. Therefore, Osaki et al. [18] developed a modified Posner task, wherein the target presentation time
was extended, and the target was presented at four
locations (upper left, lower left, upper right, and lower
right). The modified Posner task was used for patientswith USN; the RT to target the left side was significantly more than that required to target the right side
under invalid conditions [18]. Reorientation of attention is necessary to react to unpredictable movements,
such as the sudden appearance of a person crossing thestreet while walking. The modified Posner task can beused to evaluate this type of reorientation.
Furthermore, Osaki et al. [19] performed a modified Posner task in patients with USN, those withright-hemisphere injury without USN, and healthyolder participants to evaluate attentional functions,
including left/right and vertical directions. They observed no significant difference in the RT between theupper left and lower left visual fields in the desk taskin patients with USN, whereas the RT was delayed
more in the lower left visual field than that in theupper left visual field in the modified Posner task. The
present study was conducted in healthy young participants, aiming to implement the intervention in patientswith USN in the future. Based on previous results [19],attentional function should be evaluated in the four
quadrants of left, right, upper, and lower visual fields
while applying the modified Posner task to patientswith USN.
Researchers have published several reports ofinterventions on attentional function in healthy participants as the basis for USN intervention [20–22]. In
these reports, leftward visual search was increased inhealthy participants after general USN interventions,such as prism adaptation and visual search. However,this effect was observed for goal-directed attention,and the effect on stimulus-driven attention, which
is important for USN improvement, is unknown.
Furthermore, no reports are available on the effects ofelectrical stimulation on stimulus-induced attention in
healthy participants.
We hypothesized that FES of the left upper limb
facilitates brain activity in the right hemisphere andimproves responses to the left space. Therefore, before
applying FES to patients with USN, we aimed todetermine whether (1) FES affects stimulus-driven

Asian J Occup Ther 19: 213−222, 2023

attention and (2) attention tasks are more effective
when performed simultaneously with FES or after FES
in healthy participants. Our findings will be applied to
the rehabilitation of patients with USN in the future.

2. Materials and Subjects
2.1. Participants
In this interventional study, 28 right-handed
young and healthy individuals without neurologicalor medical history were included (12 men and 16
women: mean age, 24.9 ± 4.5 years). Sample sizes
were calculated using G*Power 3.1 [23] for the test
family (F-test) and analysis of variance (ANOVA) (repeated measures; intermediate interactions). Based on
an a priori power analysis performed with G*Power,
Cohen’s d [24], we assumed a moderate effect size
(f=0.25), 5% significance level (α=0.05), 80% statistical power (1-β), 2 group (between) x 4 position (within)interaction, 0.50 correlation among repeated measures,and 1.00 nonsphericity correction. The sample size
was 12 dropouts per group (24 total). This number was
set to 12 persons per group to account for unexpected
dropouts. We set the number of participants to 14 pergroup.
The study procedures were performed in accordance with the ethical standards of the Declarationof Helsinki, and all participants provided written
informed consent to participate. The study protocol
was approved by the Ethics Committee of Tokyo
Metropolitan University (approval number: 19094, approval date: February 14, 2020) and Kansai University
of Health Sciences (approval number: 19-56, approvaldate: June 19, 2020).

Figures

Yoshihiro N et al.

215

3. Methods
3.1. Modified Posner task
The modified Posner task (Figure 1) was used to
examine the effects of FES on attentional function [12].
The task was displayed on a 15.6-inch monitor (120-Hz
refresh rate) using a computer (MSI GL65-9SD-046JP,
New Taipei, Taiwan). Behavioral responses were elicited using a numeric keypad (ELECOM TK-TCM011,
Osaka, Japan) connected to the computer. We used
the stimulation presentation software SuperLab 5.0(Cedrus Corporation, San Pedro, USA) to create a
modified Posner task. A cross fixed at the center (fixed
viewpoint) and a frame of four squares arranged left
to right along the horizontal meridian were presented
on the monitor. Each square was presented at a visual
position of 4.3° from a fixed viewpoint. The diameterof each square was within a visual angle of 1°, and acircular target appeared at the center of the square. The
diameter of each target had a visual angle of 0.3°.
After 500 ms at the beginning, an arrow cue indicating left or right appeared at the fixation point for
2,000 ms. Subsequently, after a delay of 1,000–2,000
ms, a target (circle) appeared in one of the four frames(upper left, lower left, upper right, and lower right)
for 3,000 ms. Each session comprised 60 trials. The
target appeared at the location indicated by the cue in
80% (48 trials) of the trials (valid condition) and on
the opposite side in 20% (12 trials) of the trials (invalid
condition). We instructed the participants to detect thetarget rapidly and press the key with their right hands.
The RT of the key and the accuracy of the keypress
timing were recorded.
3.2. Apparatus
The IVES+® (OG Giken Co., Ltd., Okayama,

Figureelectrical
2. Functional
electrical stimulation a
Fig. 2. Functional
stimulation apparatus
In valid the condition, the target appears at(The IVES+® [OG Giken Co., Ltd.]). StimStimulationelectrodes
are attached to the exten
In valid the condition,
targetIn theappears
at the indicated position. In ulation
theinvalidthethe indicatedthe
position.
invalid condielectrodescondition,
are attached tothe extention, the target appears on the opposite side.
sor muscles of the left forearm.
Figure 1.
task
Fig.The1. modified
The modifiedPosner
Posner task

target appears on the opposite side.

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EFFECTS OF FUNCTIONAL ELECTRICAL STIMULATION ON ATTENTION

Japan) was used as the FES device (Figure 2). Stimulation electrodes were attached to the extensor musclesof the left forearm with gel conductors, and the left
wrist was moved passively with the programming set
for 5-s stimulation and alternative resting. Stimulation
was performed for 6 min. The stimulation pulse frequency was 40 Hz, pulse width was 50 μs, and stimulation intensity was set to a level that caused muscle
contraction.

two orders:(A)	Posner task with FES, rest, Posner task withsham control, rest, Posner task with shamcontrol, rest, and Posner task with FES.
(B)	Posner task with sham control, rest, Posnertask with FES, rest, Posner task with FES,
rest, and Posner task with sham control.
The entire test, including the rest period, lasted
for approximately 35 min.

3.3. Procedures
Figure 3 depicts the measurement protocol for the
online- and after-effect conditions.
Twenty-eight participants were assigned randomly to the online- and after-effect condition groups (14participants in each).

3.3.2. After-effect condition
The after-effect condition comprised 6 min eachof the pre-FES Posner task, FES or sham control, andpost-FES Posner task. Fourteen participants were assigned randomly to perform in either of the following
two orders:(A)	Posner task before FES, FES, Posner task
after FES, rest, Posner task before sham control, sham control, and Posner task after shamcontrol.
(B)	Posner task before sham control, shamcontrol, Posner task after sham control, rest,

3.3.1. Online-effect condition
The online-effect condition included the Posnertask that lasted for 6 min and a rest period that lasted
for 3 min. Fourteen participants were randomly assigned to perform the tasks in either of the following

Fig. 3.

Measurement protocol.
Figure3. Measurement
The
two columnson the left showprotocol.
the measurement protocol for the online-effect condition consisting of the Posnertask that lasted for 6 min and the rest condition that lasted for 3 min in each set. Participants are randomly assigned to
The two columns on the left show the measurement protocol for the online-effect condition
perform the tasks in either of the two orders.
The two columns on the right show the measurement protocol for the after-effect condition consisting of 6 min of theconsisting of the Posner task that lasted for 6 min and the rest condition that lasted for 3 min in
pre-FES Posner task, 6 min of FES or sham control, and 6 min of the post-FES Posner task in each set. Fourteen participants
randomly
assigned toare
perform
the tasks ineither of theorders. the tasks in either of the two orders.
eachareset.
Participants
randomly
assigned
totwo
perform

The two columns on the right show the measurement protocol for the after-effect condition
consisting of 6 min of the pre-FES Posner task, 6 min of FES or sham control, and 6 min of the
post-FES Posner task in each set. Fourteen participants are randomly assigned to perform the tasks

Asian J Occup Ther 19: 213−222, 2023

Yoshihiro N et al.

Posner task before FES, FES, and Posner task
after FES.
The entire test, including 3 min of rest, lasted forapproximately 40 min.
3.4. Statistical analysis
For the modified Posner task, we analyzed theamount of change in RT for the four conditions as follows: (a) Lt-invalid condition, the target appeared on
the left side and a cue was demonstrated for the rightside in the invalid condition; (b) Lt-valid, the target
appeared on the right side and a cue was demonstrated
for the right in the valid condition; (c) Rt-invalid,
the target appeared on the right side and a cue wasdemonstrated for the left in the invalid condition; and(d) Rt-valid, the target appeared on the right side and acue was demonstrated for the right in the valid condition.
The Shapiro–Wilk test indicated consistent datawith a normal distribution. The formula for calculating
the amount of change in RT was as follows: online-effect condition = RT with FES – RT with sham control;
after-effect condition = RT post-FES – RT pre-FES.
Two-way mixed ANOVA with online- and after-effect conditions as between-subject factors andtarget condition (Lt-invalid, Lt-valid, Rt-invalid,
Rt-valid) as the within-subject factor was used to analyze the modified Posner task performance.
Post-hoc tests with Bonferroni correction
were used for multiple comparisons between thegroups (p=0.05/2=0.025) and within each group(p=0.05/4=0.012). IBM SPSS Statistics ver. 25 (IBMCorp., Armonk, NY, USA) was used for the statisticalanalysis.

4. Results
Table 1 and Figures 4 and 5 summarize themodified Posner task RT results. Figure 6 depicts theamount of change in RT.
Regarding the amount of change in RT of themodified Posner task, ANOVA demonstrated a main
effect for the groups (online- and after-effect conditions) (F (1, 222) =3.3, p<0.05) and condition (target
conditions) (F (3, 220) =6.2, p<0.05). Significant interactions were absent. Post-hoc analyses demonstrated
the following differences in the tasks with the Lt-valid
conditions (online-effect, 26.7 ms longer; after-effect,-0.4 ms [reduction]; p=0.01).
In tasks with the Lt-invalid conditions, the difference in the amount of change in the RT tended to begreater in the after-effect condition group (online-effect, 8.1 ms longer; after-effect, -13.1 ms [reduction];
p=0.05). Furthermore, in tasks with the Rt-valid
condition, the difference in the amount of change in
the RT tended to be greater in the after-effect conditiongroup (online-effect, 19.6 ms longer, after-effect, -1.4
ms [reduction]; p=0.06).
Regarding the target presentation conditions, theLt-valid condition tasks in the online-effect conditiongroup demonstrated a significantly greater amount ofchange in the RT than those in the Lt- and Rt-invalid
condition tasks (p=0.01).

5. Discussion
We investigated the effects of involuntary limb
activation by FES on attentional function using the
Posner task. The effects of FES differed between the
online-effect and after-effect condition groups. In addition, the effects of FES differed between the Posnertasks with invalid and valid conditions.

Table 1 Reaction time of the modified Posner task (ms)Online-effect condition

217

After-effect condition

Sham
M (SD)FES
M (SD)

Post-Sham
M (SD)

Post-FES
M (SD)

Lt-target
invalidvalid

368.5 (60.0)
350.0 (52.1)

376.5 (63.0)
377.0 (62.1)

360.9 (70.5)
332.3 (35.8)

357.6 (54.4)
348.6 (43.4)

Rt-target
invalidvalid

372.5 (65.3)
352.7 (50.7)

377.4 (55.4)
372.3 (48.3)

366.8 (69.8)
335.8 (45.2)

365.0 (47.9)
347.1 (34.7)

FES: functional electrical stimulation, Lt-target: Target appeared in the left space, Rt-target: Target appeared in theright space, invalid: targets appeared on the opposite side that was indicated by a cue, and valid: targets appeared on
the side that was indicated by a cue valid condition for target presentation in the left space.

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EFFECTS OF FUNCTIONAL ELECTRICAL STIMULATION ON ATTENTION

Fig. 4.

Reaction time of modified Posner task on online-effect condition (ms)Lt-invalid: invalid condition for target presentation in left space, Lt-valid: valid condition for target presentation in left
Figure4. Reactionof modified
Posner task
onspace,online-effectspace, Rt-invalid:invalidtime
condition
for target presentationin right
Rt-valid: validcondition
condition for(ms)target presentation in left space. ◦ : outlier.

Lt-invalid: invalid condition for target presentation in left space, Lt-valid: valid condition for target
presentation in left space, Rt-invalid: invalid condition for target presentation in right space, Rt5.1. Differences between online- and after-effect conditions
upper limb resulted in brain activity in thevalid: valid condition for target presentationforinthe
leftleftspace.
◦：outlier.
The RT was delayed in the online-effect condition
somatosensory region of the right hemisphere. FES
group. Therefore, the FES-induced brain activity may
may have improved the spatial representations on thehave interfered with the brain activity attributed to theleft side of the brain, resulting in a tendency to reducetask performance. Regarding the interference of brain
the RT in the Lt-invalid condition.
activity, dual-task interference occurs when two tasks
are performed simultaneously, resulting in increased
5.2. Differences between the target-present conditions
errors and delayed RTs in one or both tasks [25–27]. In
The online-effect condition group, wherein thethe online-effect condition, FES increased the amount
Posner task was performed simultaneously with FES,of external stimulation, which required more processdemonstrated a greater change in the RT in valid coning resources to pay attention to and respond to thedition tasks than in invalid condition tasks.
target. In practice, several participants reported that
Previous studies that compared invalid and valid
their attention turned to the FES and left upper limb,
conditions in the Posner task reported on longer RT insuggesting dual-task interference between FES and
the invalid condition tasks than in the valid condition
task performance.
tasks performed by healthy individuals and patients
In contrast, the RTs tended to reduce in thewith USN [29,30]. In the valid condition, attention is
Lt-invalid condition tasks in the after-effect condition.
focused on the target, which can be predicted (volunA previous study on healthy individuals reported
tary attention). Moreover, responses are faster in thethat unilateral sensory stimulation acts on the spatial
valid condition than in the invalid condition [31,32].
representations and shifts the self-centered coordiIn the invalid condition, the focus of attention needs
to be shifted away from the location predicted by thenate system to the stimulated side [28]. In addition,cue to a new location (attentional shift). Difficulties in
FES of the extensor muscles of the left forearm in
shifting attention persist even in patients without clinipatients with USN reduces severe USN symptoms,
and the effect continues 6 months post-intervention.
cal signs of USN [33,34]. In a previous study wherein
Furthermore, FES could activate the intrinsic receptive
tDCS was performed on right-handed healthy particsensory map in the right parietal lobe [11]. Thus, FES
ipants in the parietal region, the response was signifi-

4Asian J Occup Ther 19: 213−222, 2023

Fig. 5.

Yoshihiro N et al.

219

Reaction time of modified Posner task on after-effect condition (ms)Lt-invalid:invalid condition
target presentation
left space,Lt-valid: valid condition
for target
Figure5. Reaction
time offormodified
Posnerintask
on after-effectcondition(ms)presentation in left
space, Rt-invalid: invalid condition for target presentation in right space, Rt-valid: valid condition for target presenta-★ : outlier.
tion in left
space. ◦,condition
Lt-invalid:invalid
for target presentation in left space, Lt-valid: valid condition for target

presentation in left space, Rt-invalid: invalid condition for target presentation in right space, Rtvalid: valid condition for target presentation in left space. ◦,⋆：outlier.

Fig. 6.

Amount of change of average RT.

Figure 6.Lt-invalid:
Amountinvalidof change
RT. in left space, Lt-valid: valid condition for target presentation in leftconditionof
foraveragetarget presentation
space, Rt-invalid: invalid condition for target presentation in right space, Rt-valid: valid condition for target presenta-

Lt-invalid:
condition for target presentation in left space, Lt-valid: valid condition for target
tioninvalid
in left space.
presentation in left space, Rt-invalid: invalid condition for target presentation in right space, Rtvalid: valid condition for target presentation in left space.

5

220

EFFECTS OF FUNCTIONAL ELECTRICAL STIMULATION ON ATTENTION

cantly faster in the valid condition than in the invalid
condition. Nonetheless, no effect of tDCS implementation was noted [35]. Contralateral parietal tDCS may
have facilitated hemispheric perceptual bias, without
significant differences. However, our results demonstrated that the longer RT attributed more to FES in
the valid condition than in the invalid condition in the
online-effect condition group. This finding indicates aceiling effect because invalid conditions, which require
more attentional resources than valid conditions, had amore severe task difficulty and slower RT before FES.
In the after-effect condition group, the RT demonstrated a marginal change in the valid conditions andtended to reduce in the invalid conditions.
Invalid conditions are reportedly associated withthe reorientation of attention [15]. Corbetta and Shulman [36] suggested that voluntary attention was related
to the dorsal pathway in the bilateral hemispheres, andthe reorientation of attention was related to the ventral
pathway that is dominant in the right hemisphere.
However, Corbetta and Shulman [36] only included
patients with USN, whereas we included healthy participants; therefore, it is difficult to compare the twostudies directly. However, FES of the left upper limb
activates the intrinsic receptive sensory map of theright parietal lobe [13], suggesting that it activated theventral pathway of the attentional network, resulting ina tendency to reduce the RT under the invalid condition rather than the valid condition.
Upon focusing attention to the unaffected side inpatients with USN, it is difficult to shift the attention to
the affected side [37]. In the Posner task, patients with
USN show a greater delay in RTs under the invalid
condition than that under the valid condition [27]. FES
may be considered a more effective intervention forpatients with USN if FES of the left upper limb can
activate the reorientation of attention in the ventral
pathway in the right hemisphere.
5.3. Limitations
This interventional study was based on healthy
individuals; future studies should consider enrolling
patients with USN. Furthermore, we examined theeffects of FES based on the results of the Posner task;
however, we did not examine the patients’ brain activity, which should be evaluated in future studies.
The setting of the modified Posner task was according to previous studies [18,19], and a 1,000–2,000
ms delay occurs between the cue and the target
appearance. We selected this long timing because weultimately intended to apply the intervention to patients with USN; however, the time is sufficiently longto trigger some inhibition of return in healthy young

participants.

6. Conclusions
We examined the effects of limb activation by
FES on attentional function. The effects of FES differed in the RT in the Posner task between the onlineand after-effect condition groups, indicating that FESof the left upper limb could affect the invalid condition
involving the reorientation of attention. Thus, involuntary upper limb activation by FES may be an effective
intervention to manage USN.

Funding
This research received no external funding.

Institutional Review Board Statement
The study was conducted in accordance with the
Declaration of Helsinki and approved by the Ethics
Committee of Tokyo Metropolitan University (approval number: 19094) and Kansai University of Health
Sciences (approval number: 19-56).

Informed Consent Statement
Informed consent was obtained from all participants involved in the study.

Acknowledgements
We acknowledge the cooperation of all the participants in the study.

Conflicts of Interest
The authors declare no conflict of interest.

References[1] Heilman KM, Valenstein E. Mechanisms underlying
hemispatial neglect. Ann Neurol. 1979;5(2):166-70.
[2] Corbetta M, Kincade MJ, Lewis C, Snyder AZ, Sapir A.
Neural basis and recovery of spatial attention deficits inspatial neglect. Nat Neurosci. 2005;8(11):1603-10.
[3] Kleinman JT Newhart M, Davis C, Heidler-Gary J,
Gottesman RF, Hillis AE. Right hemispatial neglect:
frequency and characterization following acute left
hemisphere stroke. Brain Cogn. 2007;64(1):50-9.
[4] Cubelli R. Definition: spatial neglect. Cortex. 2017;
92:320-1.
[5] Nijboer T, van de Port I, Schepers V, Post M, Visser-Meily A. Predicting functional outcome after stroke:Asian J Occup Ther 19: 213−222, 2023

the influence of neglect on basic activities in dailyliving. Front Hum Neurosci. 2013; 7:182.
[6] Luauté J, Halligan P, Rode G, Rossetti Y, Boisson D.
Visuo-spatial neglect: a systematic review of current interventions and their effectiveness. Neurosci Biobehav
Rev. 2006;30(7):961-82.
[7] Robertson IH, North NT. Spatio-motor cueing in unilateral left neglect: the role of hemispace, hand and motor
activation. Neuropsychologia. 1992;30(6):553-63.
[8] Làdavas E, Berti A, Ruozzi E, Barboni F. Neglect as a
deficit determined by an imbalance between multiple
spatial representations. Exp Brain Res. 1997; 116:493500.
[9] Stewart A, Pretty C, Chen X. A portable assist-as-needupper-extremity hybrid exoskeleton for FES-induced
muscle fatigue reduction in stroke rehabilitation. BMC
Biomed Eng. 2019;1(1):1-7.
[10] Eskes GA, Butler B, McDonald A, Harrison ER, Phillips SJ. Limb activation effects in hemispatial neglect.
Arch Phys Med Rehabil. 2003;84(3):323-8.
[11] Polanowska K, Seniów J, Paprot E, Leśniak M, Członkowska A. Left-hand somatosensory stimulation combined with visual scanning training in rehabilitation forpost-stroke hemineglect: a randomised, double-blind
study. Neuropsychol Rehabil. 2009;19(3):364-82.
[12] Eskes GA, Butler B. Using limb movements to improve
spatial neglect: the role of functional electrical stimulation. Restor Neurol Neurosci. 2006;24(4-6):385-98.
[13] Harding P, Riddoch MJ. Functional electrical stimulation (FES) of the upper limb alleviates unilateralneglect: a case series analysis. Neuropsychol Rehabil.
2009;19(1):41-63.
[14] Posner MI, Walker JA Friedrich FJ Rafal RD. Effects ofparietal injury on covert orienting of attention. J Neurosci. 1984;4(7):1863-74.
[15] Astafiev SV, Stanley CM, Shulman GL, Corbetta
M. Extrastriate body area in human occipital cortex
responds to the performance of motor actions. Nat Neurosci. 2004;7(5):542-8.
[16] Rapcsak SZ, Cimino CR, Heilman KM. Altitudinalneglect. Neurology. 1988;38(2):277-81.
[17] Shelton PA, Bowers D, Heilman KM. Peripersonal andvertical neglect. Brain. 1990;113(1):191-205.
[18] Osaki S, Amimoto K, Miyazaki Y, Tanabe J, Yoshihiro
N. Investigating the characteristics of covert unilateral spatial neglect using the modified Posner task: asingle-subject design study. Prog Rehabil Med. 2021;
6:20210014.
[19] Osaki S, Amimoto K, Miyazaki Y, Tanabe J, Yoshihiro
N. Reaction time analysis in patients with mild left unilateral spatial neglect employing the modified Posnertask: vertical and horizontal dimensions. Exp Brain
Res. 2022;240(7-8):2143-53.
[20] Bracco M, Veniero D, Oliveri M, Thut G. Prismatic
adaptation modulates oscillatory EEG correlates ofmotor preparation but not visual attention in healthy
participants. J Neurosci. 2018;38(5):1189-201.

Yoshihiro N et al.

221[21] Ludwig K, Schmid D, Schenk T. Gaze-contingent
stimulus removal leads to subsequent changes inovert attentional allocation. Neuropsychologia. 2020;
139:107297.
[22] Ludwig K, Schenk T. Long-lasting effects of agaze-contingent intervention on change detection in
healthy participants – implications for neglect rehabilitation. Cortex. 2021; 134:333-50.
[23] Faul F, Erdfelder E, Buchner A, Lang AG . Statisticalpower analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods
2009;41:1149–1160.
[24] Cohen J. Statistical power analysis for the behaviouralsciences, 2nd edn. Lawrence Erilbaum Associates,
Hillsdale 2009.
[25] Welford AT. Single-channel operation in the brain. Acta
Psychol. 1967; 27:5-22.
[26] Pashler H. Dual-task interference in simple tasks: data
and theory. Psychol Bull. 1994;116(2):220-44.
[27] Begeman M, Kumru H, Leenders K, Valls-Sole J. Unilateral reaction time task is delayed during contralateral
movements. Exp Brain Res. 2007; 181:469-75.
[28] Karnath HO, Fetter M, Dichgans J. Ocular explorationof space as a function of neck proprioceptive andvestibular input – observations in normal subjects andpatients with spatial neglect after parietal lesions. Exp
Brain Res. 1996; 109:333-42.
[29] Rengachary J, d’Avossa G, Sapir A, Shulman GL
Corbetta M. Is the Posner reaction time test moreaccurate than clinical tests in detecting left neglect inacute and chronic stroke? Arch Phys Med Rehabil.
2009;90(12):2081-8.
[30] Arif Y, Spooner RK, Wiesman AI, Embury CM,
Proskovec AL, Wilson TW. Modulation of attention
networks serving reorientation in healthy aging. Aging.
2020;12(13):12582-97.
[31] Ristic J, Kingstone A. Attention to arrows: pointing to a new direction. Q J Exp Psychol (Hove).
2006;59(11):1921-30.
[32] Bonato M, Lisi M, Pegoraro S, Pourtois G. Cue-target
contingencies modulate voluntary orienting of spatialattention: dissociable effects for speed and accuracy.
Psychol Res. 2018; 82:272-83.
[33] Losier BJW, Klein RM. A review of the evidence for adisengage deficit following parietal lobe damage. Neurosci Biobehav Rev. 2001;25(1):1-13.
[34] Bartolomeo P, Chokron S. Orienting of attentionin left unilateral neglect. Neurosci Biobehav Rev.
2002;26(2):217-34.
[35] Lucia ML, Leech R, Scott G, Malhotra P, Seemungal
B, Sharo DJ. The effect of oppositional parietal transcranial direct current stimulation on lateralized brain
functions. Eur J Neurosci. 2015;42(11):2904-14.
[36] Corbetta M, Shulman GL. Control of goal-directed andstimulus-driven attention in the brain. Nat Rev Neurosci. 2002;3(3):201-15.
[37] Rastelli F, Funes MJ, Lupiáñez J, Duret C, Bartolomeo

222

EFFECTS OF FUNCTIONAL ELECTRICAL STIMULATION ON ATTENTION

P. Left visual neglect: is the disengage deficit space- or
object-based? Exp Brain Res. 2008; 187:439-46.

■ORIGINAL ARTICLE

Surveys of the Efficacy, Technical Difficulty, Ethics,
and Dissemination of Splint/Orthosis Fabrication
Using Thermoplastic Splint Sheets
Kazuo Saito1, Daichi Narita2, Mikayo Omori3
1

Department of Rehabilitation, Faculty of Health Sciences, Tokyo Kasei University
Rehabilitation Center, Sagamihara Kyodo Hospital, Sagamihara, Japan3
Rehabilitation Center, St. Marianna University Hospital, Kawasaki Japan
2

Abstract: Objective: For splints/orthoses fabricated by therapists during hand therapy to be recognized as a novel
specialized medical technology, we demonstrated their ease of dissemination, ethics, safety, and effectiveness. We also
investigated the technical difficulty and dissemination of splints/orthoses in a first study on the current situation of
splint/orthoses fabrication using thermoplastic splinting sheets, and evaluated the effectiveness, safety, and ethics of
splinting sheets in a second study.
Methodology: In the first study, we investigated the name of the target diagnosis, purpose of fabrication, time of fabrication, joints involved, presence or absence of component connections, and fabrication time. In the second study, we investigated basic attributes, explanations and consent, prescriptions, difficulties, and efficacy indicators. The participants
were 49 therapists from 46 institutions who completed the academic society-approved seminars in the first and second
studies.
Results: The subjects were 31 out of the 49 therapists (response rate: 67.4%), and the target splints were 547. The
splints/orthoses were used in daily clinical practice after surgery or immediately after injury, and various splints/orthoses were fabrication according to a specific purpose, even during treatment. Moreover, regarding the difficulty level, thesplints/orthoses could be fabrication in a relatively short time by a advanced hand therapist. For instance, 260 (48%)
were produced within 20 minutes.
Conclusion: The safety and ethics of the splint/orthoses showed high values, but further objective indicators and subjective data indexing of efficacy are required.
Keywords: splint/orthosis, technical difficulty, dissemination, ethics, effectiveness(Asian J Occup Ther 19: 223−229, 2023)

1. Introduction
A splint/orthosis is an extremely effective therapeutic tool for correcting problems of bones/joints or
the neuromuscular systems. A splint/orthosis has beenused to solve problems that affect functional prognosis, based on close collaboration between doctors andtherapists [1-3]. Therefore, it is important for theraReceived: 9 November 2022, Accepted: 29 May 2023
Corresponding to: Kazuo Saito, Department of Rehabilitation, Facultyof Health Sciences, Tokyo Kasei University, 2-15-1 Inariyama Sayama
City, Saitama, 350-1398, JAPANe-mail: saito-kaz@tokyo-kasei.ac.jp©2023 Japanese Association of Occupational Therapists

pists who fully understand the goals and content oftherapy to provide treatment promptly according to thetimeline of therapy. The main advantage of splints/orthoses fabricated by therapists is that they are available
on time in clinical settings. Most splints/orthoses arethermoplastic splint sheets with plastic properties thatsoften at low temperatures and can be molded directly
to the patient’s upper limb. Various innovations havebeen made according to this application [4,5].
An analysis of the actual use of splints/orthoses
and orthotics by certified hand therapists in the UnitedStates and Canada [6-8] showed that those fabricatedby certified hand therapists are a common and important part of the practice of hand therapy [9-12]; thus,
they are emphasized in clinical practice, research, and224

SURVEYS OF THE ACTUAL SITUATION OF SPLINT FABRICATION AND EFFECTIVENESS

training. Additionally, the Centers for Medicare andMedicaid Services, the primary entity that manages
the public health insurance system in the UnitedStates, covers splints/orthoses and orthotics fabricatedby occupational therapists and physical therapists as
specialized medical technology.
In Japan, the certified hand therapist system
launched in 2009 includes a training system aimed at
improving the specialized knowledge and practicalabilities of hand therapy practitioners, developing
and expanding therapeutic techniques, and improving
educational and research standards related to handsurgery. Qualification as a certified hand therapist
requires 6,400 minutes of training and other credits,followed by passing a certification examination. Partof the examination consists of splint training, which
includes a basic hand splint seminar (720 minutes) andadvanced hand splint seminar (720 minutes), totaling
1,440 minutes or 23% of the entire curriculum. This
training is backed by specialized knowledge and skills,
is promoted to eliminate disparities among therapists
and facilities, and plays a major role in improving
the skills, environments, and other aspects of splint
fabrication. However, despite the maturing conditions
surrounding therapeutic splint fabrication, assessmentsof splint and orthotics fabrication by occupational
therapists and physical therapists as a specialized medical technology are not yet fully established in Japan’s
medical fee structure for health insurance.
Japan’s Advanced Medical Care Program aims
to make promising medical technologies available
to patients through coverage by the National Health
Insurance. For splints/orthoses fabricated by therapists
during hand therapy to be recognized as novel specialized medical technology, it is essential to describe thelevel of technical difficulty involved and demonstrate
its ease of dissemination, ethics, safety, and effectiveness [13]. Hence, fact-finding surveys regarding splint
fabrication are extremely important.
Herein, we conducted two fact-finding surveys on
the fabrication of splints/orthoses using thermoplastic
splint/orthosis sheets to obtain basic data for setting
new medical fees. We aimed to investigate the actual
situation of splint fabrication and the technical difficulty and ease of dissemination of splints/orthoses andevaluate the ethics, safety, and effectiveness of splints/
orthoses.

2. Methods
2.1. Ethics statement
This study was commissioned by the Japan Hand
Therapy Society (JHTS). The surveys were conducted

after the respondents were given sufficient explanations and provided informed consent. This study wasapproved by Tokyo Kasei University Ethics Committee (approval no.: SKE2020-70; year: 2020), and allparticipants provided written informed consent. The
study was conducted in accordance with the principlesof the Declaration of Helsinki. The participants wereassigned arbitrary subject numbers so that no individual could be identified. The document listing matched
participants with their corresponding subject numbers
was stored on a password-protected USB drive thatremained locked in the principal investigator’s laboratory. The data analysis file was stored on a different
password-protected USB drive locked in the principal
investigator’s laboratory.
2.2. Survey 1
The purpose of the first study was to investigate
the technical difficulty and ease of dissemination of
splints/orthoses. This survey targeted 49 therapists
from 46 facilities who had completed the advanced
splint/orthosis seminar part of the Japan Hand Therapy
Society’s certified hand therapist training curriculumfrom fiscal years 2013 to 2018.
The survey was conducted by emailing therapists
a questionnaire about their basic attributes and practiceof splint fabrication. The email also included an explanation of the survey, and we considered that informed
consent was obtained if they responded. The survey
period lasted 2 months, from September 1, 2019 to
October 31, 2019.
The survey items were as follows: a) subjects’basic attributes, b) diagnostic classifications that the
fabricated splint/orthosis was used for, c) the purposeof fabrication, d) fabrication timing, e) joints involved(size), f) presence or absence of component connections, g) fabrication time, and h) material size. The
details of these items are listed in Tables 1 and 2.
2.3. Survey 2
The purpose of the second study was to investigate the ethics, safety, and effectiveness of splints/
orthoses. The subjects and methods were the sameas those for survey 1, and the survey period lasted 2
months, from October 1, 2020, to November 30, 2020.
The survey items were as follows: a) subjects’basic attributes, b) the presence or absence of informed
consent, c) presence or absence of a splint prescription
from a doctor and the prescribing doctor, d) trouble
while wearing the splint and its content and remedies,and e) presence or absence of splint effectiveness indicators and their content. The details of these items arelisted in Tables 1 and 2.

Asian J Occup Ther 19: 223−229, 2023

Saito K et al.

225

Table 1 Survey details
Survey 1

Survey 2

PurposeTo investigate the technicaldifficulty and ease of dissemination of splints/orthoses

To investigate the effectiveness, safety, and ethics of
splints/orthoses

Facility and subjects

49 therapists from 46 facilities

49 therapists from 46 facilities

Investigation period

September 2019 to October
2019: 2 months

October 2020 to November
2020: 2 months

Number of target splints/
orthoses547

937

Table 2 Items and content of Survey 1 and 2
Survey 1

Survey 2

Item

Content

Item

Content

a. Subjects’ basic attributes

Age, years of experience as a handtherapist, affiliationa. Subjects’ basic attributes

Age, years of experience as a handtherapist, affiliationb. Diagnosis classifications

Bone/joint diseases, neuromotor
diseases, amputations/complex injuries, and othersb. Informed consent

Explanation from a doctor or therapist (Y/N)

c. Purpose of fabrication

Immobilization/rest/support, extension/correction, tendon excursion/restriction, functional compensation/training, otherc. Splint prescription

Splint prescription from a doctor(Y/N), prescribing doctor

d. Timing of fabrication

Within 1 week, 1–4 weeks, 5–12
weeks, more than 12 weeks post
injury or surgery, unknown

d. Difficulties

Trouble while the wearing splint,
methods of addressing it

e. Joints involved

Finger, thumb, wrist, forearm, elbow, shoulder, non-classified joint(duplicate responses allowed)

e. Effectiveness indicators

Splint effectiveness indicators (Y/N), content

f. Components (Y/N)

Elastic or nonelastic component
connections (Y/N)

g. Fabrication time

10–40 min (10-minutements), more than 40 min

h. Material size

Size (when the commercial size
approximately 24×18 inches istaken as 1)

incre-Y, yes; N, no2.4. Statistical analysis
Descriptive statistics were used to summarize
the survey data in Excel 2019 (Microsoft Corp.). The
subjects of this study were 49 people from 46 facilities who completed all the Hand Therapist Training
Curriculum Hand Split Advanced Seminars conductedby academic societies from 2013 to 2018 without performing detection ability analysis. Data pertaining tothree cases and five facilities were missing and had tobe obtained by contacting each patient individually byemail.

3. Results
The proportion of participants was different ineach study, as described below.
3.1. Survey 1
Consent and responses were obtained from 31of the 49 therapists (response rate: 67.4%), and 547
splints/orthoses were fabricated during the survey
period.

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SURVEYS OF THE ACTUAL SITUATION OF SPLINT FABRICATION AND EFFECTIVENESS

Table 3 Therapist demographics
Survey 1

Survey 2

67.4%, 31

42.9%, 21Age30s, 71%; 40s, 23%; 20s, 6%30s, 63%; 40s, 33%; 20s, 4%Years of experience

5–10 years, 76%; 11–15 years, 24%

5–10 years, 37%; 11–15 years, 59%

Affiliation

General hospital, 68%; special function
hospital, 22%; clinic 10%

General hospital, 78%; special function
hospital, 19; clinic, 4%

Recovery rate, number of respondents
Basic attributes

Table 4 Indications for splints/orthoses

Table 5 Characteristics of splint procedures

Survey 1

Survey 2

Bone/joint diseases

86%

72%

Neurological/motor diseases

7%

18%

Amputations/complex injuries

4%8%

Other diseases

3%2%

Immobilization/rest/support

64%

63%

Correction

20%

20%

Excursion/restriction

9%9%Compensation/training

7%

8%

Target disease

Target purpose

3.1.1. Participants’ basic attributes
Overall, 71% of therapists were in their 30s, 23%
in their 40s, and 6% in their 20s (Table 3). Their yearsof clinical experience were 5–10 years (76%) and
11–15 years (24%). Their affiliations were general
hospitals (68%), advanced treatment hospitals (22%),and clinics (10%).
3.1.2. Target diseases for splints/orthoses
Bone/joint diseases accounted for 86% of splints/
orthoses, neurological/motor diseases for 7%, amputations/complex injuries for 4%, and other diseases for
3% (Table 4).
3.1.3. Purpose of splint fabrication
Immobilization/rest/support was the purpose forsplint fabrication in 64% of splints/orthoses, correction
in 20%, excursion/restriction in 9%, and functional
compensation/training in 7% (Table 4).
Fabrication timing: Most splints/orthoses were
fabricated within 1 week post surgery or injury in 40%(220) of splints/orthoses, followed by 1–4 weeks in

Survey 1, %(quantity)

Survey 2, %(quantity)

Within 1 week

40% (220)

36% (333)

1–4 weeks

26% (142)

34% (351)

5–12 weeks

16% (89)19% (180)

12 weeks or later

12% (68)

8% (70)

10 min or less

40% (107)

28% (258)

10–20 min

48% (153)

47% (441)

20–30 min

6% (35)17% (159)

30–40 min

6% (32)

6% (54)40 min or later

0% (2)

2% (25)Fabrication timing

Fabrication time

26% (142), 5–12 weeks in 16% (89), 12 weeks or laterin 12% (68), and unknown in 6% (28) (Table 5).
3.1.4. Joints involved
The most common joints involved were the fingers in 275 splints/orthoses, followed by joints fromthe fingers/thumbs to the wrist in 115, wrist only in 73,
thumbs in 53, and elbows in 19.
3.1.5. Component connections
Most splints/orthoses had no component connections (81%, 445 splints/orthoses).
3.1.6. Fabrication time
Fabrication took 10–20 minutes in 48% (153)of splints/orthoses, 10 minutes or less in 40% (107),
20–30 minutes in 6% (35), and 30–40 minutes in 6%(34).

Asian J Occup Ther 19: 223−229, 2023

Saito K et al.

3.1.7. Material size
The size of the material was 1/10 in 60% (329) of
splints/orthoses, 1/6 in 24% (134), and 1/8 in 13% (73)
(1 sheet size, 460 × 610 mm).
3.2. Survey 2
Consent and responses were received from 21
of 49 participants (response rate: 42.9%). During thesurvey period, 937 splints/orthoses were fabricated.
3.2.1. Participants’ basic attributes
The attributes of the therapists were similar to
those of the therapists who responded to survey 2(Table 3). Overall, 63% of therapists were in their 30s,
33% were in their 40s, and 4% were in their 20s. Their
years of clinical experience were 5–10 years (37%)
and 11–15 years (59%). Their affiliations were general
hospitals (78%), advanced treatment hospitals (19%),and clinics (4%).
3.2.2. Explanation and consent
Informed consent was obtained for splint fabrication in 892 out of 937 splints/orthoses (95%). The
following is the purpose of the physician prescription
instructions for the 892 approved splints/orthoses:
immobilization/rest/support, 99%; correction, 100%;
excursion/restriction, 58%; and compensation/training,
97% (Table 6).

Table 6 Splint/orthosis indications and physician prescription information in Survey 2
Percentage of splints/orthoses
Target purpose
Immobilization/rest/support

99%

Correction

100%

Excursion/restriction

58%

Compensation/training

97%

3.2.3. 
Presence or absence of a splint prescription
from a doctor and the prescribing doctor
Prescriptions were provided for 77% of splints/
orthoses. There were differences in the presence or absence of a prescription depending on the purpose: immobilization (88%), prevention (78%), compensation(57%), and extension (49%). The prescribing doctor
was a hand surgeon or an orthopedic surgeon (81%).
3.2.4. Trouble while wearing the splints/orthosis
Problems with wearing the splint/orthosis wereobserved in 7% of splints/orthoses (70). Table 7 showsa breakdown of the data.

4. Discussion and implications
According to the membership statistics of the Japanese Association of Occupational Therapists, 75% ofregistered occupational therapists are in their 20s and
30s, and 72% work at general hospitals. Additionally,
the number of therapists who treat orthopedic diseases
including trauma is 14%, which is second only tocerebrovascular diseases [14]. This study will help
determine the direction and content of occupational
therapy splints in the future.
We will first discuss the technical difficulty andease of dissemination based on the results of the survery 1. Regarding technical difficulty, when the purposeof fabrication was immobilization/rest/support, thesplint was a so-called static splint that functions toimmobilize the joint. Fabrication of such splint tookapproximately 20 minutes or less for fingers and 40
minutes or less when including the wrist. We believe
this is because the therapists acquired the skills tofabricate a basic static splint in approximately 20
minutes through the splint-related seminars provided
by the JHTS. For purposes other than immobilization/
rest/support, mobilization splints/orthoses that supply
some forms of movement are used, and they are often
attached the elastic or nonelastic component to a static

Table 7 Troubles while wearing the splints/orthoses by the purpose of the splint/orthosis
Fixation

ExtensionCompensation

Issue involving fitting

68%(32)50%(2)

100%(9)

Damage, deterioration

9%(4)50%(2)

Skin issues

17%(8)

37.5%(3)Angle adjustment

6%(3)

25%(2)

Total

100%(47)

227

100%(4)

Prevention

37.5%(3)100%(9)100%(8)% (quantity)

228

SURVEYS OF THE ACTUAL SITUATION OF SPLINT FABRICATION AND EFFECTIVENESS

splint. Although fabrication of this kind of splint only
made up about 10% of splints/orthoses, this showedthat even more complex splints/orthoses are sometimes
fabricated in daily clinical practice. We are convincedthat it’s crucial to train therapists who can safely andeffectively apply forces to joints based on fundamental
knowledge of physiology as well as mechanics andphysics. Expanding the training of advanced therapists
in the educational curriculum of the JHTS will ensurethat the technical difficulty of splints/orthoses fabrication will be relatively low and that many patients will
be able to use this technique.
Regarding ease of dissemination, most splints/
orthoses (220) were fabricated within the first weekin terms of the timing of fabrication and the mostcommon purpose was immobilization/rest/support (171splints/orthoses). These also included a complex splintthat had connecting parts to supply early movement
after surgery to repair the finger flexor muscles andtendons. These results indicate that a splint/orthosis isa medical technology that can be fully utilized evenwhen risks need to be managed, including addressing
acute inflammatory symptoms, such as post-injury or
postoperative pain, dealing with wound status, andbeing careful about contraindications. Concerning thetiming of fabrication by purpose, the most common
time was within 4 weeks for the purpose of immobilization/rest/support; after 5 weeks onward, the purpose
was for extension/correction, and after 12 weeks,
there were various purposes. So that it was showedthat splint/orthosis is a medical technology that can beadapted to the course of treatment.
Next, we discuss ethics, safety, and showedorthosis effectiveness of splints/orthoses based on the
results of survey 2.
Concerning ethics, informed consent for splint
fabrication was obtained for 892 of 937 splints/orthoses, with consent obtained in 95% overall. However,for fabrication purposes, consent was obtained for only
57% (35 of 81) of splints/orthoses for compensation/
training. Overall, there were prescriptions for splints/
orthoses in 77% of splints/orthoses. These results indicate that the use of a splint/orthosis for immobilizationand excursion tended to be prescribed at the start ofrehabilitation, while prescriptions, explanations, andinformed consent for splint/orthosis adapted to thecourse of treatment were not sufficient.
Regarding safety, trouble while wearing a splint
was observed in 7% of all splints/orthoses. These canbe classified as trouble related to fitting, splint damage
and deterioration, skin issues, and adjustments to theoutrigger angle. These results indicate that the incidence of trouble was low and that the characteristics ofthermoplastic splint/orthosis sheets promptly adupted
the patients’ situations. However, it was also found thatmild skin problems, which could be a significant risk
factor, were difficult to avoid completely and require
countermeasures, such as post-fabrication evaluations
and supervisory reports.
Concerning effectiveness, objective or subjective
indicators were used in 74% of all splints/orthoses.
Objective indicators could be classified as range of
motion, imaging and clinical findings, inflammatory
findings, and activities of daily living. Subjective indicators could be classified as pain, quality of life, andother narrative data. The use of effectiveness indicatorsin splints/orthoses for immobilization was low (60%).
In studies on the effects of splint/orthosis for various
diseases, pain and disease-specific scales were often
used as subjective assessments [15-17], although few
used the amount of time until surgery [18, 19].
This study has some limitations. First, the therapists were experts who were attending seminars
offered by the Japan Hand Therapy Society. Second,
the survey periods of the first and second studies werelimited to 2 months. Important issues going forward
are the need to summarize the various effectiveness indicators for different purposes, coherence in the selection of objective indicators, and creation of indicatorsof subjective data for individualized responses.

5. Conclusions
We conducted fact-finding surveys regarding
splint fabrication with 49 therapists who had completed the certified hand therapist training curriculum of
the JHTS and discussed the technical difficulty, easeof dissemination, ethics, safety, and effectiveness of
splints/orthoses based on the survey results. In the
future, we would like to further increase the numberof subjects and the survey period. We also hope to add
to the literature on splint effectiveness to standardize
effective splint types and effectiveness indicators.

Declaration of conflicting interests
This study was contracted research from theJHTS.

Funding
This work was supported by Japan Hand Therapy
Society Social Insurance Committee [No. 2002001].

Asian J Occup Ther 19: 223−229, 2023

Acknowledgments
We would like to thank Editage (www.editage.
com) for English language editing and journal submission support. The authors have authorized the submission of this manuscript through Editage.

References[1] Wong SK. Classification of hand splinting. Hand Surg.
2002; 7: 209–13.
[2] Li-Tsang CW. Application of splinting in hand rehabilitation: a reflection of local practice. Hand Surg. 2002; 7:
207–8.
[3] Schwartz DA. Orthoses: essential comments. In: Wietlisbach CM, Christine M, editors. Cooper’s Fundamentals of Hand Therapy. Elsevier Health Sciences; 2019;89–98.
[4] Jacobs ML, Coverdale J. Concepts of orthotic fundamentals. In: Jacobs ML, Austin NM, editors. Orthotic
Intervention for the Hand and Upper Extremity: Splinting Principles and Process. 3rd ed. Wolters Kluwer
Health/Lippincott Williams & Wilkins; 2014; 2–25.
[5] Jacobs ML, Lawrence M. Concepts of orthotic fundamentals. In: Jacobs MLA, Austin NM editors. Orthotic
Intervention for the Hand and Upper Extremity Splinting Principles and Process. 3rd ed. Wolters Kluwer
Health; 2021; 63–72.
[6] Ueda K, Sanada S, Uemura N. Advanced medical careprogram for the rapid introduction of healthcare technologies to the National Health Insurance System inJapan. Clin Transl Sci. 2020; 13: 700–6.
[7] Jacobs MA, Lawrence M. Concepts of orthotic fundamental. Jacobs MA, Austin NM, editors. Orthotic Intervention for the Hand and Upper Extremity: Splinting
Principles and Process Third Edition.: Welters Kluwer
Health; 2022; 63-77.
[8] Mathauer I, Behrendt T. State budget transfers to healthinsurance to expand coverage to people outside formal
sector work in Latin America. BMC Health Serv Res.
2017 Feb 16; 17(1): 145. doi: 10.1186/s12913-0172004-y. PMID: 28209145; PMCID: PMC5314689.
[9] Kasch MC, Greenberg S, Muenzen PM. Competencies
in hand therapy. J Hand Ther. 2003; 16: 49–58.
[10] Kingston GA, Williams G, Judd J, Gray MA. Hand

Saito K et al.

229

therapy services for rural and remote residents: resultsof a survey of Australian occupational therapists
and physiotherapists. Aust J Rural Health. 2015 Apr
23(2):112–21. doi: 10.1111/ajr.12141. Epub 2015 Jan
23. PMID: 25616064.
[11] Frye SK, Geigle PR. Current U.S. splinting practices
for individuals with cervical spinal cord injury. Spinal
Cord Ser Cases. 2020 Jun 17; 6(1): 49. doi: 10.1038/
s41394-020-0295-4. PMID: 32555151; PMCID:
PMC7298624.
[12] Kaunnil A, Sansri V, Thongchoomsin S, Permpoonputtana K, Stanley M, Trevittaya P, et al. Bridging the
gap between clinical service and academic educationof hand-splinting practice: perspectives and experiences of Thai occupational therapists. Int J Environ
Res Public Health. 2022 Jul 24; 19(15): 8995. doi:
10.3390/ijerph19158995. PMID: 35897366; PMCID:
PMC9332612.
[13] Keller JL, Henderson JP, Landrieu KW, Dimick MP,
Walsh JM. The 2019 practice analysis of hand therapy
and the use of orthoses by certified hand therapists. J
Hand Ther. 2021: S0894-1130(21)00055-7.
[14] The Journal of Japanese Association of Occupational
Therapists (JJAOT) No.102 September, 518, 2020,(Japanese), https://www.jaot.or.jp/files/page/jimukyoku/
kaiintoukei2019.pdf.
[15] Beasley J, Ward L, Knipper-Fisher K, Hughes K,
Lunsford D, Leiras C. Conservative therapeutic interventions for osteoarthritic finger joints: a systematic
review. J Hand Ther. 2019; 32: 153–64.e2.
[16] Egan M, Brosseau L, Farmer M, Ouimet, MA, Rees
S, Tugwell P, et al. Splints/orthoses in the treatment ofrheumatoid arthritis. Cochrane Database Syst Rev. doi:
10.1002/14651858.CD004018.
[17] Dunn JC, Kusnezov N, Orr JD, Pallis M, Mitchell JS.
The boxer’s fracture: splint immobilization is not necessary. Orthopedics. 2016; 39: 188–92.
[18] Page MJ, Massy-Westropp N, O’Connor D, Pitt
V. Splinting for carpal tunnel syndrome. Cochrane
Database Syst Rev. 2012. doi: 10.1002/14651858.
CD010003.
[19] Amirfeyz R, McNinch R, Watts A, Rodrigues J, Davis
TR, Glassey N, et al. Evidence-based management of
adult trigger digits. J Hand Surg (Eur). 2017 Jun; 42(5):473–80.

■RAPID COMMUNICATIONS

Effectiveness of Self-help Device in Closing Zippers
Using a Single Hand in Patients with Hemiplegia:
A Retrospective Observational Study
Daisuke Sakagawa1, Daisuke Konda2, Miyu Kawato3, Kyoko Chiba4,
Kazuki Wakasa5, Shuhei Sasahara6, Takaki Kafuku6
1

Department of Rehabilitation,Morioka Red Cross Hospital
Department of Rehabilitation, Hakodate Ryohoku Hospital3
After School Day Service Kibougaoka
4
Department of Rehabilitation, National Hospital Organization Hachinohe National Hospital
5
Department of Rehabilitation, Tsurukawa-kinen Hospital
6
Department of Occupational Therapy, Tohoku Medical school
2

Abstract: Purpose: For patients forced to use only one hand, closing a zipper is challenging. Therefore, we developed
a self-help device that uses a string and clothespins; the device stretches the zipper, allowing the individual to close it
easily with one hand. We aimed to 1) demonstrate the effectiveness of this device by comparing the zipper closing
motion when the device is used (“usage motion”) with that when it is not used (“non-usage motion”) and 2) determine
whether difficulty level changes when using either the left or right hand.
Methods: This study included 38 patients with hemiplegia. Participants were asked to close the zipper with one hand
after being instructed on how to perform the usage and non-usage motions. Next, we judged whether the participants
could perform the movements, and measured the time taken to close the zipper using video.
Results: All participants could close the zipper using the usage motion; however, time taken to close the zipper was
significantly shorter when the device was used than when it was not. On comparing the zipper closing time between theleft and right hand for the usage motion, no significant differences were noted.
Conclusion: Experimental results suggest that device-based zipper closure is an efficient method for patients withhemiplegia. Furthermore, we demonstrated that a self-help device, combining inexpensive everyday items, could enable
patients with hemiplegia to successfully dress themselves without difficulty.
Keywords: zipper, hemiplegia, self-help device, dressing(Asian J Occup Ther 19: 230−235, 2023)

Introduction
Separating zippers, comprising a chain, insertion
pin, retainer box, slider, and pull tab, are used forjackets and coats [1]. Zippers with a right-hand-side
insertion pin (“right-insertion zipper”) are commonlyused in Europe and Asia, whereas those with a leftReceived: 12 April 2023, Accepted: 29 May 2023
Corresponding to: Daisuke Sakagawa, Department of Rehabilitation,Morioka Red Cross Hospital, 1-1, 6chiwari, Sanbonyanagi, Morioka, Iwate, 020-8560 Japane-mail: takakafu@rinken.ac.jp©2023 Japanese Association of Occupational Therapists

hand-side insertion pin (“left-insertion zipper”) arecommonly used in the United States [2]. Right-insertion zippers are fixed by holding the slider and retainer
box in close contact using the left hand, the insertion
pin is inserted with the right hand, and the pull tab of
the slider is pulled with the left hand while pullingthe hem to prevent the insertion pin from slipping outof the retainer box [3]. The procedure is flipped forthe left-insertion zipper [4]. In either case, closing thezipper with one hand (“closing motion”) is extremely
difficult. Therefore, zipper closing is difficult for patients with hemiplegia or individuals with diseases or
injuries that limits them to using a single hand [5].
Some patients with hemiplegia use a self-help

Asian J Occup Ther 19: 230−235, 2023

Sakagawa D et al.

231

device to facilitate the closing motion. However,self-help devices for right-insertion zipper [6,7] andleft-insertion zipper [5] closing motions only provide
an explanation for the procedure using either theright or left hand, with no reports on the procedure
for the other hand; furthermore, their effectiveness is
unknown. We developed a self-help device for left- orright-handed use.
This study aimed to demonstrate the effectivenessof this device by comparing the closing motion when
the device was used (“usage motion”) or not used(“non-usage motion”) in patients with hemiplegia.
We further explored differences in difficulty levels
between the left and right hand.

impairment, which would interfere with daily life,
manifesting in the upper limbs, fingers, or lower limbs
on non-paralyzed side, (3) an absence of higher brain
dysfunction, (4) a revised Hasegawa Simplified Intelligence Scale score that was within the normal rangeof 21 or more [8], (5) the ability to stably maintain asitting position.

Methods

Equipment
The device is shown in Figure 1. The self-help
tool studied here has the same chain tension mechanism as several existing self-help tools [5-7]. However,
the existing self-help tools pull only on the hem of theinsertion pin’s side to apply the tension required toclose the chain. In contrast, the studied self-help tool
applies tension on the chain by pulling the hem onboth the slider side and the insertion pin side. Pullingon both sides makes the tension on both the left andright chains more even, making it easier to raise theslider and close the zipper. Additionally, the string of
the clothes pin that holds the insertion pin side is made10 mm shorter than the string of clothespin a that

Participants
We recruited 38 hemiplegic stroke patients (19males, 19 females; nine right hemiplegic males, nineright hemiplegic females; 10 left hemiplegic males, 10
left hemiplegic females) who regularly attended daytime nursing care facilities. All participants were in
the chronic phase, at least one year after stroke onset.
Of the 38 patients, 17 suffered cerebral infarctionand 21 suffered cerebral hemorrhage. The mean ageof the participants was 72 ± 10 years (range, 48–90
years). The participation criteria for this study were
(1) unilateral motor paralysis, (2) a lack of functional

EthicsThis study was approved by the Institutional
Review Board of the A Hospital (approval date: March
28, 2020) and conducted in accordance with the Declaration of Helsinki. Written informed consent was
obtained from all participants.

a
a

b
b

Full image
Fig. 1.

Enlarged image of clothespin part

Device structure
The string is polypropylene, and one end of the string is divided into two, as shown by “a” and “b,” and clothespins areattached at each end of the string. Clothespin string “a” is 10 mm longer than clothespin string “b.” The string is connected to one handle of the clothespin. The opposite end of the string is made into a loop so that it can be hooked on theleg. This device was used for experiments; the part indicated by an arrow was made into an adjustable grip hitch toallow the total length to be adjusted in the range of 600–800 mm.

232

EFFECTIVENESS OF SELF-HELP DEVICE TO CLOSE ZIPPER

holds the slider side, making it difficult to remove theinsertion pin from the slider.
Experiments were conducted in a sitting position,and the height of the seat surface was set so thatthe hip and knee joints were at 90°. The device washooked onto the leg in that position, and the length of
the string was adjusted to allow the tip of the clothespin to reach the trochanter major. The jacket used
for the experiment was a zip-up hoodie or tracksuit,owned by the patients. The jackets had insertion pin on
the right and were made in Japan.

Step 22
Step

Step 33
Step

Closing Motion Procedure
Figure 2 shows the procedure of the closing operation for use and non-use where:(a) depicts the usage motion, with the procedure

Step 44
Step

Step 55
Step

Step 66
Step

Right
hand
Right hand

Step 11
Step

The closing motion was captured using web
camera (c920r; Logicool Co Ltd., Lausanne) from two
directions (non-paralyzed side and front side), and theimages were uploaded at 30 frames/s in myoVIDEO(NORAXON USA Inc, Scottsdale) and simultaneously
recorded and analyzed.

Right
hand
Right hand

Left
hand
Left hand(a)(a)

Left
hand
Left hand(b)(b)

Fig. 2.

Procedure for closing motion

Figure. 2. Procedure
forprocedureclosing motion(a) Usage motion

The procedure for the right hand (upper row) is to hold the clothespins shown in Fig. 1a, pinch the hem around the box(a) Usage motion
procedure(Steps 1 and 2), put the loop on the right leg, extend the leg, insert the insertion pin (Steps 3 and 4), pinch the hem near

the insertion
withhandclothespins
in Fig.
5), andthe
tiltclothespins
the trunk backwards,
the right
leg to the
The procedure
for the pin
right(upperrow)1bis(Stepto hold
shownextend
in Fig.
1a, pinch
theleft side,and raise the pull tab (Step 6). The procedure for the left hand (lower row) is to hold the clothespins shown in Fig. 1b,

hem aroundpinch
the box(Steps1 theandinsertion2), putpinthe(Steps
loop1 onright
leg, onextendinserttheinsert
insertion
the hemaroundand the2), put
the loop
the leftthe
leg,leg,
extendthe leg,
the insertion(Steps 3 and 4), pinch the hem near the box with the clothespins in Fig. 1a (Step 5), tilt the trunk backwards, extend
pin (Steps 3pin
and4), pinch the hem near the insertion pin with clothespins in Fig. 1b (Step 5), and tilt
the left leg to the left side, and raise the pull tab (Step 6).

the trunk backwards, extend the right leg to the left side, and raise the pull tab (Step 6). The procedure(b) Non-usage procedure

for the left hand(lower forrow)
to handhold(upper
the clothespins
shown
in Fig.
the andhemmiddlearoundthepress the
The procedure
the isrightrow) is to pinch
the insertion
pin1b,
withpinch
the thumbfinger,bottom of the box with the index finger (Steps 1 and 2), insert the insertion pin (Step 3), and raise the pull tab with theinsertion pinthumb(Steps1 and 2), put the loop on the left leg, extend the leg, insert the insertion pin (Stepsand index finger while pressing the jacket with the middle and ring fingers. The raising is undertaken repeatedly

to thethedesired(Steps
4–6).
The theprocedure
for the leftrow) is5),
to insert
thetrunk
insertion
pin slightly into
3 and 4), pinch
hemposition
near theboxwithclothespins
inhandFig.(lower
1a (Step
tilt thebackwards,
the slider (Step 1), press the bottom of the box with the index finger, hold the insertion pin with the thumb and middle

extend the leftlegto 2),
theandleft
side,
raisepinthe
pull
(Step
6).the same as with the right hand.
finger(Step
inserttheandinsertion(Step3). tab(Steps4–6) are(b) Non-usage procedure

The procedure for the right hand (upper row) is to pinch the insertion pin with the thumb and middle

Asian J Occup Ther 19: 230−235, 2023

Sakagawa D et al.

for the right hand shown in the upper row, and theprocedure for the left hand shown in the lower row; (b)depicts the non-usage motion, with the procedure forthe right hand shown in the upper row, and the procedure for the left hand shown in the lower row.
Procedure
We explained the usage and non-usage motions to
the participants, who then practiced the activities until
satisfaction. Next, they were asked to close the zipperof their jacket using the non-paralyzed hand. The end
position of the slider was decided by the patients, but
the same position was used for the usage and non-usage motions.
After the experiment, we judged whether eachparticipant could perform the closing motion. Next, wemeasured the time taken to close the zipper (“closingtime”) from the captured video footage.
Analysis
Success or failure of the closing motion.
The ability to perform the closing motion using
the usage and non-usage motions was assessed. It wasconsidered a success when a patient could close thezipper up to the target height and a failure if not.
Closing time.
The setting time, pulling time, and total time(sum of setting time and pulling time) were compared
between the usage and non-usage motions. The setting

time for the usage motion was from (Step 1)–(Step 5)
in Fig. 2(a), and the pulling time was the time requiredfor (Step 6). The setting time for the non-usage motion
was the time required for (Step 1)–(Step 3), and thepulling time was the time required for (Step 4)–(Step6) in Fig. 2(b). Statistical analysis used the Wilcoxon
signed rank test, and the significance level was set toless than 5%. Participants who failed to perform either
or both the usage and non-usage motions were excluded from the comparison.
Additionally, the setting, pulling, and total timesof the usage motion were compared between patientswith left hemiplegia and those with right hemiplegia.
Statistical analysis included the Mann–Whitney U test,
and the significance level was set to less than 5%. All
statistical analyses were performed using IBM SPSS
Statistics version 22.0 (IBM Corp., Armonk, NY).

Results
Success or failure of the closing motion
All participants successfully performed the usage
motion. However, only 18 participants successfully
performed the non-usage motion, and 20 participants,
who failed, were unable to conduct the setting motion.
(Table 1)
Closing times
The closing times were compared between theusage and non-usage motions in 18 participants. For

Table 1 Success or failure of closing motion and comparison of closing time
Usage motion

Non-usage motion

38
0

18
20

30.1 (24.1-38.4)
3.0 (2.0-3.9)
33.2 (27.1-42.1)

51.6 (23.1-74.3)
19.0 (11.0-40.0)
80.6 (43.7-107.8)

Success or failure of closing motion
Success
FailureClosing time (seconds) n=18
Setting time
Pulling time
Total time

p value

.028
.001
.001

Closing times of comparison subjects are shown with median values (interquartile ranges).

Table 2 Comparison of closing times of patients with left and right hemiplegia in usage motion

Closing time (seconds)
Setting time
Pulling time
Total time

233

Patient with left hemiplegia
n=20

Patient with right hemiplegia
n=18

p value

35.2 (29.3-41.0)
3.0 (2.0-5.4)
40.5 (31.5-45.2)

43.2 (29.7-60.9)
3.4 (2.0-5.7)
48.5 (31.7-63.5)

.196
.74
.228

Closing times of all participants are shown with median values (interquartile ranges).

234

EFFECTIVENESS OF SELF-HELP DEVICE TO CLOSE ZIPPER

usage motion, setting (p <0.05), pulling (p <0.01), andtotal time (p <0.01) were significantly shorter than for
non-usage motion (Table 1).
On comparing the closing times for usage motion
between patients with left- and right-sided hemiplegia,
no significant differences were noted (Table 2).

Discussion
The results of this study suggest that the device
may help both right-sided and left-sided hemiplegicpatients to close zippers in a practical manner. All participants who failed the non-usage motion were unable
to perform the setting motion. The setting motion in
the non-usage motion involves inserting the insertion
pin while pressing the bottom of the box with theindex finger; this requires performing the two motionsof fixing and inserting with one hand at the same time.
In the usage motion, the device substitutes for fixing
the box with the right hand and fixing the insertion
pin with the left hand (Fig. 2(a). [Step 3]). Therefore,
the involvement of the hand in the setting motion of
the usage motion was only required for inserting theinsertion pin, which led to the success of all the participants. Furthermore, a comparison of the setting time
between the usage and non-usage motions showed thatthe non-usage motion was significantly longer than theusage motion, indicating the difficulty of the process[9]. In other words, the fact that the duration of theusage motion is short suggests that the difficulty of thesetting motion was lower than that of the non-usage
motion.
When conducting the pulling action in the non-usage motion, irrespective of the hand used, the movement involves pressing the jacket to the body withthe middle and ring fingers, while pulling the pull tabwith the thumb and index finger. These steps must be
repeated multiple times to pull the zipper to the neck.
For the usage motion, however, the hems on boththe insertion pin and retainer box sides are pinched,
the leg is stretched, and the trunk is leaned back tomake the chain taut in a straight line; this facilitatespulling the pull tab [10]. Furthermore, the string thatis connected to clothespin, which pinches the insertion
pin side, is 10 mm shorter than the string connected toclothespin, which pinches the retainer box side (Figure1). This makes the insertion pin side pull more tightly
when the leg is stretched, making it more difficult for
the insertion pin to come out of the slider and retainer
box. This mechanism remains same for either hand (leftor right) used. As the chain is made sufficiently taut tomake it difficult to pull the insertion pin out, the pulltab can be pulled up to the neck in one movement. The

usage motion does not involve the repetitive actions
observed in the non-usage motion, thereby, significantly reducing pulling time.
There was no significant difference in closing
time between the left- and right-handed groups. Major
differences in difficulty would have been apparent
through differences in activity time [9]. Thus, the lackof a difference in closing times suggests that the device
was not associated with differences in difficulty levels
with left- vs. right-hand.
Limitations and future directions
Our participants were limited to patients withchronic hemiplegia who could attend daycare facilities. Furthermore, we did not include patients withhemiplegia with severe higher brain dysfunction; thus,
effectiveness of the device in such cases is unclear.
The device may also be effective for patients who areforced to use only one hand due to orthopedic disease.
It can be effectively used for left-insertion jackets,
which are mainly worn in the United States, if theleft and right procedures are reversed. Future studies
should confirm the usefulness of this device in patientswith severe higher brain dysfunction and those withorthopedic diseases, as well as with left-insertion jackets.

Summary and conclusions
We asked patients with hemiplegia to conduct azipper closing motion with and without the use of selfhelp device. For usage motion, all participants successfully conducted the closing motion; however, over
50 % of the participants could close the zip using thenon-usage motion. The usage motion also resulted in asignificant decrease in the closing time, demonstrating
the practical nature of the device. There was also no
significant difference in closing times between patientswith left- vs. right-sided hemiplegia. In conclusion, aself-help device for patients with hemiplegia which
combined inexpensive everyday items could enable
them to more easily dress themselves.

Conflict of Interest
There are no conflicts of interest to declare.

Acknowledgments
I would like to sincerely thank to all participantsin this study.

Asian J Occup Ther 19: 230−235, 2023

References[1] Understanding Zipper Types, Weights, Sizes and Parts[online]. Diby Club [cited 2020 July 20]. Available
from: https://doitbetteryourself.club/blog/understanding-zipper-types-weights-sizes-and-parts/[2] What’s The Difference Between Right & Left-Sided
Insertion Pins [online]. DECORATIVE ZIPS AND
FASHION TREND [cited 2021 May 7]. Available from:https://www.sbs-zipper.com/blog/whats-the-differencebetween-right-left-sided-insertion-pins[3] Surprisingly not known?! Correct way to open andclose a zipper [online]. UNIQLO [cited 2023 March23]. Available from: https://www.uniqlo.com/jp/ja/
news/topics/2019112201/ (in Japanese)[4] Task Analysis Putting on and zippering a jacket [online].
Prezi [cited 2023 March 23]. Available from: https://prezi.com/p/ectywfq2otu-/task-analysis-putting-onand-zippering-a-jacket/[5] Jacket Zipping Aid or JZA [online]. FPO [cited 2021
May 7]. Available from: https://www.freepatentsonline.

Sakagawa D et al.

235

com/y2020/0359752.html[6] Pulling a zipper with one hand [online]. 2kaku-me [cited
2020 May 22]. Available from: https://www.nikakume.
com/2021/07/16/zipper/ (in Japanese)[7] Videos on how to use the o.h.o.-clip on different
garments [online]. o.h.o. ® one hand only [cited 2023
March 24]. Available from: https://www.oho-clip.com/
en/usage-videos/[8] Imai Y, Hasegawa K. The Revised Hasegawa`s Dementia Scale (HDS-R) – evaluation of its usefulness as ascreening test for dementia. J Hong Kong Coll Psychiatry. 1994;4:20-4.
[9] Sakamoto Y, Taniguchi T, Nagao T, Higashi T. Operation time by handedness and non-handedness inworks with degree of difficulty differences. Ability of
non-handedness and handedness (in Japanese). Bulletinof the School of Allied Medical Science, Nagasaki
University. 1994;8:93-5[10] How to Teach Your Kid to Use a Zipper [online]. wikiHow [cited 2021 May 7]. Available from: https://www.
wikihow.com/Teach-Your-Kid-to-Use-a-Zipper

■ORIGINAL ARTICLE

Observational Rating Scale of Attention Function
is Associated with Independencein Activities of Daily Living
Takayuki Miyauchi1, 2, Shotaro Sasaki1, Yoko Sasaki1,
Takuma Mogamiya1, Rumi Tanemura3, Kunji Shirahama4
1

Department of Rehabilitation, St. Marianna University Yokohama Seibu Hospital, Kanagawa, Japan
Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Hyogo, Japan3
Department of Rehabilitation, Kansai Medical University, Osaka, Japan
4
Faculty of Health and Social Work, Kanagawa University of Human Services, Kanagawa, Japan
2

Abstract: Introduction: Stroke rehabilitation that considers attention deficits and effectively improves activities ofdaily living (ADL) requires sufficient evaluation of attention functions. Attention function evaluations are generally performed using neuropsychological tests in patients with stroke. However, such tests become unviable for patients withacute stroke due to fatigue-related unstable general conditions and cannot determine how attention deficits affect ADL.
Hence, developing an appropriate observational rating scale is crucial. Therefore, we investigated the factors related
to independence in ADL in patients with acute stroke and the usefulness of the Moss Attention Rating Scale (MARS)
score in predicting independence in ADL.
Methods: In this cross-sectional single-center study, we included 154 patients admitted to Acute Hospital, Japan forstroke treatment between April 2016 and April 2020 who consented to participate. The primary outcome was the motor
functional independence measure (m-FIM) score. The secondary outcome measures were the Glasgow Coma Scale score,
Brunnstrom recovery stage, grip strength, one-leg standing time (1LST), Mini-Mental State Examination-Japanesescore, Visual Cancellation Task score, Symbol Digit Modalities Test score, and MARS score.
Results: The 1LST and MARS scores were associated with independence in ADL. The cutoff values were 2.99 seconds
for 1LST (average), 89 points for MARS total score, and 58.87 points for MARS logit score.
Discussion: The MARS score and 1LST might be useful indices for predicting independence in ADL. Thus, behavioral
assessments might be appropriately performed by implementing these indices to determine the degree of ADL independence in patients with stroke, and thereby establishing targeted rehabilitation strategies.
Keywords: stroke, attention, cognitive dysfunction, behavior rating scale, activities of daily living(Asian J Occup Ther 19: 236−242, 2023)

Introduction
Cognitive impairment is very common after stroke.
Approximately 80% of patients with stroke were reported to experience cognitive impairment [1]. In addition,
Received: 1 November 2022, Accepted: 23 July 2023
Corresponding to: Takayuki Miyauchi, Department of Rehabilitation,
St. Marianna University Yokohama Seibu Hospital, 1197-1 Yasashicho, Asahi-ku, Yokohama, Kanagawa, 241-0811, Japane-mail: t.miyauchi@marianna-u.ac.jp
Meeting presentation: This work was presented at the 44th Annual
Scientific Meeting of Japan Society for Higher Brain Dysfunction,
Okayama (Web), November 20–December 7, 2020.
©2023 Japanese Association of Occupational Therapists

approximately 40% of patients still have cognitive
impairments 3 months after stroke. [2]. Patients withstroke with cognitive impairment often require occupational therapy. Spaccavento et al. [3] reported thatapproximately 80% of patients with acute stroke had attention deficits. Attention is the basis of other cognitive
functions, and its deficits interfere with daily and social
lives [4, 5]. Therefore, stroke rehabilitation that considers attention deficits and effectively improves activities
of daily living (ADL) requires sufficient evaluation of
attention functions.
Attention function evaluations are generally performed using neuropsychological tests in patients withstroke [6]. However, in the acute phase, many patients

Asian J Occup Ther 19: 236−242, 2023

might not be able to undergo neuropsychological testing
due to their unstable general condition resulting fromfatigue. In addition, these neuropsychological tests
cannot determine the effect of attention deficits on ADL
in these patients; hence, an observational rating scale
is important for evaluating attention deficits in patientswith acute stroke.
Observational rating scales of attention include the14-item Ponsford and Kinsella’s Attention Rating Scale[7], the 6-item Behavioral Assessment of Attentional
Disturbance [8], and the 22-item Moss Attention Rating
Scale (MARS) [9, 10]. These scales have the advantage
of being widely applicable to observational evaluationand the convenience of directly relating to problems in
ADL. Among observational rating scales of attention,
the MARS has the potential to assess attention function
in a more multifaceted way than other observational
rating scales, due to the large number and segmentationof assessment items. However, the precise correlation
between the MARS score and ADL remains unclear. In
addition, the optimal MARS cutoff score for predicting
independent ADL is yet to be established.
Thus, this study aimed to identify the factors related
to independent ADL in patients with acute stroke andthe validity of using the MARS score to evaluate them.
We also aimed to determine the optimal cutoff value ofthe MARS score that is indicative of independent ADL.

Methods
Study design and participantsThis cross-sectional, single-center study was conducted at our hospital. The study was approved by thehospital’s ethics committee and was conducted according to the tenets of the Declaration of Helsinki. Written
informed consent was obtained from all patients.
The participants were patients who were admitted
between April 2016 and April 2020 for the treatmentof stroke and underwent rehabilitation. The inclusion
criteria were as follows: occupational therapy started
within 1 week of stroke onset, ability to perform various
assessments such as neuropsychological testing, adults
20 years of age or older, and consent obtained. The
exclusion criteria were as follows: admission more than
1 week after stroke onset, severe respiratory or cardiovascular diseases, orthopedic diseases such as fractureor amputation, apraxia, previous diagnosis of dementia,
and inability to provide consent.
Outcome measures and assessments
The tests were evaluated by an occupational therapist with at least five years of experience who wasfamiliar with these evaluation methods. All outcome

Miyauchi T et al.

237

measures were assessed within 1 week before discharge.
The primary outcome measure was the motor functional
independence measure (m-FIM) score. In addition,
the FIM score was defined as ADL performance. The
secondary outcome measures comprised evaluation ofclinical characteristics, neurologic tests, and neuropsychologic tests.
Clinical characteristics, including sex, age, diagnosis, lesion, date of stroke onset, presence or absence of
surgery, dominant hand, and discharge destination, werealso evaluated. Neurologic tests included the Glasgow
Coma Scale (GCS), Brunnstrom recovery stage (BRS),
grip strength, and one-leg standing time (1LST). Grip
strength was measured once on each side, and theaverage was calculated. 1LST was performed to assessbalance capacity. The dominant hand for eating andgrooming was also assessed. Neuropsychological tests
included the Mini-Mental State Examination-Japanese(MMSE-J) [11], Visual Cancellation Task (VCT) [12],and Symbol Digit Modalities Test (SDMT) [12]. Presence of attention deficits, aphasia, and unilateral spatial
neglect (USN) were also assessed.
VCT and SDMT were selected because they are relatively easy to perform even in the acute stage of stroke
and can assess selective attention (basic attention) anddivided attention (complex attention). Attention deficit
was defined as VCT results within the chronologicalmean-standard deviation or achieving an SDMT scorebelow the chronological cutoff. Presence of aphasia wasdetermined using the standard language test. The presence or absence of apraxia and USN was determined byobserving ADL, checking finger imitation, using tools
when symptoms were suspected, and conducting line
cancellation. The MARS was used as an observational
rating scale.
Functional independence measure (FIM)
ADL independence was defined as independence in
activities including self-care and outdoor walking. The
participants were divided into two groups according toprevious research: those with an m-FIM score of ≥ 85(the independent ADL group) and those with an m-FIM
score of < 85 (the dependent ADL group) [13]. The
reason for selecting the level of ADL independence wasthat a high level of ADL was judged to be necessary inanticipation of social life.
The m-FIM consists of 13 items, each scored on ascale of 1 to 7. The total m-FIM score ranges from 13 to91, with higher scores indicating greater independence
in ADL. Scoring was based on observation and evaluation of actual movement situations.

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INDEPENDENCE IN ADL IN ACUTE STROKE

Visual Cancellation Task (VCT)The VCT [12], which is a neuropsychological test,
was used for assessing visual selective attention inthree modalities: shape, number, and cursive Japanesesyllabaries. Four relatively simple tasks were evaluatedaccording to the time required for completion, percentage of correct answers, and percentage of hit rate.
Symbol Digit Modalities Test (SDMT)The SDMT [12] was utilized to assess divided
attention and conversion abilities. The test lasts for only
90 s, during which specific symbols and corresponding
numbers are filled in. The results are expressed as percentage of achievement, ranging from 0% to 100%.
Moss Attention Rating Scale (MARS)The MARS was translated into Japanese by Sawa­
mura et al. in 2012 [14]. It consists of 22 items, andeach is scored from 1 to 5: 1, definitely false; 2, false
for the most part; 3, sometimes true, sometimes false;
4, true for the most part; and 5, definitely true. The total
MARS score is calculated as the sum of scores of 22
items that ranges from 22 to 110, with higher scoresindicating better attention. In addition, there are scoresfor three-factor subitems: restlessness/distractibility, 5;
initiation, 3; and consistent/sustained, 3. The MARS
total score was converted to a logit score, an interval
scale. MARS total and logit scores were used in thisstudy. MARS total and logit scores were extracted asfactors related to ADL independence, and when calculating the cutoff values, we checked for any discrepancy
between the two scores.
Statistical analysis
The normality test for continuous variables was
performed using the Shapiro-Wilk test. The unpaired
t-test, Mann–Whitney U test, and χ2 test were used forassessing differences between the two groups based on
the degree of independence in ADL. Univariate logistic
regression analysis was performed with the FIM motor
item as the objective variable, and explanatory variables
with a P value of < 0.2 were extracted. Spearman’s rankcorrelation coefficient was calculated considering themulticollinearity of the extracted factors, and factors
with | ρ | ≥ 0.7 were excluded from the analysis. Multiple
logistic regression analysis (backward elimination) was
performed using the significant factors from the univariate logistic regression analysis and Spearman’s rankcorrelation coefficient as explanatory variables. Multiple
logistic regression analysis created models using MARS
total and logit scores. The R2 and χ2 tests, corrected
Akaike information criterion (AICc), and Bayesian
information criterion (BIC) were used to evaluate thegoodness of fit of each model. Significant factors in
the multiple logistic regression analysis were analyzed
using the receiver operating characteristic (ROC) curve
to calculate their cutoff value, sensitivity, specificity,area under the curve (AUC), positive predictive value,
positive likelihood ratio, and accuracy. Regarding thecutoff value [15], we adopted a value that minimizes(1-sensitivity) + (1-specificity) [2]. The criteria for determining the AUC of the ROC curve were as follows: AUC= 0.9–1.0, high accuracy; 0.7–0.9, moderate accuracy;
and 0.5–0.7, low accuracy [16]. All statistical analyses
were performed using the JMP Pro 15 software (SASInstitute Inc. Japan). The explanatory variables used in
the multiple logistic regression analysis were explanatory variables × 10 cases, as previously described [17].
Statistical significance was set at a P value of < 0.05.

Results
In total, 154 patients with an average age of 73.0
years were evaluated. Among them, 86 (55.8%) and 68(44.2%) were men and women, respectively. The clinicalcharacteristics and neurologic and neuropsychologicaltest results of the patients are shown in Table 1. Overall,
109, 19, and 26 patients were diagnosed with cerebral
infarction, intracerebral hemorrhage, and subarachnoid
hemorrhage (SAH), respectively. The independent ADL
group included 94 patients with an average age of 71.0
years: 54 (57.4%) men and 40 (42.6%) women. The
dependent ADL group comprised 60 patients with an average age of 78.0 years: 32 men (53.3%) and 28 women(46.7%).
With respect to clinical characteristics, there weresignificant between-group differences in the date of thelast evaluation, age (Mann–Whitney U test, P < 0.05),
lesion, and discharge destination (χ2 test, P < 0.05). Neurologic and neuropsychological tests showed significant
differences in grip strength and GCS, 1LST, MMSE-J,
VCT, SDMT, and MARS scores (Mann–Whitney U test,
P < 0.05). There were also significant differences in thepresence or absence of motor paralysis, attention deficit,
and USN (χ2 test, P < 0.05).
The possible explanatory variables were age, GCS,
grip strength on the side used for performing ADL,
1LST, MMSE-J, VCT (shape), SDMT, presence of USN,MARS total score, and MARS logit score. Multicollinearity was confirmed for MMSE-J, SDMT, MARS
total score, and MARS logit score. In the multiple
logistic regression analysis, the objective variables weremotor FIM (0, greater than 85; 1, less than 85) andvariables in Model 1 (explanatory variables; GCS, gripon the side of ADL use, 1LST [average], VCT [shape1],
presence of USN, MARS total score) and Model 2 (ex-

Asian J Occup Ther 19: 236−242, 2023

Miyauchi T et al.

239

Table 1 Patient Clinical Characteristics, Neurologic and Neuropsychologic examinations.

sex* male/femle
first evaluation datelast evaluation datedischarge Day
agediagnosis* CI
ICH
SAH
surgery* presence/absence
lesion* right/left/both    front/back/both
dominant hand* right/left
destination* home/transfer
GCS
motor paralysis*
paralytic side* right/left
BRS [arm] Ⅰ/Ⅱ/Ⅲ/Ⅳ/Ⅴ/Ⅵ[finger] Ⅰ/Ⅱ/Ⅲ/Ⅳ/Ⅴ/Ⅵ[leg] Ⅰ/Ⅱ/Ⅲ/Ⅳ/Ⅴ/Ⅵ
Grip [right][left][average][ADL use side]
1LST [right][left][average]
Motor FIM
Cognitive FIM
Total FIM
Aphasia*
MMSE-J
USN*
Attention deficit*
VCT [shape 1] timecorrect answers
hit rate
VCT [shape 2] timecorrect answers
hit rate
VCT [number] timecorrect answers
hit rate
VCT [pseudonym] timecorrect answers
hit rate
SDMT achievement rate
MARS total score   logit score    Restlessness/Distractibility   Initiation    Consistent/Sustained

All (n = 154)

independent group (n = 94)

dependent group (n = 60)

P value

86/68
4.0 (2.0–6.8)
17.0 (10.0–26.0)
19.0 (13.0–26.0)
73.0 (62.3–79.0)
109
19
26
36/11867/58/29
111/34/ 9
152/2
95/59
15.0 (14.0–15.0)
63 (40.9%)
27/36
0/11/5/0/5/38
1/13/2/2/2/38
0/ 3/5/4/2/48
22.0 (15.8–29.0)
20.0 (12.0–28.0)
20.1 (14.4–28.0)
22.6 (16.0–29.0)
4.8 (0.0–17.5)
4.2 (0.0–15.8)
5.1 (0.0–16.8)
88.0 (65.5–91.0)
33.0 (27.0–35.0)
120.0 (90.3–125)
27 (17.5%)
26.0 (22.0–28.8)
15 (9.7%)
111 (72.1%)
60.0 (49.4–84.9)
98.2 (96.4–100.0)
100.0 (100.0–100.0)
67.9 (53.2–98.3)
100.0 (98.2–100.0)
100.0 (100.0–100.0)
111.9 (91.2–141.3)
99.1 (98.2–100.0)
100.0 (100.0–100.0)
142.4 (111.3–173.2)
96.4 (91.2–98.2)
100.0 (100.0–100.0)
31.8 (21.8–42.7)
92.5 (78.3–106.0)
61.4 (54.3–76.2)
4.6 (4.2–5.0)
4.6 (3.4–5.0)
4.0 (3.0–4.6)

54/40
3.5 (2.0–5.0)
15.5 (10.0–22.0)
18.0 (11.3–24.0)
71.0 (57.0–77.0)
69
10
15
18/76
41/38/15
63/27/ 4
93/1
78/16
15.0 (15.0–15.0)
29 (30.9%)
14/15
0/0/0/0/1/25
0/0/0/0/0/26
0/0/0/0/0/28
26.0 (19.1–32.3)
23.0 (17.0–31.3)
24.1 (19.0–31.7)
26.0 (19.5–32.3)
9.9 (3.7–30.0)
9.3 (3.4–30.0)
10.9 (4.5–29.7)
91.0 (89.0–91.0)
35.0 (33.0–35.0)
125.0 (121.0–126.0)
14 (14.9%)
28.0 (25.3–29.0)
2 (2.1%)53 (56.4%)
54.3 (45.8–67.5)
98.3 (98.2–100.0)
100.0 (100.0–100.0)
63.1 (50.1–78.0)
100.0 (98.2–100.0)
100.0 (100.0–100.0)
99.9 (87.6–129.9)
100.0 (98.2–100)
100.0 (100.0–100.0)
131.5 (108.1–161.3)
96.4 (92.5–98.7)
100.0 (100.0–100.0)
36.3 (27.7–45.0)
104.5 (94.0–108.0)
72.3 (62.4–82.7)
5.0 (4.7–5.0)
5.0 (4.6–5.0)
4.6 (4.3–5.0)

32/28
4.0 (2.0–7.0)
20.0 (12.0–30.3)
22.5 (15.8–34.0)
78.0 (68.8–83.0)
40
9
11
18/42
26/20/14
48/ 7/ 5
59/1
17/43
14.0 (14.0–15.0)
34 (56.7%)
13/21
0/11/5/0/4/13
1/13/2/2/2/12
0/ 3/5/4/2/20
14.9 (4.5–22.0)
10.6 (2.0–20.0)
12.0 (7.1–19.0)
16.8 (10.0–22.9)
0.0 (0.0–2.3)
0.0 (0.0–2.5)
0.0 (0.0–2.6)
55.5 (22.8–70.3)
24.0 (15.0–28.3)
81.0 (41.0–97.3)
13 (21.7%)
21.0 (16.8–25.0)
13 (21.7%)
58 (96.7%)
90.4 (71.7–137.8)
98.2 (91.2–100.0)
100.0 (98.2–100.0)
109.7 (87.5–145.3)
98.2 (96.6–100.0)
100.0 (97.0–100.0)
152.4 (134.2–185.2)
98.7 (96.0–99.1)
100.0 (100.0–100.0)
176.6 (152.4–237.6)
92.9 (84.2–98.2)
100.0 (99.1–100.0)
19.0 (12.7–26.4)
70.0 (55.8–81.3)
51.0 (45.5–55.6)
4.0 (3.0–4.4)
3.0 (2.3–4.0)
3.0 (2.6–3.6)

0.62
0.17
< 0.01< 0.01< 0.01
0.45
0.14
0.87
0.03
0.75
< 0.01< 0.01< 0.010.34< 0.01< 0.01< 0.01< 0.01< 0.01< 0.01< 0.01< 0.01< 0.01< 0.010.28< 0.01< 0.01< 0.01< 0.01< 0.01< 0.01< 0.010.02< 0.01< 0.01< 0.010.02< 0.010.02
0.04< 0.01< 0.01< 0.01< 0.01< 0.01< 0.01

Median (Quartile range)
Mann-Whitney U test, * χ2 test
P < 0.05
CI: cerebral infarction, CH: cerebral hemorrhage, SAH: subarachnoid hemorrhage, GCS: Glasgow Coma Scale, ADL: Activities of Daily Living,
BRS: Brunnstrom motor Recovery Stage, 1LST: one-leg standing time, FIM: Functional Independence Measure, USN: unilateral spatial neglect,
MMSE-J: Mini Mental State Examination-Japanese, VCT: Visual Cancellation Task, SDMT: Symbol Digit Modalities Test, MARS: Moss Attention Rating Scale

240

INDEPENDENCE IN ADL IN ACUTE STROKE

planatory variables; GCS, grip, 1LST [average], VCT[shape1], presence of USN, and MARS logit score). In
addition, each model was adjusted for age. The resultsof multiple logistic regression analyses are presented
in Table 2. The two models were well fitted with a

Table 2 Results of Multiple Logistic Regression Analysis for the Prediction of ADL independence in the Derivation Sample.
Explanatory variableβSE

P value

Odds
ratio

95%CI

Model 1
1LST [Average]
MARS total score

0.12
0.20

0.06
0.04

0.03
< 0.01

1.13
1.22

1.03–1.30
1.14–1.34

Model 2
1LST [Average]
MARS logit score

0.13
0.33

0.06
0.07

0.02
< 0.01

1.14
1.39

1.03–1.30
1.23–1.64

Objective variable: motor FIM (0: ≥ 85, 1: < 85)
Explanatory variables:
Model 1; GCS, grip on the side of ADL use, 1LST [Average], VCT[shape 1], presence of USN, MARS total score
Model 2; GCS, grip on the side of ADL use, 1LST [Average], VCT[shape 1], presence of USN, MARS logit scoreadjustment variable: age
Model χ2 test: Model 1; p < 0.05, Model 2; p < 0.05
R2: Model 1; 0.69, Model 2; 0.68
AICc: Model 1; 73.03, Model 2; 74.40
BIC: Model 1; 84.92, Model 2; 86.28
1LST: one-leg standing time, MARS: Moss Attention Rating Scale,
FIM: Functional Independence Measure, GCS: Glasgow Coma Scale,
ADL: Activities of Daily Living, VCT: Visual Cancellation Task, USN:
unilateral spatial neglect

coefficient of determination (R2) > 0.6 and χ2 test of P
< 0.05. AICc was 73.03 in model 1 and 74.40 in model2, and BIC was 84.92 in model 1 and 86.28 in model 2.
1LST (average) (odds ratio [OR]: 1.13, P = 0.03) and
MARS total score (OR: 1.22, P < 0.01) in Model 1 and
1LST (average) (OR: 1.14, P = 0.02) and MARS logit
score (OR: 1.39, P < 0.01) in Model 2 were identified asfactors related to independent ADL.
Figure 1 shows the ROC curves for the 1LST (average), MARS total score, and MARS logit score. The
optimal cutoff values were 2.99 s for 1LST (average)(sensitivity: 0.830, specificity: 0.767, AUC: 0.867), 89
points for MARS total score (sensitivity: 0.872, specificity: 0.917, AUC: 0.965), and 58.87 points for MARS
logit score (sensitivity: 0.883, specificity: 0.917, AUC:
0.967). When the MARS logit score was converted tothe total score, it was 88 points [18].
From each model, the MARS total score and logit
score were extracted as factors related to ADL independence. The cutoff values for the MARS total score andthe logit score showed little divergence.

Discussion
The influencing factors for independence in ADL
after acute stroke are yet to be clarified. The current
study identified 1LST and MARS scores as factors associated with independence in ADL among patients withacute stroke. The optimal cutoff values were 2.99 s forFig. 1. ROC curves for factors related to ADL independence.
Abbreviations: 1LST, one-leg standing time; ADL, activities of daily living; AUC, area under the curve; MARS, Moss Attention
Rating Scale; ROC, receiver operating characteristic.

Asian J Occup Ther 19: 236−242, 2023

1LST, 89 points for MARS total score, and 58.87 points
for MARS logit score. There were significant differences between the independent ADL and dependent ADL
groups with respect to the date of the last evaluation,age, lesion, and discharge destination. The significant
differences in these factors could be related to stroke severity. There were more patients in the dependent group
who were indicated for rehabilitation after surgery for
cerebral hemorrhage or SAH. Neurologic tests showedsignificant between-group differences in GCS scores,
presence of paralysis, grip strength, and 1LST.
A ceiling effect was considered to be present in
GCS, suggesting that the current study was biased
toward mild cases. This is supported by the BRS bias,
which was mildly biased in the independent ADL group.
Statistical analysis could not be performed due to theinsufficient number of cases in each stage of the BRS.
Therefore, in this study, the presence of paralysis was
only considered to be related to the degree of independence in ADL. Neuropsychological tests showedsignificant differences in all items, except for presenceof aphasia, suggesting that attention deficit was involvedin the degree of independence in ADL. Comparisons of
the clinical characteristics, neurologic tests, and neuropsychological tests between the two groups showed significant differences in many items. This suggests that awide variety of assessments might be needed to examine
independence in ADL in patients with acute stroke.
The MMSE-J showed multicollinearity with VCT,
SDMT, and MARS, indicating that it was a multidimensional assessment of cognitive function and may berelated to different attentional functions. The multicollinearity between SDMT and MARS could be attributed
to distributive attention being a higher attention function
among all functions, which controls other attentional
functions [19]. In addition, divided attention functions
are often required in ADLs [20]. Therefore, there might
be an association between SDMT and MARS, which assesses attention function from multiple perspectives. In
multiple logistic regression analysis, 1LST and MARS
were identified as significant factors in both Models 1
and 2. This suggests that MARS could be an indicator ofindependence in ADL and might be a useful evaluation
method for rehabilitation in patients with acute stroke.
Many factors such as equilibrium, muscle, osteoarticular, sensory, and cognitive functions have beenshown to be related to balance ability [21]. This study
evaluated patients with impaired physical and cognitive
functions after stroke. Therefore, identification of theassociation of 1LST with independence in ADL might
be considered a reasonable result. Age, sex, level ofconsciousness (GCS), paralyzed side, muscle strength,balance, cognitive functions (attention function andMiyauchi T et al.

241USN), and pre-onset ADL were also reported to berelated to independence in ADL after acute stroke. In thecurrent study, balance (1LST) and MARS score, whichindicates attention function, were identified as related
to independence in ADL. These findings are consistent
with those in previous studies, supporting the validity ofthese findings [22–24].
The cutoff values of 1LST, MARS total score, and
MARS logit score, which were identified as influencing
factors for independence in ADL in multiple logistic
regression analysis, were calculated using the ROC
curve. The AUC of 1LST (average) was 0.867, indicating its moderate accuracy, while that of MARS was> 0.900, indicating high accuracy. This indicated that the
MARS score was superior to the 1LST for identifying
independence in ADL. Furthermore, it showed that an
observational rating scale was also useful for evaluating
rehabilitation in patients with acute stroke.
This study had several limitations. First, the relationship between degree of independence in ADL andchanges in the MARS score could not be evaluatedowing to the cross-sectional study design. Second, thestudy sample size was small because the assessment was
conducted in a single center, and the study populations
appear to be dominated by patients with mild stroke,possibly limiting the generalizability of the study findings. Lastly, neuropsychological tests were limited inthis study, and intelligence and executive functions wereinsufficiently evaluated. Future longitudinal studies areneeded to clarify the relationship between degree of independence in ADL and changes in MARS score. Serialcase studies and multicenter studies with neuropsychological tests to evaluate intelligence and executivefunctions and multifaceted evaluations are also needed.

Conclusions
The MARS score, an observational rating scale ofattention function, and balance were associated withindependence in ADL in patients with acute stroke.
Thus, the MARS might be a useful tool for behavioral
assessments to determine the degree of independence in
ADL in this patient population.
Cut-off values for MARS scores that result in ADL
independence were identified. The cutoff values for
the MARS total score and the logit score showed little
divergence. The MARS total score required for ADL
independence is 88 or higher.

Funding
This research did not receive any specific grants
from funding agencies in the public, commercial, or not-

242

INDEPENDENCE IN ADL IN ACUTE STROKE

for-profit sectors.

Conflict of Interest
None.

Acknowledgment
The authors thank the patients who participated in
the study and staff members of St. Marianna University
Yokohama Seibu Hospital for their assistance with thedata.

References[1] Jokinen H, Melkas S, Ylikoski R, Pohjasvaara T, Kaste
M, Erkinjuntti T, et al. Post-stroke cognitive impairment
is common even after successful clinical recovery. Eur J
Neurol. 2015; 22(9): 1288–94, doi:10.1111/ene.12743.
[2] Hurford R, Charidimou A, Fox Z, Cipolotti L, Werring
DJ. Domain-specific trends in cognitive impairment after
acute ischaemic stroke. J Neurol. 2013; 260(1): 237–41,
doi:10.1007/s00415-012-6625-0.
[3] Spaccavento S, Marinelli CV, Nardulli R, Macchitella L,
Bivona U, Piccardi L, et al. Attention deficits in stroke patients: The role of lesion characteristics, time from stroke,and concomitant neuropsychological deficits. Behav
Neurol. 2019; 23: 1–12, doi:10.1155/2019/7835710.
[4] Cumming TB, Marshall RS, Lazar RM. Stroke, cognitive
deficits, and rehabilitation: still an incomplete picture.
Int J Stroke. 2013; 8(1): 38–45, doi:10.1111/j.1747-4949.
2012.00972.x.
[5] Tanaka H, Toyonaga T, Hashimoto H. Functional andoccupational characteristics predictive of a return to workwithin 18 months after stroke in Japan: implications forrehabilitation. Int Arch Occup Environ Health. 2014;
87(4): 445–53, doi:10.1007/s00420-013-0883-8.
[6] Faria AL, Pinho MS, Bermúdez I Badia S. A comparisonof two personalization and adaptive cognitive rehabilitation approaches: a randomized controlled trial withchronic stroke patients. J Neuroeng Rehabil. 2020; 17(1):78, doi:10.1186/s12984-020-00691-5.
[7] Ponsford J, Kinsella G. The use of a rating scale ofattentional behaviour. Neuropsychol Rehabil. 1991; 1(4):241–57, doi:10.1080/09602019108402257.
[8] Toyokura M, Yamashita K, Hayashi T, Nishimura Y,
Sawatari M, Kikui R, et al. A newly developed assessment scale for attentional disturbance based on behavioral
problems: Behavioral Assessment of Attentional Disturbance (BAAD). Tokai J Exp Clin Med. 2006; 31(1):29–33, PMID: 21302217.
[9] Hart T, Whyte J, Millis S, Bode R, Malec J, Richardson
RN, et al. Dimensions of disordered attention in traumatic brain injury: further validation of the Moss Attention
Rating Scale. Arch Phys Med Rehabil. 2006; 87(5):647–55, doi:10.1016/j.apmr.2006.01.016.
[10] Whyte J, Hart T, Ellis CA, Chervoneva I. The Moss

Attention Rating Scale for traumatic brain injury: further
explorations of reliability and sensitivity to change. Arch
Phys Med Rehabil. 2008; 89(5): 966–73, doi:10.1016/
j.apmr.2007.12.031.
[11] Folstein MF, Folstein SE, McHugh PR. ‘Mini-mental
state’: a practical method for grading the cognitive stateof patients for the clinician. J Psychiatr Res. 1975; 12(3):
189–98, doi:10.1016/0022-3956(75)90026-6.
[12] Kato M. The development and standardization of Clinical
Assessment for Attention (CAT) and Clinical Assessment
for Spontaneity (CAS). Higher Brain Function Research.
2006; 26(3): 310–9 (Japanese), doi:10.2496/hbfr.26.310.
[13] Tsuji T, Sonoda S, Chino N. The ADL Structure for Stroke
Patients at admission and discharge based on the Functional Independence Measure. Jpn J Rehabil Med. 1996;
33(5): 301–9 (Japanese), doi:10.2490/jjrm1963.33.301.
[14] Sawamura D, Ikoma K, Ogawa K, Kawato T, Goto, T, Ino­ue, K, et al. Reliability and validity of the Moss Attention
Rating Scale for use in Japan. Higher Brain Function Res.
2012; 32(3): 533–41 (Japanese), doi:10.2496/hbfr.32.533.
[15] Akobeng AK. Understanding diagnostic tests 3: Receiver
operating characteristic curves. Acta Paediatr. 2007; 96(5):644–7, doi:10.1111/j.1651-2227.2006.00178.x.
[16] Swets JA. Measuring the accuracy of diagnostic systems.
Science. 1988; 240(4857): 1285–93, doi:10.1126/science.
3287615.
[17] Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein
AR. A simulation study of the number of events pervariable in logistic regression analysis. J Clin Epidemiol.
1996; 49(12): 1373–9, doi:10.1016/S0895-4356(96)00236-3.
[18] Moss Rehabillitation Research Institute [online]. Elkins
Park, PA: Moss attention rating scale (MARS) [cited
2023 March 14]. Available from: https://mrri.org/mossattention-rating-scale-mars/.
[19] Sohlberg MM, Mateer CA. Cognitive Rehabilitation: An
integrative neuropsychological approach. NewYork: The
Guilford Press; 2001.
[20] Hyndman D, Ashburn A. People with stroke living in thecommunity: Attention deficits, balance, ADL ability andfalls. Disabil Rehabil. 2003; 25(15): 817–22, doi:10.1080/
0963828031000122221.
[21] Huxham FE, Goldie PA, Patla AE. Theoretical considerations in balance assessment. AustJ Physiother. 2001;
47(2): 89–100, doi:10.1016/s0004-9514(14)60300-7.
[22] Weimar C, Ziegler A, König IR, Diener HC. Predicting
functional outcome and survival after acute ischemic
stroke. J Neurol. 2002; 249(7): 888–95, doi:10.1007/
s00415-002-0755-8.
[23] Reid JM, Gubitz GJ, Dai D, Kydd D, Eskes G, Reidy Y,
et al. Predicting functional outcome after stroke by modelling baseline clinical and CT variables. Age Ageing.
2010; 39(3): 360–6, doi:10.1093/ageing/afq027.
[24] Cioncoloni D. Martini G, Piu P, Taddei S, Acampa M,
Guideri F, et al. Predictors of long-term recovery in complex activities of daily living before discharge from thestroke unit. NeuroRehabilitation. 2013; 33(2): 217–23,
doi:10.3233/NRE-130948.

■ORIGINAL ARTICLE

Measurement of Arm Mass Putting Arm
on The Platform Scale in a Sitting Position
and Analyzing Based on a Theoretical Model
Manabu Sasaki
Department of Occupational Therapy,Yamagata Prefectural university of Health Sciences

Abstract: Background: A simple method for measuring arm mass in clinical practice would be useful for medical
records and experimental approaches; however, which but there is no popular measurement method.
Objective: To develop a simple, accurate, and reliable method for approximating arm masses.
Methods: A theoretical model for estimating the mass of the lower and upper arms was proposed. The validity of themodel was confirmed via 34 measurements on a steel model in each of the nine upper arm abduction positions using
one-sample t-tests. The reproducibility of the method was investigated by performing repeat measurements for 29 participants and was confirmed using paired t-tests.
Results: One-sample t-tests showed no significant differences ( p < 0.05) in the mean of the nine upper arm abduction
positions investigated during the model validation. Regarding reproducibility, the paired t-tests showed no significant
differences ( p < 0.05), and the 95% confidence intervals were corroborated by previous reports. Interpretation of intraclass correlation (ICC) was difficult because of inappropriate application.
Limitations: The reproducibility of the suggested method should be verified using an appropriate statistical method.
Conclusions: Because of insufficient reproducibility, supplemental method is required, such as the adjusted backrest
fitting better for all subject, and assessor must try to achieve reproducibility when the therapists use this method inclinical practice.
Keywords: estimated arm mass, clinical use, validation and reproducibility(Asian J Occup Ther 19: 243−249, 2023)

Introduction
Somatometry is a branch of anthropometry thatinvolves measuring the weight and dimensions ofvarious body parts, including the limbs. Therapists canobtain useful information via somatometry. For example, Sasaki et al. [1] performed a dynamic joint torquecalculation during the line-drawing task based on thearm mass measurement. They showed that simple instructions on strengths or weaknesses were insufficient.
However, it is difficult to find a practical and accuratemass measurement method that can be used by therapists.
Received: 7 December 2021, Accepted: 11 May 2023
Corresponding to: Manabu Sasaki, Department of Occupational Therapy, Yamagata Prefectural university of Health Sciences, 260 Kamiyanagi, Yamagata city, Yamagata, 990-2212, Japane-mail: msasaki@yachts.ac.jp; manabuta2011@gmail.com©2023 Japanese Association of Occupational Therapists

Various measurement procedures have been proposed for this purpose. Direct methods that use either
dead or living specimens are not applicable to subject
evaluations. Indirect methods include mathematicalmodels [2], nuclear magnetic resonance imaging [3],water displacement [4], and center-of-mass measurements [5]. Several studies on mass measurements havedeveloped mathematical models to examine physicaland internal mass ratios using force plates, which arelarge, expensive, and challenging to operate [6]; thus,
these methods are not suitable for routine use in clinicalpractice. In addition, crucial information regarding thearm mass and the corresponding measurement method
are not included in the human characteristic databases ofphysical measurements [7]. These methods are proposed
without defining the upper and lower arm, test-retest
reproducibility, and reliability.
There is no mass measurement method for clinicaluse. Hence, we must define it. A simple and easy approach to minimize a patient’s stress during measurement

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MEASUREMENT OF ARM MASS

is to sit the person on a chair before a table and put his
arm on two box scales placed on the desk. However, it
is sometimes difficult to accommodate the patient in thesame position because of pain, contracture, and otherreasons. Therefore, a revised method to estimate theresults of mass measurement will also be necessary.
To address this issue, we proposed a simple method
based on a theoretical model that can be used by therapists and confirmed its validity and reproducibility.
The study was approved by the Ethical Committeeof Yamagata Prefectural University of Health Sciences(0908-13), and conducted in accordance with the Helsinki Declaration.

Materials and Methods
Evaluation of PostureParticipants placed their arms on a desk-mounted
platform scale while adopting a seated posture, and theupper arm was positioned according to the scapularplane, preventing substantial weight from being applied
to the scale. The lower arms were positioned according
to the middle supination and pronation digits; this position allows leeway in the range of motion of each joint
and enables the movement or position that minimizes
the loading on the joint to be investigated.
Scapular plane elevation elevates the humerus in thescapular plane and has been applied for the managementof rotator cuff problems [8] and rehabilitation [9, 10].
The pressure between the scapula and humerus ateach angle of the scapular plane elevation is not linear[11], and the evaluation angle must be constant for reliability.
Humeral elevation is also associated with scapulohumeral rhythm, and the scapulohumeral and scapulothoracic joints move at a ratio of 2:1 [12]. However,this ratio is not constant [13]; thus, to minimize themeasurement error, the shoulder abduction angle should
be constant.
These findings were suggested by the active movements, measurements were performed in a static position
to prevent scapulohumeral rhythm, and internal/externalrotation angles were consistent although some participants reported difficulty in relaxing their muscles.
Therefore, measurements were performed with participants sitting on a chair with their shoulder abducted
and elevated at 45°, the elbow rotated internally at a
flexion angle of 90°, the wrist in a neutral position, andthe fingers flexed (Fig. 1).
Simplified model
Joint movement around the center of gravity point
is muscle-based, and as the muscle mass and morphol-

Shoulder (S)Platform scale 1

W1
L1

PS2 Hand (H)
Elbow
PS1
(E)
W2
Elbow (E)

Platform scale 2

L2

Fig. 1. Schematic of the measurement setup. L1 denotes
the distance from the acromion to the olecranon; W1
denotes the upper arm mass (the upper arm center ofmass is defined as L1/2); L2 denotes the length of thelower arm from the olecranon to the two distal interphalangeal joints of the index finger (with the hand ina gripping position); W2 denotes the lower arm mass(the lower arm center of mass is defined as L2/2).
Platform scales 1 and 2 were placed under the elbow
and hand, respectively, corresponding to the recorded
measurements PS1 and PS2 .

ogy are not uniform between individual participants,
identifying the center of gravity in individuals can bedifficult. To simplify the center of gravity determination
process, the upper and lower arms were considered as
two rigid bodies, with the mass of the hand included in
the lower arm region. Therefore, the effects of muscle
tone and joint geometry for a complete ball and socket
joint were not incorporated into the mathematical model.
Measurement materials
To perform measurements, two platform scales (1and 2) were placed such that their inter-center distancewas equivalent to the lower arm length of the participant
being measured. Additionally, spacers (i.e., 1 ¥ coins)were placed on each platform scale, on top of which
wooden boards were placed. After the spacers andboards were placed on the platforms, they were reset
to 0 g before the participant placed their arms on theboards (Fig. 1).
Once the balance reading had stabilized and muscle
relaxation had been confirmed, the shoulder elevation
angle was measured, and the masses recorded by platform scales 1 and 2 were noted. The inclination of theupper arm was measured using an inclinometer (DL155V, STS Corporation, Nagoya, Japan).
Arm mass calculation
Figure 2a shows the mechanical relationship between the upper and lower arms in a horizontal position.

Asian J Occup Ther 19: 243−249, 2023

Sasaki M

PS2
PS1 = PE + PS2
L2

PS

Platform scale 2

L1
E

S

PS

S

H

L1

∅

Platform scale 1
W2

PE
W1

W1
a. Upper and lower arm position
in horizontal position

245

E

Platformscale 1PEH

b. Upper arm position
during upper arm elevation

Fig. 2. Mechanical relationships at the time of measurement. The upper arm mass (W1 ) and lower arm mass (W2 ) were estimated using
the upper arm length (L1 , shoulder [S ] to elbow [E ]) and lower arm length (L2 , elbow [E ] to hand [H ]), respectively. (a) The
values measured by platform scale 1 (PS1 ) are equivalent to the combined forces of the upper arm (PE ) and the lower arm (PS2 ).
(b) PS denotes the force exerted by the body perpendicular to the upper arm model vector, SE, while Ø denotes the upper arm
elevation angle relative to normal.

The lower arm region (EH ) ran from the elbow (E )to the hand (H ), which were placed on platform scales 1
and 2, respectively. Assuming that the lower arm region(EH ) is detached from the upper arm when placed on
the platform scales, its mass according to its center ofgravity can be approximated as
PS2 =

W2
2

(1)

The force exerted on platform scale 1, where the elbow
was placed, comprises the forces exerted by the massesof the upper and lower arms, and is expressed as follows:
PS1 = PE + (W2 - PS2 )(2)

Because PE = W1/2 and PS2 = W2/2, when the upperand lower arms are horizontal, Eq. (2) can be rewrittenas
W W
PS1 = PE + PS2 = 1 + 2
2
2

PS sin Ø + PE - W1 = 0(3)Because maintaining the upper and lower arms in ahorizontal position is difficult in clinical practice, measurements performed with the shoulder in an elevatedposition were considered. The mechanical relationshipfor the upper arm when positioned at a shoulder elevation angle of Ø is shown in Fig. 2b. The shoulder(S ) experiences a force perpendicular to the upper arm(4)Considering the moment at the elbow (E ) when a rigid
body with one fixed point is balanced, the sum of thecounterclockwise moments at the fixed point is equivalent to the clockwise moment and can be expressed asfollows:( L2 )W sin Ø = (L )P

(5)

1

1

1

S

Then, substituting Eq. (4) into Eq. (5) yields:( sin2Ø − sin Ø) P = P
STherefore, the upper arm mass W1 can be derived by thefollowing equation:
W1 = 2(PS1 - PS2 )vector, SE, which is countered by the force exerted by
the scapula, PS . The counterforce exerted on the upperarm mass is denoted by PE , whereas PEH is the force
exerted horizontally on platform scale 1 by the deadweight of the elbow. As the forces perpendicular to theground cancel each other, we can write:

E

Considering (2/sin Ø - sin Ø) = k, this can be simplified to:
PE = kPS(6)

Additionally, assuming that the lower arm has a uniform
mass, the counterforce exerted on the upper arm can be
expressed as:
PE = PS1 - PS2(7)

Specific post-measurement calculation procedure
The coefficient, k, was calculated from the elevation

246

MEASUREMENT OF ARM MASS

angle, Ø. The lower arm mass, PS2 , was derived using
Eq. (1), while the upper arm mass, PE , was derived
using PS1 and PS2 from Eq. (7). Next, PS was derived
using the PE from Eq. (6). Finally, the upper arm mass,
W1 , was derived using the values for PE and PS from Eq.
(4).
Verification of theoretical validity and reproducibility
Because the effects of soft tissues cannot be excluded in living organisms, an experiment was conducted toverify the theoretical validity of the mathematical modelusing a steel model. Repeated measurements were performed to determine the model reproducibility.
Statistical analyses were conducted using GNU
R3.4.3 [14] and G*Power3 [15]. Statistical tests were
performed using the 95% confidence level and twotailed method.

Experiment 1: Verification of validity based
on upper arm model
PurposeTo verify the theoretical validity of our mathematical model.
Methods
A steel rod with uniform mass and a measured massof WT1 = 678.0 g was used as an upper arm model (Fig.
3a) and was placed on the measurement platform. The
measurement platform was placed on a tripod (GPD2;
Vixen., Co, Ltd. Tokorozawa, Saitama, Japan), thereby
allowing for fine positional adjustments.
The measurement platform comprised an L-shaped
flat steel bar with compression-type load cells G1,
G2, and G4 (TC-SR(T)10N-G; TEAC, Tokyo, Japan)
connected to a digital indicator (TD-700T, TEAC), fromwhich values were read. The load cell G3 was considered a test dummy and yielded values equivalent to G2.
Designating measurements at G1, G2, G3, and G4 asforce vectors PG1, PG2, PG3, and PG4, respectively,
resulted in the following equations: PG1 = PS , PG2 =PG3, and PE = (2 PG 2) 2 + ( PG 4) 2 (Fig. 3b). During
the measurements, the forces exerted on the small compression-type load cells were recorded at measurement
platform inclination angles from 10° to 90° in increments of 10°. As the coefficient k cannot be calculated at
an inclination angle of 0° (sin 0 = 0), no measurements
were performed at this angle. All the measurements
were performed at a constant temperature of 25°C.
Statistical processing and experimental procedures
In accordance with the discussion on statisticalpower testing proposed for psychological experimentsa. Overhead view

G3
G4

Upper arm model

G1

Measurement platformb. Side view

G4

G2

PG1
Upper arm model
G1

2PG2
PG4

Measurement platform
G4
W1

G2, G3Fig. 3. Schematic of the measurement platform showing theparameters used in the verification equations. The
measurement platform is an L-shaped flat steel bar
bearing the compression-type load cells G1, G2, andG4, which are connected to a digital indicator. Notethat G3 is a point of support yielding similar values to
G2. The force direction arrows represent PG1, 2PG2,
PG4, and PE .

by Cohen, a priori statistical power testing for a
one-sample t-test was performed (effect size: d = 0.5;
significance threshold: p = 0.05; statistical power: 1-β= 0.8; two-tailed) [15, 16]. A sample size (n) of 34 wasused for each angle.
If the statistical power was < 0.5, the measurement
was continued. After the measurement at each angle was
performed, the arm masses were calculated using the
aforementioned methods. Descriptive statistics, namely
a Shapiro–Wilk test of normality and an F-test, were
performed for each angle. Based on these test results,
a one-sample t-test was performed using a population
mean of WT1 = 678.0 g, d, 1-β , and 95% confidence
interval (CI).
Results
The mean mass (M ) at each angle ranged from677.5 g to 678.5 g, with a standard deviation (SD) of
0.7–2.3. The angle-dependent measurements showed anormal distribution according to the Shapiro–Wilk normality test, W = (0.95–0.98), p = (0.06–0.45) (Table 1).
The one-sample t-tests showed no significant differences irrespective of the angle, t = -1.89–1.13, p =0.07–0.68, d = 0.00–0.28, 1-β = 0.50–0.70. For eachangle, the true mass (WT1 ) measured at the beginning of
the experiment was situated within the upper and lower
limits of the 95% CI.

Asian J Occup Ther 19: 243−249, 2023

Sasaki M

247

Table 1 Results of the theoretical validity investigation
Elevation
anglea(°)

M (SD)[g]

95% CI

10
20
30
40
50
60
70
80
90

678.1 (1.2)
678.2 (1.4)
677.8 (0.7)
677.5 (2.0)
677.8 (1.8)
678.5 (1.9)
677.5 (2.3)
677.7 (1.1)
677.7 (1.3)[677.7, 678.4][677.8, 678.6][677.6, 678.0][676.9, 678.1][677.3, 678.4][677.9, 679.0][676.8, 678.1][677.4, 678.0][677.6, 678.4]

MSE
0.18
0.20
0.11
0.30
0.27
0.29
0.34
0.16
0.20

Shapiro–Wilk
test of normality

One-sample t-test

Post hoc power testfor one-sample t-test

W

p

t

p

d (Cohen)

1-β

0.96
0.96
0.97
0.96
0.96
0.98
0.95
0.95
0.95

0.14
0.09
0.38
0.12
0.14
0.45
0.07
0.06
0.06

0.42
1.13
−1.89
−1.67
−0.63
1.68
−1.56
−1.81
0.00

0.68
0.26
0.07
0.10
0.53
0.10
0.13
0.08
1.00

0.06
0.17
0.28
0.25
0.09
0.25
0.24
0.27
0.00

0.70
0.52
0.50
0.50
0.61
0.50
0.50
0.50
1.00

Note. a n = 44. SD = standard deviation; CI = confidence interval; MSE = mean standard error; W = test statistic; p = asymptotic
significance probability; t = test statistic; 1-β = statistical power.

Experiment 1 Discussion
Based on the effect size and appropriate sample
number, no significant differences were found between
WT1 and the angle-resolved mean mass values, indicatingthat the proposed method could estimate the true mass.
The measurement conditions were the same for eachangle. This can be attributed to factors such as angle
configuration. These results demonstrate the theoretical
validity of the proposed method.

Experiment 2: Verifying reproducibility inliving subjects
PurposeTo verify the reproducibility and accuracy of themeasurements.
Methods
Because resting state muscle tone, length, andcenter of gravity can change with differences in arm
elevation, we expected corresponding changes in massaccording to the elevation angle. However, this only
verified our proposed method at the angular position described in the “Overview of the measurement method”
section. Multiple assessors (28 women; 8 men; meanage, 21.2 years; age range, 19–22; all occupational
therapy students who completed 1,000 hours of fieldwork) conducted two mass measurements on a Japaneseman (age, 55 years, height, 167 cm, weight, 72 kg),height of chair, 43 cm; height of desk, 70 cm. Measurements were performed using platform scales 1 and 2(KD2002141; maximum weight, 5 kg; minimum weight,
5 g; KD2002161; maximum weight, 1 kg; minimum
weight, 1 g; height of scales, 74 mm; TANITA, Tokyo,
Japan;). After providing instructions and demonstrations
regarding the measurement method, several tests wereconducted to assess whether each reviewer could adequately perform the measurement method. After the firstmeasurement was performed, the second measurement
was conducted 30 min later.
Experimental procedures and statistical processing
Statistical analyses were performed using the paired
t-tests. The required experimental sample size (n = 27)
was calculated a priori based on statistical power testing(r = 0.5, α = 0.05, 1-β = 0.8) [16]. Once the experiment commenced, the post hoc power tests on n = 27
showed that 1-β was lower than 0.5, and the sampling
was continued. The final sample size was found to be
34. Outlying data (points beyond twice the SD) were
rejected; therefore, the final data represented the W1 andW2 values for 29 participants (Table 2).

Results
Table 2 shows the descriptive statistics for eachmeasurement. The Shapiro–Wilk test for normality
showed that each distribution was normal. The F-test forthe 1st and 2nd measurement sets had the same variance.
The paired t-test showed no significant difference in W1
W2 . Post hoc power tests for the paired t-test yielded 1-β= 0.83, d = 0.04, and 1-β = 0.51, d = 0.29 for W1 andW2 , respectively. The intraclass correlation coefficient(ICC) (2, 29) for W1 and W2 were 0.00, and 0.51, respectively.
Experiment 2 Discussion
The four measurements showed normal distributions and the same variance, indicating that the measurement conditions were almost identical. No significant
differences were observed using the paired t-test, while
the post hoc power tests (1-β > .5) showed middle

248

MEASUREMENT OF ARM MASS

Table 2 Verification of reproducibility
Estimation
Parametera

Measurement

W1

W2

M (SD)[g]

95% CI

1st
2nd
1st & 2nd1284.41 (119.28)
1291.37 (137.84)

1st
2nd
1st & 2nd1411.10 (101.08)
1375.79 ( 99.69)

Shapiro–Wilk
test of normalityWp[1241.00, 1327.82][1241.20, 1341.54]

0.98
0.98

0.93
0.73

[1374.31, 1447.89][1339.51, 1412.07]

0.97
0.97

0.53
0.64

F-testPaired t-test

Post hoc power testfor paired t-test

F

p

t

p

d (Cohen)

1-β

0.75

0.45

–0.22

0.83

0.04

0.83

1.03

0.94

1.55

0.13

0.29

0.51

Note. a n = 29; M = Mean; SD = Standard deviation; CI = Confidence interval; W, F , t = test statistics; p = asymptotic significance probability;d = Effect size, 1-β = Statistical power.
Table 3 Estimation of arm mass in previous research
Researcher typeof subjects
Akou et al.
young Japanese athletesnage

GUA GLA GH[%] [%] [%] M (SD)
[g]

W2

W1
95% CIM (SD)[g]

95% CIW3
M (SD)[g]

W4

95% CIM (SD)
95% CI[g]

215 19.9

52.9

41.5 89.1 1879.2 [1851.3,(208.8) 1970.1]

1531.2 [1503.3,(208.8) 1559.1]

1113.6 [1095.0,(139.2) 1132.2]

417.6 [408.3,( 69.6)426.9]

Cheng et al.
Chinese Labors

8 26.043.4

47.3 42.0 2560.0 [2338.3,(320.0) 2781.8]

1382.4 [1107.5,(396.8) 1657.4]

960.0 [ 827.0,(192.0) 1093.1]

422.4 [280.5,(204.8)564.3]

Park et al.
Korean Geriatrics

7 67.9–1432.9 [1342.4,(122.2) 1523.5]

1005.1 [ 939.7,( 88.3) 1070.5]

427.8 [402.7,( 34.0)453.0]–– 1460.1 [1238.7,(298.8) 1681.4]

Note. GUA = Gravity point from the proximal part of the upper arm; GLA = Gravity point from the proximal part of the lower arm; GH = Gravity
point from the proximal part pf the hand.

powers [16]. However, since the ICC for W1 and W2
showed low reproducibility, interpretation of the results
was difficult. Because W1 measures were calculatedusing W2 , which is not the appropriate use of the ICC
as it is based on a one-way model (meaning one fixed
effect); we could not consider the reproducibility for thesuggested method using the ICC. These results indicatethat the reproducibility of the measurements performedby multiple researchers for each participant was insufficient.

Discussion
Comparison with previous research
The 95% CIs of Experiment 2 were comparedwith those of previous studies on Asian participants[2–4]. The 95% CIs in previous research (Table 3) were
derived from the M, SD, and sample numbers. W2 wasderived from W3 (the lower arm mass without the hand)
and W4 (the hand mass without a lower arm mass).
Our 95% CIs of W1 and W2 (Table 2) almost overlapped with those of Park [4] (Table 3), indicating theaccuracy of our method.
Furthermore, both previous [2, 3] studies and thecurrent research used the fixed definition of the center ofgravity and not the measurement method of the centerof gravity. The fixed center of gravity minimized themeasurement error; however, as each gravity point wasdifferent, the measurement method of the center of gravity should also be considered.
Clinical measurement
Because of insufficient reproducibility, a supplemental method, such as the adjusted backrest fitting
better for all subjects, is needed; and the assessor must
try to achieve reproducibility.
Appropriate training in this measurement method isimportant, and the assessor should interpret several samplings and 95% CIs. Notably, the requirement of 95% CI
in clinical practice is unclear and needs to be consideredby individual clinical practices.
Applying this method in clinical situations judged
to assess the arm mass, but no suitable method wasfound, for example, stiffness or edema, diet therapy, or
exercise therapy.
Limitations and prospects of this study
Definitions of upper and lower masses were unclear.

Asian J Occup Ther 19: 243−249, 2023

Adjustments may be necessary depending on the typeof physical range estimated. So, the assessor must notcompare the estimate using this method and the estimate
using other methods.
The reproducibility in Experiment 2 was confirmed
for targeting a normal subject. However, a reliability test
will also be needed, although the condition of patients
will not be consistent. Hence, the reliability should be
confirmed by a test for each case.
Since there was no proper statistical method available for measuring reproducibility, we consider our
results insufficient. The reproducibility of the suggested
method should be tested again using the appropriate
statistical method that can evaluate the two-way model.
The significance of this study is that it suggests a
measurement method. We however could not use a statistical method to verify the reproducibility of proposed
measurement method.

Conclusion
This study presents a method for conducting
somatometric measurements, which are both accurate,
reliable, and convenient for therapists to use in clinicalenvironments. Statistical analyses of the measurements
recorded for the participants in this study using the proposed method confirmed its validity, but reproducibility
was insufficient. Next, the proposed method should betrialed by clinicians to quantify its clinical usefulness
and identify areas requiring refinement. Although theproposed method may not be suitable for all subjects, it
is expected to provide broad applicability.

Funding statement or Declaration of conflicting interests
The authors received no financial support for the
research, authorship, and/or publication of this article.

References[1] Sasaki M. A computational inquiry into movement
instruction methods based on joint torque indices (inJapanese). Jpn J Occup Ther (sagyouryouhou). 2012; 31:
473–82.
[2] Michiyoshi AE, Tang H, Yokoi T. Estimation of inertia

Sasaki M

249

properties of the body segments in Japanese athletes.
Biomechanisms. 1992; 11: 23–33.
[3] Cheng CK, Chen HH, Chen CS, Chen CL, Chen CY.
Segment inertial properties of Chinese adults determinedfrom magnetic resonance imaging. Clin Biomech (BristolAvon). 2000; 15(8): 559–66.
[4] Park SJ, Kim CB, Park SC. Anthropometric and biomechanical characteristics on body segments of Koreans.
Appl Human Sci. 1999; 18(3): 91–9.
[5] Dempster WT. Space requirements of the seated operator.
WADC Tech. Report. 1955. p. 55–159.
[6] Drillis R, Contini R, Bluestein M. Body segment parameters: a survey of measurement techniques. Artif Limbs.
1964; 8: 44–66.
[7] National Institute of Technology and evaluation: humancharacteristics database. [Cited 2021 Apr 1]. Available
from: http://www.tech.nite.go.jp/human/indexeng.html.
[8] Tashijan RZ. AAOS clinical practice guideline: optimizing the management of rotator cuff problems. Am Acad.
Orthop Surg. 2011; 19(6): 380–3.
[9] Scibek JS, Carcia CR. Assessment of scapulohumeralrhythm for scapular plane shoulder elevation using amodified digital inclinometer. World J Orthop. 2012;
3(6): 87–94.
[10] Castelein B, Cagnie B, Parlevliet T, Cools A. Superficial
and deep scapulothoracic muscle electromyographic
activity during elevation exercises in the scapular plane. J
Orthop Sports Phys Ther. 2016; 46(3): 184–93.
[11] Massimini DF, Warner JJ, Li G. Glenohumeral joint cartilage contact in the healthy adult during scapular planeelevation depression with external humeral rotation. J
Biomech. 2014; 47(12): 3100–6.
[12] Inman VT, Saunders deCM. JB, Abbott LC. Observationon the function of the shoulder joint. J Bone Joint Surg.
1944; 26(1): 1–30.
[13] McQuade KJ, Smidt GL. Dynamic scapulohumeralrhythm: the effects of external resistance during elevationof the arm in the scapular plane. J Orthop Sports Phys
Ther. 1998; 27(2): 125–33.
[14] R Core Team. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing. [Cited 2021 Apr 1]. Available from:https://www.r-project.org/.
[15] Heinrich-Heine-Universität Düsseldorf. G*Power: statistical power analyses for Windows and Mac. [Cited 2020
Sep 1]. Available from: http://gpower.hhu.de/.
[16] Cohen J. Statistical power analysis for the Behavioral
Science. 2nd ed. Hillsdale, New Jersey: Lawrence Erlbaum Associates; 1988.

■ORIGINAL ARTICLE

Factors Related to Functional Outcome in Patientswith Moderate or Higher Upper Limb Paralysis
using ReoGo®-J– A Retrospective Observational Study –Shintaro Kawano1, Shinnosuke Hatabe2, Shinsuke Imaoka3
1

Department of Rehabilitation, Medical Corporation Jinsenkai Hata Hospital
Department of Rehabilitation, Social Medicalcorporation Keiwakai Oita Rehabilitation Hospital3
Department of Rehabilitation, Oita Oka Hospital2

Abstract: Background: Several guidelines recommend robotic therapy for upper extremity motor paralysis after stroke,
but the number of eligible patients is unknown. This study aimed to examine predictors of functional outcomes after
robotic therapy in patients with moderate or severe upper extremity paralysis.
Methods: This retrospective observational study included 53 patients with subacute stroke. Patients received daily occupational therapy (OT) for 4 weeks and robotic therapy 3 to 4 times per week for 20 min per session. Binomial logistic
regression analysis was performed to estimate predictors of participants with a minimal clinically important difference(MCID) of 9 points or greater in the Fugl-Meyer Assessment of Upper Extremity (FMA-UE) after 4 weeks based on
FMA-UE shoulder and elbow forearm scores, days since onset, and amount of OT training. Cutoff values were calculated using receiver operating characteristic curves.
Results: Only the FMA-UE shoulder and elbow forearm score (odds ratio = 0.913, p = 0.014) was a predictor of FMAUE improvement in MCID after 4 weeks. The cutoff value was calculated to be 12.5 points.
Conclusion: The FMA-UE shoulder and elbow forearm score at the start of interventions may be a useful predictor offunctional outcomes after robotic therapy in patients with moderate or severe upper limb motor paralysis after stroke.
Furthermore, an FMA shoulder and elbow forearm score of 12.5 might be necessary to show improvement over MCID
in the short term.
Keywords: robot-assisted therapy, predictor, subacute phase, paralyzed upper extremity(Asian J Occup Ther 19: 250−255, 2023)

1. Introduction
Robotic therapy for upper limb paralysis after
stroke is an evidence-based intervention method that
can help participants with moderate to severe upper
limb paralysis maintain training volume [1]. ReoGo®-J(RGJ) is one of the upper limb robots used in Japan,
and its usefulness for upper limb voluntarism in patientswith stroke has been observed [2–4]. Furthermore, due
to the newly established additional fee for equipment
Received: 24 October 2022, Accepted: 12 September 2023
Corresponding to: Shinsuke Imaoka, Department of Rehabilitation,
Oita Oka Hospital, 3-7-11 Nishitsurusaki, Oita City, Oita Prefecture
870-0192, Japane-mail: ptssinnsukeimaoka@yahoo.co.jp©2023 Japanese Association of Occupational Therapists

to increase locomotion in the 2020 revision of medical
reimbursement, the opportunity for indication of robotic
therapy for upper limb paralysis after stroke is expected
to increase.
A certain effectiveness of robotic therapy was recognized in a review of robotic therapy [5], but the needfor examination of training intensity, duration, and participant characteristics was noted. In contrast, it is wellknown that many interacting factors influence the functional outcome of upper limb paralysis [6], but there
have only been sporadic studies of factors influencing
functional outcomes after robotic therapy [7–9]. Furthermore, it is critical that rehabilitation effectivenessmeasures are meaningful to the participant, but there are
few reports [9, 10] that have predicted changes beyond
the minimal clinically important difference (MCID) in
the Fugl-Meyer Assessment (FMA), and we did not find

Asian J Occup Ther 19: 250−255, 2023

any in RGJ as far as we could wade through. Based on
the recommendations in the aforementioned guidelines[1], the target population for robotic therapy is expected
to be individuals with moderate to severe upper limb
paralysis, but selecting eligible patients is often difficult.
Therefore, this study aimed to investigate predictors of functional outcomes in patients with moderate
to severe upper limb paralysis using RGJ to help selectcases for robotic therapy.

2. Materials and Methods
Study design and participantsThis is an observational study that was conductedin the past. The participants were patients with strokewith moderate to severe upper limb paralysis who
were admitted to our hospital between March 2018 andDecember 2021 and were treated with robotic therapy
using RGJ in addition to standard occupational therapy(OT). According to Daly et al. [11], the severity ofupper limb paralysis was defined as FMA 49 or less.
The inclusion criteria were patients who could continue
robotic therapy using the RGJ for 20 min three to fourtimes a week for four weeks, whereas the exclusion
criteria were patients with recurrent stroke and thosewith deficiencies in the survey items described below.
Patients with FMA changes of nine or more points [12],considered to have subacute MCID, were classified as
the improvement group, whereas patients with FMAchanges of eight points or less were classified as thenonimprovement group.
This study was carried out in accordance with theHelsinki Declaration (as revised in Brazil in 2013), andapproval was obtained from the Ethical Committee of
the Oita Oka Hospital Ethics Review Committee (approval number: A046). Instead of obtaining informed
consent from each participant, consent was obtained bypublishing study details on the homepage of the research
institute website, as well as onsite posting in the facility.
The survey items included age, gender, disease type,paralytic side, time from onset to start of robotic therapy(hereafter, onset period), total number of OT units during
the period of robotic therapy (hereafter, total number of
OT units), degree of sensory impairment, FMA, Functional Independence Measure (FIM), modified Ashworth
Scale (mAS), and Frontal Assessment Battery. Each occupational therapist who was not involved in this study
measured these items within 3 days of beginning robotic
therapy.
Robotic therapy protocol
In this study, RGJ was used for robotic therapy,
which is a Japanese-specific version of ReoGo® by

Kawano S et al.

251

Motrica Inc. of Israel. Upper limb functional training is
performed by the participant by grasping a handle attached to the arm and reaching toward a target displayedon the screen. The training menu includes 17 different
types of exercise trajectories that can be selected basedon the participant’s ability. The robot can provide five
types of assistance and resistance load: full assistance,
initial load, automatic assistance, trajectory assist, andautomatic exercise. It is also possible to adjust the reach
range, load amount, and arm movement speed [13].
Robotic therapy with RGJ was used as an adjuncttherapy to traditional OT, either through voluntary practice or during the OT intervention period. The duration
was 20 min per day, three to four times per week. The
upper limb joint movements required for the targeted
activities, as well as the joint movements that wereantagonistic to the abnormal joint movement patterns,
were analyzed, and menus that included these joint
movements were preferred. The orbit-assist mode was
the basic assistance mode, which was combined withthe automatic exercise mode based on the quality of the
movements performed. When adjusting the difficultylevel, we observed the quality of movement (ordinalscale of quality of movement in the Motor Activity
Log [14]) during the robotic therapy, referring to Takebayashi’s report [15]. The reach range was adjusted to
3.5–4.0 by referring to the compensatory movements ofthe trunk and shoulder girdle. Moreover, the occupational therapist in charge adjusted each practice menu anddifficulty level, and the difficulty level was adjusted atleast once every 2 weeks.
Approaches other than robotic therapy
As part of the recovery rehabilitation, OT, including
upper limb function training, was provided daily for
40–100 min. Upper limb function training included taskoriented training such as manual therapy, neuromuscular
stimulation, object manipulation, and use of the paralyzed hand, as well as daily living activities and applied
daily living activities provided in parallel based on
the needs and demands of the patients. Daily physicaltherapy and speech-language pathology services werealso provided, but none involved active intervention for
upper limb function.
Statistical analysis
The Shapiro–Wilk test was performed to confirm
the normality of continuous variables for the improvement and nonimprovement groups, followed by uncorrelated t-tests for age and motor FIM, duration of onset,
total OT units, surface sensation, and deep sensation.
The Mann–Whitney U test was performed for sensation,
FMA, cognitive FIM, and mAS. The following factors

252

FACTORS RELATED TO TREATMENT OUTCOMES OF UPPER LIMB ROBOTIC THERAPY

Table 1 Characteristics of participants

Gender (male/female), n
Stroke type (infarction/hemorrhage), nAge, year
Affected side (right/left)
Period from stroke onset, days
Length of daily occupational therapy (min)Superficial sensory
Deep sensory
Total FMA (Point)
4weeks Total FMA (Point)
FMA-UE (Point)
4weeks FMA-UE (Point)
Motor FIM Score (Point)
Cognitive FIM score (Point)mAS score shoulder flexors
mAS score elbow flexors
mAS score wrist flexors
FAB (Point)

Improvement group (n = 27)

Non-improvement group (n = 26)

p-value

14/13
18/9
71.1 ± 10.7
13/14
38.0 [31.3–44.5]
108 [88.5–124.5]
1.0 [0.0–1.0]
1.0 [0.3–2.0]
31 [17.3–42.3]
42.0 [33.8–55.8]
17.0 [11.8–22.8]
28.0 [23.0–30.8]
51.9 ± 17.6
29.0 [26.0–33.0]
0 [0.0–1.0]
1.0 [0.0–1.0]
1.0 [0.0–1.0]
14.0 [11.3–15.0]

15/11
18/8
71.6 ± 11.5
18/8
45.5 [35.3–55.0]
103.5 [89.8–118]
1.0 [1.0–2.0]
1.0 [1.0–2.0]
7.0 [4.0–21.5]
12.0 [9.3–27.3]
6.5 [4.0–16.3]
10.5 [8.0–22.8]
39.3 ± 13.8
27.0 [20.3–31.0]
1.0 [0.0–1.0]
1.0 [0.0–1.8]
1.0 [0.0–1.0]
12.5 [8.3–14.8]

0.669
0.842
0.872
0.166
0.223
0.408
0.52
0.66
0.009**< 0.001**
0.007**< 0.001**
0.007**
0.116
0.298
0.985
0.884
0.169

Mean ± Standard deviation, Median [interquartile range], **: p < .01
FMA, Fugl–Meyer Assessment; FIM, Functional Independence Measure; mAS, modified Ashworth Scale

were also considered: gender, disease type, and paraplegia. The χ2 test was also performed to compare gender,
disease type, and paralytic side. Multivariate analyses
were performed on participants who met the inclusionand exclusion criteria. In the multivariate analyses, abinomial logistic regression analysis was performed,
with the dependent variable being the presence of FMA
MCID (9 points) improvement at 4-week follow-up andthe independent variables being FMA shoulder, elbow,
and forearm items, total OT units, and days since stroke
onset at the start of interventions and FMA. The reasonsfor selecting these independent variables are as follows.
An association has been reported between FMA scoresat the start of interventions and functional prognosis,
and lower scores have been reported to be associatedwith worse functional prognosis [6]. Regarding total
OT units, a greater functional improvement has beenreported to be associated with more upper extremity
training [16]. Regarding the number of days since stroke
onset, a previous study [17] reported better functional
prognosis for those who started rehabilitation earlier
after stroke onset. Based on these studies, factors that
could be considered to be closely related to the functional outcomes of FMA were selected as independent
variables. Spearman’s rank correlation coefficient andvariance expansion factor (VIF) were checked for thesevariables to check for multicollinearity. In the binomial
logistic regression analysis, if a variable was found tobe significantly related to the independent variables,
the Youden index on the receiver operating characteristic (ROC) curve was used to define the cutoff point

at which the sum of sensitivity and specificity−1 was
the greatest. This was calculated as the (“ROC curve”)
value. Statistical analysis was performed using SPSS 2.0.
SPSS 26 was used as the statistical analysis software,and the significance level was set at 5%.

3. Results
Univariate analysis (Table 1)
The analysis included 53 of the 81 patients who
met inclusion criteria, excluding 28 patients who met
exclusion criteria. Of these, 27 were in the improvement
group and 26 in the nonimprovement group. FMA total( p = 0.009), FMA shoulder elbow forearm items ( p =0.007), and exercise FIM ( p = 007) showed significant
differences in univariate analysis.
Multivariate analysis (binomial logistic regression analysis)
Spearman’s rank correlation coefficient revealed
no significant correlation between any of the variables(Table 2), and the VIF among the independent variables
were all less than 2, implying that no multicollinearity
existed [18]. Binomial logistic regression analysis
revealed the number of FMA shoulder elbow forearm
items (odds ratio (OR): 0.913, 95% confidence interval(95% CI): 0.851–0.980, p = 0.011), the number of OT
units (OR: 0.998, 95% CI: 0.974–1.023, p = 0.892),
and the onset period (OR: 1.023, 95% CI: 0.989–1.058,
p = 0.181) (Table 3). Based on these findings, the ROC
curve of the FMA shoulder elbow forearm item wasAsian J Occup Ther 19: 250−255, 2023

Kawano S et al.

253

Table 2 Correlations among independent variables used in the binomial logistic regression analysis.
variables

FMA-UE

Length of daily
Period fromoccupational
stroke onset
therapy

FMA-UE

1.00

Length of daily occupational therapy

−.141

1.00

Period from stroke onset

−.108

.120

1.00

Spearman’s rank correlation coefficient, FMA, Fugl–Meyer Assessment

Table 3 Logistic regression analysis with Improved FMA over
MCID as a dependent variable.
Explanatory variables

B

OR

95%CI

p-value

FMA-UE

−0.91

0.913

0.851–0.980

0.011*

Length of daily occupational therapy

−0.02

0.998

0.974–1.023

0.892

Period from stroke onset

0.23

1.023

0.989–1.058

0.181

B, Partial regression coefficient; OR, odds ratio; 95% CI, 95% confidence interval; FMA, Fugl–Meyer Assessment *: p < .05

depicted, and the cutoff was calculated using the Youden
index, which was 12.5 points (area under the curve: 0.72,
sensitivity: 74%, specificity: 69%, 95% CI: 0.58–0.86),
indicating a good model fit. The area under the curve
was larger than the recommended value of 0.7 [19](Fig. 1).

4. Discussion
In this study, we investigated predictors of thefunctional outcome of FMA 4 weeks after robotic therapy based on FMA shoulder and elbow forearm items
at the start of interventions, duration of onset, and total
number of OT units. The findings revealed that the FMA
shoulder and elbow forearm items were significantly
related at the start of interventions, and a cutoff value of
12.5 points could be calculated.
Differences in basic attributes
Significant differences in FMA total, FMA shoulder
and elbow forearm items, and FIM motor items were
found in univariate analysis. This could be due to thevoluntary nature of upper limb paralysis at the beginning of the intervention, as Coupar et al. [5] found thatthe severity of upper limb paralysis at the beginning ofintervention affects functional outcomes. In addition to
motor paralysis, other factors such as balance function[20] and higher brain dysfunction [21] are known toaffect FIM motor items in patients with stroke, and theFig. 1. Receiver operating characteristic curve for FMA-UE
items.

impact of these factors on upper limb function must be
considered.
Usefulness of FMA as a predictor of functional outcomes
after robotic therapy
The Box and Block Test (BBT) [8] and the Hand
Movement Scale [10] have been proposed as predictorsof functional outcomes after robotic therapy for patientswith subacute stroke. However, it is well known thatupper limb paralysis after stroke occurs primarily in the
distal joints [22], and these assessments, which require
hand joint and hand function, are expected to be difficult
to use in participants with moderate to severe upper
limb paralysis. The FMA is useful in this regard because
it can be used easily even in cases of moderate or severe
upper limb paralysis [23] because its responsiveness has
been reported in cases of moderate or severe upper limb
paralysis, implying that it can be used as a functional
outcome after robotic therapy. As a result, this index isuseful because it is simple to use in cases of moderate tosevere upper limb paralysis.
According to Duret et al. [9], the FMA shoulder andelbow forearm items were included as potential predictors of MCID after robotic therapy. Recovery is thought
to be task-specific [24]. Therefore, our findings supported previous studies on the relationship between FMA
shoulder elbow forearm items and functional outcomes
after robotic therapy.
FMA, on the other hand, has not been shown to predict improvement beyond MCID in cases of moderate
to severe upper limb paralysis and associated symptoms
such as sensory impairment, hemispatial neglect, andaphasia [9]. Furthermore, it has been reported that inmild to moderate cases, prediction using BBT was more
useful than FMA [7]. This implies that the accuracy of

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FACTORS RELATED TO TREATMENT OUTCOMES OF UPPER LIMB ROBOTIC THERAPYFMA as a predictor of improvement over MCID in predicting functional outcomes of robotic therapy is dependent on background factors and intervention protocols
and that the results of this study should be validated in
the future.
Limitations
Because this was a retrospective observational study,
the content of training other than robot therapy was notcontrolled, and the predictors of robot therapy could not
be rigorously investigated. Furthermore, the sample size
was not designed to ensure adequate power. In addition,
we only looked at short-term predictors over a 4-weekperiod and did not predict mid- to long-term functional
outcomes. Furthermore, because the study was conducted at a single institution, the possibility of selection bias
cannot be ruled out. Based on this, it may be necessary
in the future to design a sample size, select participants
based on a cutoff index, develop and validate a systematic intervention strategy, re-examine mid- to long-term
predictors through follow-up during hospitalization andafter discharge, and conduct joint validation at otherinstitutions for external validation. External validity must
be through joint validation at other institutions, according to experts.

5. Conclusions
With robotic therapy using RGJ, the FMA-UE
shoulder and elbow forearm item scores at the start ofinterventions were most related to the short-term FMAUE functional outcomes. The study results suggest that ascore of 12.5 is necessary for the participants to achieve
short-term improvement beyond MCID.

Conflicts of Interest
No potential conflict of interest was reported by theauthors.

Acknowledgments
We are grateful to the staff and patients of our hospital for their support.

References[1] Winstein CJ, Stein J, Arena R, Bates B, Cherney LR,
Cramer SC, et al. Guidelines for adult stroke rehabilitation and recovery: A guideline for healthcare professionals from the American Heart Association/American Stroke
Association. Stroke. 2016; 47(6): e98–169.
[2] Takahashi K, Domen K, Sakamoto T, Toshima M, Otaka

Y, Seto M, et al. Efficacy of upper extremity robotic
therapy in subacute poststroke hemiplegia: an exploratory
randomized trial. Stroke. 2016; 47(5): 1385–8.
[3] Anmoto N, Takebayashi T, Itou R, Suga K, Tanaka S.
The efficacy and safety of self-training using the ReoGo-J
robotic device for upper extremities in subacute hemiplegia after stroke (in Japanese). Jpn Occup Ther Res. 2018;37(2): 153–60.
[4] Ishigaki M, Takebayashi T, Maeda J, Kubokida Y, Taka­hashi Y. The usefulness of ReoGo-J robot for upper limb
training in subacute stroke patients: an exploratory com­parative study using propensity score matching (in Japa­
nese). Jpn Occup Ther Res. 2019; 38(5): 575–84.
[5] Mehrholz J, Pohl M, Platz T, Kugler J, Elsner B. Electromechanical and robot-assisted arm training for improving
activities of daily living, arm function, and arm muscle
strength after stroke. Cochrane Database Syst Rev. 2018;
9(9): CD006876.
[6] Coupar F, Pollock A, Rowe P, Weir C, Langhorne P. Predictors of upper limb recovery after stroke: a systematic
review and meta-analysis. Clin Rehabil. 2012; 26(4):291–313.
[7] Hsieh Y, Lin K, Wu C, Lien H, Chen J, Chen C, et al.
Predicting clinically significant changes in motor andfunctional outcomes after robot-assisted stroke rehabilitation. Arch Phys Med Rehabil. 2014; 95(2): 316–21.
[8] Franceschini M, Goffredo M, Pournajaf S, Paravati S,
Agosti M, De Pisi F, et al. Predictors of activities of dailyliving outcomes after upper limb robot-assisted therapy
in subacute stroke patients. PLOS ONE. 2018; 13(2):e0193235.
[9] Duret C, Pila O, Grosmaire AG, Koeppel T. Can robotbased measurements improve prediction of motor performance after robot-assisted upper-limb rehabilitation inpatients with moderate-to-severe sub-acute stroke? Restor
Neurol Neurosci. 2019; 37(2): 119–29.
[10] Lee JJ, Shin JH. Predicting Clinically significant improvement after robot-assisted upper limb rehabilitationin subacute and chronic stroke. Front Neurol. 2021; 12(1):668923.
[11] Daly JJ, Hogan N, Perepezko EM, Krebs HI, Rogers JM,
Goyal KS, et al. Response to upper-limb robotics andfunctional neuromuscular stimulation following stroke. J
Rehabil Res Dev. 2005; 42(6): 723–36.
[12] Arya KN, Verma R, Garg RK. Estimating the minimal
clinically important difference of an upper extremity
recovery measure in subacute stroke patients. Top Stroke
Rehabil. 2011; 18; Suppl 1: 599–610.
[13] Medical Web T. Inc [online]. Upper Limb Robotic Exercise Training Device Reogo®-J [cited Sep 22 2022]. Available from: https://medical.teijin-pharma.co.jp/product/
zaitaku/reogo-j/index.html.
[14] Takahashi K, Domen K, Sano K, Takebayashi T, Hachisuka K. Reliability and validity of the motor activity log
in Japan [in Japanese]. J Japanese Occup Ther Assoc.
2009; 28(6): 628–36.
[15] Takebayashi T, Amano A, Hanada K, Uchiyama Y, Domei

Asian J Occup Ther 19: 250−255, 2023

K. Robotic therapy in multiple interventions for severeto-moderate arm deficits in chronic stroke patients (inJapanese). Jpn Occup Ther Res. 2017; 36(2): 148–58.
[16] Kwakkel G, Wagenaar RC, Twisk JW, Lankhorst GJ,
Koetsier JC. Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial.
Lancet. 1999; 354(9174): 191–6.
[17] Paolucci S, Antonucci G, Grasso MG, Morelli D, Troisi
E, Coiro P, et al. Early versus delayed inpatient stroke
rehabilitation: A matched comparison conducted in Italy.
Arch Phys Med Rehabil. 2000; 81(6): 695–700.
[18] Shintani A. Multivariate analysis – complete mastery ofbasic theory and EZR in 10 days! 1st ed (in Japanese).
Tokyo: Kodansha Ltd; 2017.
[19] Hisashige A. Indicators of usefulness of tests and ROC
analysis [in Japanese]. J Clin Lab Med. 2005; 49(12):1335–40.
[20] Hama S, Yamashita H, Shigenobu M, Watanabe A, Hira­moto K, Takimoto Y, et al. Sitting balance as an early

Kawano S et al.

255

predictor of functional improvement in association withdepressive symptoms in stroke patients. Psychiatry Clin
Neurosci. 2007; 61(5): 543–51.
[21] Revet M, Immerzeel J, Voogt L, Paulis W. Patients withneuropsychological disorders short after stroke haveworse functional outcome: a systematic review and metaanalysis. Disabil Rehabil. 2021; 43(16): 2233–52.
[22] Hatakenaka M, Miyai I, Sakoda S, Yanagihara T. Proximal paresis of the upper extremity in patients with stroke.
Neurology. 2007; 69(4): 348–55.
[23] Rabadi MH, Rabadi FM. Comparison of the action
research arm test and the Fugl-Meyer assessment as measures of upper-extremity motor weakness after stroke.
Arch Phys Med Rehabil. 2006; 87(7): 962–6.
[24] Pila O, Duret C, Laborne FX, Gracies JM, Bayle N,
Hutin E. Pattern of improvement in upper limb pointing
task kinematics after a 3-month training program withrobotic assistance in stroke. J Neuroeng Rehabil. 2017;
14(1): 105.

■CASE REPORTS

Acquiring Practical Cooking Skillsin the Non-Dominant Hand
after Severe Right Hemiplegia: A Case Report
Kei Ito1, Shota Suzumura1, 2, Yoshikiyo Kanada2, Yoko Nagakawa1,
Rie Narukawa1, Hiroaki Sakurai2, Kondo Izumi1
1
2

Department of Rehabilitation Medicine, National Center for Geriatrics and Gerontology
Faculty of Rehabilitation, School of Health Sciences, Fujita Health University

Abstract: Purpose: There are no reported cases of reacquisition of cooking ability in patients with severe hemiplegiaof the dominant hand due to stroke. Thus, this study reports a case in which a patient with severe hemiplegia on thedominant hand side due to stroke reacquired practical cooking ability after being trained on cooking using the nondominant hand.
Methods: The patient was a right-handed woman with severe right hemiplegia due to left capsular hemorrhage who
needed to be able to cook by herself. The patient had difficulty cooking with her right upper limb because of severe
right hemiplegia; therefore, we examined cooking methods suited to the patient using various tools so that she could
manage to cook using only her left upper limb. In addition, we asked her family members to help her repeat and practice what we had trained her to do.
Results: The mean performance score and satisfaction, obtained using the Canadian Occupational Performance Measure,improved by 3 points after the intervention. The patient was able to cook independently.
Conclusions: Our results suggest that patients with severe hemiplegia on the dominant hand side may be able to reacquire cooking ability using the non-dominant hand through repeated practice of cooking-related tasks adjusted to an
appropriate level of difficulty while using cooking apparatus.
Keywords: stroke, non-dominant hand, cooking, Canadian Occupational Performance Measure, rehabilitation(Asian J Occup Ther 19: 256−259, 2023)

Introduction
Cooking is one of the most difficult independently
performed post-stroke instrumental activities of dailyliving (IADLs). Approximately 77% of post-stroke
patients require assistance with cooking [1]. Only 15%
patients with upper limb paralysis can use their upper
limbs in daily life without difficulty [2]. Therefore, considering compensatory strategies to reacquire cooking
related movements is crucial.
Compensatory use of the non-dominant hand is an
option for post-stroke patients with paralyzed dominantReceived: 7 January 2023, Accepted: 2 October 2023
Corresponding to: Kei Ito, Department of Rehabilitation Medicine,National Center for Geriatrics and Gerontology, 7-430, Morioka-cho,
Obu, Aichi, 474-8511, Japane-mail: 110kei0509@gmail.com©2023 Japanese Association of Occupational Therapists

hand. Philip et al. reported that training to draw precisely with the non-dominant hand for 30 min/day for 10
days improved the speed and ease of non-dominant handuse, and the effect persisted for 6 months post training[3]. Therefore, for post-stroke patients with severe upper
limb paralysis who wish to resume cooking, practicing
compensatory movements with the non-dominant handis critical.
The Canadian Occupational Performance Measure(COPM), a patient-centered instrument, allows patientsto determine and rank problematic tasks of daily living[4]. In a survey of tasks using the COPM for chronic
hemiplegia of the upper limbs, 17% respondents listed
cooking tasks as a goal [5]. However, to our knowledge,
there is no published report on chronic-stroke patientswith paralyzed dominant hand reacquiring practicalcooking abilities with the non-dominant hand.
We report a case of a right-handed patient withsevere right hemiplegia due to left capsular hemorrhage

Asian J Occup Ther 19: 256−259, 2023

Ito K et al.

257

Fig. 1. Cooking methods used in the case study.
A) Fixing spherical foods: A wet towel of appropriate size was looped; its two ends were clipped together to create a hollow inwhich the food was placed to prevent it from rolling.
B) Fixing stick-shaped foodstuffs: A rubber band was tied to a cutting board, and the foodstuff was secured to the cutting board
with the rubber band. A silicon mat was placed under the food to prevent it from sliding.
C) Peeling food: A wet towel was laid on the cutting board, and the foodstuff was placed on the towel with the cut end facing
down to expand the ground contact area and prevent it from rolling.

who reacquired practical cooking ability using thenon-dominant hand and had improved COPM performance and satisfaction scores.

Material and subject
This case is that of a right-handed woman in her
50s who had been independent in IADLs before stroke.
The patient was discharged 141 days after stroke witha Mini-Mental State Examination score of 27. Afterdischarge, right upper limb paralysis prevented herfrom cooking. To train for independent living, she had
60-min home-visit rehabilitation sessions twice weekly.
The patient set the following goals: “be able to cook,”“be able to take in and fold laundry,” and “be able togo out for walks.” The importance of each of these
items as perceived by the patient was scored 5, 6, and3, respectively. During the early phase of rehabilitation,
the patient began outdoor practice and soon was able towalk independently. She was able to take in the laundry,
partly because she had only mild lower limb motor
paralysis; she was able to fold her laundry with compensatory support from her non-paralyzed side. However,
she was unable to cook with one hand or with thenon-dominant hand. Thus, practicing cooking was added
to the home-visit rehabilitation program. This study
was conducted in accordance with the Declaration of
Helsinki after obtaining both oral and written informed
consent.

Methods
Pre-intervention
Methods used to cook independently, namely, cut-ting and peeling, were analyzed. Several problems wereencountered during cooking. First, insufficient fixationof foodstuff made cutting them into pieces difficult.
Second, difficulty peeling skin using a peeler along
spherical contours with one hand.
Cooking Instruction
Initially, we used a cutting board with nails holding the food in place. However, even with a cuttingboard with nails, securing the food was difficult, andinjury risk was high. Therefore, after consulting withthe patient and her family, patient appropriate cooking
methods were implemented.
Figure 1 illustrates the improvised cooking methods. (1) Food preparation: To prevent rolling of spherical items, we clipped both ends of a wet towel to create
an appropriate-sized circle, placing the foodstuff in its
hollow (Fig. 1-A). Stick-shaped food items, such as
carrots, were fixed to the cutting board by securing themwith a rubber band. Food items were placed on a silicon
mat to prevent them from sliding (Fig. 1-B). (2) Peeling:
The cut food was placed on a wet towel placed on the
cutting board. The cut end of the food item was placed
face down to increase the contact area and preventrolling. Food items were then peeled from top to bottom
direction (Fig. 1-C). To prevent injury, the patient was
instructed to lower the knife from the tip of the blade,while being lowered vertically.
The patient was asked to cook with her family atleast once weekly, gradually increasing the frequency.
The patient continued these tasks for 3 months. Simultaneously, self-training exercises using hand grippers to
improve her grip strength, 3 sets of 50 repetitions daily,
helped her further.

258

REGAINING COOKING SKILLS AFTER A STROKE

The minimal clinically critical difference in COPM is achange of ≥ 2 points in the average scores of both performance and satisfaction [8]. In this study, “be able tocook” increased from 2 to 7 points in both performanceand satisfaction, the largest change among the items; webelieve this led to an improved COPM.
Setting appropriate difficulty level of the tasks is
crucial for movement acquisition. Tasks appropriately
challenging to the individual’s proficiency level produce
better motor learning than tasks with a constant difficulty level [9]. Conversely, tasks with difficulty level
too high for the patient’s proficiency level are unable
to sustain performance ability [10]. Since the patient
had difficulty cutting food with a knife before the intervention, we used other tools and cutting techniques toreduce the associated difficulty level to a level that was
patient appropriate, which helped her regain her cooking
ability. Regarding physical function, improved grip
strength was observed. We believe that this was because
the patient continued with the provided training andhad opportunities to perform household activities apartfrom cooking. Assumably, improvement in grip strength
perfected movements involved in cutting food.

Table 1 Physical function assessment pre- and post-intervention

Rt BRS (stage)
Upper extremities
FingerLower limbs
Rt SIAS motor (score)
Knee-mouth test
Finger-function test
Hip-flexion test
Knee-extension test
Foot-pat test
Lt MMT (score)
Lt Grip strength (kg)

Pre

Post

Ⅲ
Ⅱ
Ⅳ

Ⅲ
Ⅲ
Ⅴ

2
1A
4
5
4
5
13

2
1A
4
5
4
5
25

BRS, Brunnstrom Recovery Stage; SIAS, Stroke Impairment Assessment Set; MMT, Manual Muscle Test; Rt, Right; Lt, Left.
MMT measured shoulder flexor strength, shoulder abductor strength,
hip flexor strength, and knee extensor strength.

Results
The Brunnstrom recovery stage to determine thedegree of paralysis increased from II to III for the righthand. No significant changes were noted in the Stroke
Impairment Assessment Set. The gross muscle strengthof the left upper and lower limbs was measured using
manual muscle test and was approximately 5 points bothpre- and post-intervention. The grip strength of the left
hand increased from 13 to 25 kg (Table 1).
Table 2 shows the pre- and post-COPM intervention results. Pre-intervention, the mean score for both
performance and satisfaction were 5; both increased to
8 post-interventions. Furthermore, for the “be able tocook” task, both performance and satisfaction scores
increased from 2 to 7 points.
The patient was able to safely cook without supervision, and she began cooking for her husband. Moreover, she began doing her own laundry and resumed herrole and activities in her home.

Summary and Conclusions
Appropriate selection of utensils and improvisationof cooking techniques compensated for the reduced
movement ability and enabled the patient to practice at
an appropriate difficulty level. We believe this led to theacquisition of cooking skills using the non-dominant
hand.

Conflicts of interest
None declared.

Acknowledgment

Discussion

The authors thank the patient who participated inthis study.

COPM, a patient-centered scale, has been used todetermine the effectiveness of various interventions [6, 7].

Table 2 Changes in Canadian Occupational Performance Measure before and after intervention
Occupational Performance Problem
Be able to cook
Be able to take in and fold laundry
Be able to go out for walks
Average Score

BeforeAfter

Importance

Performance

Satisfaction

Performance

Satisfaction

5
6
3

2
4
9

2
4
9

7
7
10

7
7
10

5

5

8

8

Asian J Occup Ther 19: 256−259, 2023

References[1] Hartman-Maeir A, Soroker N, Ring H, Avni N, Katz N.
Activities, participation and satisfaction one-year post
stroke. Disabil Rehabil. 2007; 29(7): 559–66.
[2] Hendricks HT, van Limbeek J, Geurts AC, Zwarts MJ.
Motor recovery after stroke: a systematic review of theliterature. Arch Phys Med Rehabil. 2002; 83(11): 1629–
37.
[3] Philip BA, Frey SH. Increased functional connectivity
between cortical hand areas and praxis network associated with training-related improvements in non-dominant
hand precision drawing. Neuropsychologia. 2016; 87:
157–68.
[4] Law M, Baptiste S, McColl M, Opzoomer A, Polatajko
H, Pollock N. The Canadian occupational performancemeasure: an outcome measure for occupational therapy.
Can J Occup Ther. 1990; 57(2): 82–7.
[5] Waddell KJ, Birkenmeier RL, Bland MD, Lang CE. An
exploratory analysis of the self-reported goals of individuals with chronic upper-extremity paresis following
stroke. Disabil Rehabil. 2016; 38(9): 853–7.

Ito K et al.

259[6] Eng JJ, Chu KS, Kim CM, Dawson AS, Carswell A,
Hepburn KE. A community-based group exercise program for persons with chronic stroke. Med Sci Sports
Exerc. 2003; 35(8): 1271–8.
[7] Simpson LA, Eng JJ, Chan M. H-GRASP: the feasibilityof an upper limb home exercise program monitored byphone for individuals post stroke. Disabil Rehabil. 2017;
39(9): 874–82.
[8] Law M, Polatajko H, Pollock N, McColl MA, Carswell
A, Baptiste S. Pilot testing of the Canadian Occupational
Performance Measure: clinical and measurement issues.
Can J Occup Ther. 1994; 61(4): 191–7.
[9] Christiansen L, Madsen MJ, Bojsen-Møller E, Thomas
R, Nielsen JB, Lundbye-Jensen J. Progressive practicepromotes motor learning and repeated transient increases
in corticospinal excitability across multiple days. Brain
Stimul. 2018; 11(2): 346–57.
[10] Bootsma JM, Caljouw SR, Veldman MP, Maurits NM,
Rothwell JC, Hortobágyi T. Failure to engage neuralplasticity through practice of a high-difficulty task isaccompanied by reduced motor skill retention in older
adults. Neuroscience. 2020; 451: 22–35.