■ORIGINAL ARTICLE

Changes in Health-Related Quality of Life After Driving
Cessation in Older Adults
Koki Kishimoto1, Shinichi Noto2
1
2

Master’s Program in Rehabilitation Sciences, Graduate School of Niigata University of Health and Welfare, Niigata, Japan
Major in Rehabilitation Sciences, Graduate School of Niigata University of Health and Welfare, Niigata, Japan

Abstract: Purpose: This study aimed to examine the effects of driving cessation on the health-related quality of life
(HRQOL) of older adults who do not have a driver’s license.
Method: A cross-sectional study using a web-based questionnaire was conducted. Participants were 1,200 individuals aged 65 years or older who did not have a driver’s license in Japan. Participants answered questions about their
HRQOL (HUI3 and SF-8) and driving cessation using a self-administered questionnaire. Those who had surrendered
their driver’s license were also asked about their HRQOL before driving cessation.
Results: The HRQOL scores of the drivers who ceased driving were significantly lower than those of non-drivers. The
HRQOL scores of the drivers who ceased driving were also significantly decreased—from -.816 to -.728 (< .001) for
the HUI3 and from 51.5 to 49.5 (< .001) for the physical component summary of the SF-8—when comparing scores
before and after driving cessation. The results of our multiple regression analysis showed that the number of years since
driving cessation and incidence of major illness also affected HRQOL.
Conclusion: There is a clear relationship between driving cessation and a decrease in HRQOL. This confirms the necessity of implementing measures in the future to address this issue, such as securing means of transportation for older
people who have ceased driving.
Keywords: driving cessation, health-related quality of life, older adults(Asian J Occup Ther 18: 1−8, 2022)

Introduction
In recent years, the number of older drivers has
been increasing in Japan: the number of driver’s license
holders aged 70 years or older has increased to 11.95
million in 2019, accounting for 14.5% of all driver’s
license holders. [1]As a result, accidents caused by older drivers, suchas those caused by driving in the wrong direction or
mistakenly stepping on the gas pedal and brake, havebecome a social problem. While the number of fatal
accidents per 100,000 licensed population under the ageof 75 is 3.1, the number is more than double that—6.9
per 100,000—for those over 75 years old. [2] FurtherReceived: 4 November 2021, Accepted: 30 November 2021
Corresponding to: Shinichi Noto, Major in Rehabilitation Sciences,
Graduate School of Niigata University of Health and Welfare,1398
Shimami, Niigata, 950-3198 Japane-mail: noto@nuhw.ac.jp©2022 Japanese Association of Occupational Therapists

more, nearly 50% of those who had undergone cognitive
function tests prior to the accident were judged to have“possible dementia” or “possible cognitive decline.” In2017, the Road Traffic Laws were amended to make itcompulsory for drivers aged 75 and above to take anolder adult’s driving course and cognitive function testwhen renewing their license every three years. [3]The number of people who voluntarily surrendertheir driver’s license is increasing, as the trend of encouraging older adults, as well as their families, to do so
spreads. In 2012, 81,711 people surrendered their licenses; this number increased to 200,000 in 2015, 358,740
in 2019, and 510,9188 in 2020. [1].
Recent studies on driving cessation among older
adults find that driving cessation is accompanied by substantial declines in physical and social function, physicalperformance, and physical role. Edwards et al. followed
the lives of community-dwelling older adults for five
years and report a rapid decline in health-related qualityof life (HRQOL) with driving cessation. [4] Edwards etal. also report that driving cessation increased mortality

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DRIVING CESSATION IN OLDER ADULTS

by up to four to six times after three years. [5] There
are also existing reports of a significant increase indepressive symptoms after driving cessation and results
showing that not driving increases the risk of futurenursing home placement. [6, 7] Furthermore, a study inJapan reports that driving cessation is associated with anincreased risk of functional limitations in older adults;
however, the study states that this risk of functional limitations may be reduced if independent mobility can be
maintained using public transportation or bicycles after
driving cessation. [8]To date, no study has examined the impact of driving cessation on the HRQOL of older adults in Japan.
In addition, if HRQOL is decreased by the surrenderingof a driver’s license, it is necessary to clarify the factorsthat contribute to this decrease. Therefore, this study examines the changes in HRQOL related to the surrenderof a driver’s license and examine how much the driving
cessation affects the body and mind.

value indicating a higher HRQOL. [10] The HUI3 isa generic, multi-attribute, preference-based system forassessing HRQOL. [11] The system defines 972,000
unique health statuses, as it focuses on eight attributes(vision, hearing, speech, ambulation, dexterity, emotion,
cognition, and pain or discomfort), with each stratified
into five to six functional levels. The global score shows
health utility, with 0 indicating death and 1 indicating
perfect health. The scoring function developed by Notoet al. was used to calculate the global HUI3 score. [12]Those who had ceased to drive were asked thefollowing questions: 1) How long ago they surrendered
their driver’s license, 2) Who made the decision tosurrender their driver’s license, 3) Whether they had any
illness or injury that interfered with their life after surrendering their driver’s license, 4) The purpose of theircar, 5) The problems they faced when they surrendered
their driver’s license, and 6) What services they received
after surrendering their driver’s license.

Methods

Statistical Analysis and Ethical Procedures
The HRQOL of those who surrendered theirdriver’s license and those who did not drive were compared; further, for those who surrendered their license,
their HRQOL scores before and after surrender werecompared using a paired t-test. A multiple regression
analysis was conducted using the HRQOL scores afterdriver’s license surrender as the objective variable.
The explanatory variables used were age, gender, economic status, distance from home to the transportation
facility normally used, and whether or not the license
was surrendered. In addition, the difference in HRQOL
before and after the surrender of the driver’s license
was determined, and with that as the objective variable,
related factors were examined by multiple regression
analysis. The significance level was set at 0.05. Statistical analyses were performed using STATA 16.0 software. This study was approved by the Ethics Committeeof the Niigata University of Health and Welfare (No.
18549–201221). Written informed consent was obtained
from all participants who took part in the study.

Study Design and Participants
We conducted a cross-sectional study using a webbased questionnaire. The survey was conducted by
Rakuten Insight, Inc. in December 2020. The numberof participants was set at 1,200 and the ratio of male tofemale participants was set at 1:1. Participants who did
not have a driver's license were recruited from a panelof one account per person pre-registered on Rakuten
Insight, Inc. For each question, the respondents wereasked to answer in a selective manner, except for somefree descriptions. To eliminate differences between themetropolitan and rural areas, the number of questionnaires collected in Tokyo and Osaka was limited to
200 per city, and the same upper limit was set for eachprefecture.
Questionnaires
Participants answered questions related to their
HRQOL and driving status in a self-administeredquestionnaire. Those who had ceased driving were retrospectively asked about their HRQOL before they surrendered their driver’s license. Respondents’ HRQOL wasmeasured using the Short Form-8 survey (SF-8) and the
Health Utilities Index – Mark 3 (HUI3). The SF-8 is anabridged version of the Short Form-36 survey that measures HRQOL. [9] The SF-8 contains eight items thatare separated into two components; physical health (domains: physical functioning, role physical, bodily pain,
and general health) and mental health (domains: vitality,
social functioning, role emotional, and mental health).
Each subscale used norm-based scoring, with a higher

Results
Participant Characteristics
Table 1 shows the results in terms of the entire
sample, those who did not drive, and those who hadceased driving. The mean age of the total sample was
72.3 (±5.3) years, 71.2 (±5.1) years for those who never
had a driver’s license, and 73.9 (±5.3) years for those
who had ceased driving. Our comparison of the twogroups showed differences in education, income permonth, and family structure. There was no difference inAsian J Occup Ther 18: 1−8, 2022

Kishimoto K et al.

3

Table 1. Socio-demographic characteristics of respondents
Total sample(n=1200)
Variable

Non-drivers(n=733)Ceased drivers(n=467)

Mean

SD

Mean

SD

Mean

SD

p value

Age

72.3

5.3

71.2

5.1

73.9

5.3

<0.001

SexMale

600

287

313

Female

600

446

154

Education<0.001
0.002

Junior High

45

27

18

High

484

320

164

Junior College

197

130

67

University

421

230

191

Graduate

53

26

27

<100,000

363

255

108

100,000-200,000

444

268

176

200,000-300,000

248

138

110

> 300,000

145

72

73

Monthly income (JPY)<0.001

Household status

0.001

Single household

289

170

119

Couple only

600

343

257

Two households

267

191

76

Three households

44

29

15

Distance from public transportation

0.564< 5 minutes
5-10 minutes

420

255

165

10-15 minutes

424

265

159

15-20 minutes

214

121

93

>20 minutes

70

45

25

72

47

25

SD: Standard Deviation

terms of distance from public transportation.
HRQOL Scores
Table 2 shows the global HUI3 and SF-8 scores.
The overall HUI3 score was .777 (±.205) for non-drivers and .728 (±.235) for those who ceased driving,showing a significant difference (p < .001). In terms of
the SF-8, there was a difference in physical functioning,role physical, and physical component summary (PCS)
between the two groups. Table 3 shows a comparisonof the results of those who ceased driving before andafter surrendering their licenses; there was a significant
decrease in the global HUI3 score and in all SF-8 subscores.
Responses regarding driving cessation
A variety of responses were obtained to the ques-

tions posed to those who ceased driving. The mostcommon illnesses and injuries that occurred after driving
cessation were cancer, fracture, heart failure, and stroke.
The most common uses of the car were commuting anddaily life. The most common problems after surrendering the license were work, distance to the station, andidentification. As for the services they received, theyanswered that they received discounts for transportationand shopping.
Regression Analysis
Table 4 shows the results of the multiple regression
analysis with the global HUI3 score and the SF-8 scoreas the objective variables. Considering the global HUI3
score and the PCS component of the SF-8, in addition
to driving cessation, low income per month and distancefrom public transportation had a negative impact on

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DRIVING CESSATION IN OLDER ADULTS

Table 2. Summary statistics of HRQOL scores
Total(n=1200)

Non-drivers(n=733)Ceased drivers(n=467)

Mean

SD

Mean

SD

Mean

SD

p value

HUI3

0.758

0.219

0.777

0.205

0.728

0.235

<0.001

PF

51.6

5

52

4.7

50.9

5.5

<0.001

RP

52.1

5.5

52.5

5

51.3

6.1

<0.001

BP

50.9

7.5

51.1

7.4

50.7

7.5

0.382

GH

53.1

6.7

53.3

6.6

52.8

6.9

0.162

VT

52.4

5.5

52.5

5.4

52.2

5.6

0.292

SF

51.9

6.3

52.1

6.1

51.6

6.5

0.138

RE

52.2

5.3

52.3

5.4

52.2

5.2

0.695

MH

52.7

5.4

52.6

5.5

52.9

5.4

0.265

PCS

50.3

5.9

50.8

5.7

49.5

6.2

<0.001

MCS

51.9

5.5

51.7

5.6

52.2

5.4

0.18

Table 3. Comparison of HRQOL scores before and after driving cessation
Before

After

Mean

SD

Mean

SD

p value

HUI3

0.816

0.202

0.728

0.235

<0.001

PF

52.1

4.7

50.9

5.5

<0.001

RP

52.3

5.7

51.3

6.1

<0.001

BP

53.9

6.5

50.7

7.5

<0.001

GH

55.1

6.5

52.8

6.9

<0.001

VT

53.9

4.8

52.2

5.6

<0.001

SF

53.1

4.9

51.6

6.5

<0.001

RE

53.1

4.7

52.2

5.2

<0.001

MH

54.4

4.4

52.9

5.4

<0.001

PCS

51.5

5.4

49.5

6.2

<0.001

MCS

53.1

4.4

52.7

5.4

<0.001

HRQOL. Moreover, in terms of the mental component
summary (MCS) of the SF-8, driving cessation had no
significant effect. Table 5 shows the results of our multiple regression analysis, with the difference between
the global HUI3 score and the PCS and MCS scores of
SF-8 before and after driving cessation as the objective
variables. The global HUI3 score and the PCS component of the SF-8 were affected by driving cessation andincidence of illness, while the MCS component of theSF-8 was affected only by incidence of illness.

Discussion
This study used an online questionnaire survey todetermine whether driving cessation is a factor in the
decline of HRQOL among older adults. Of the 1,200

respondents, 467 ceased driving; we believe that wewere able to collect a large enough sample to withstandstatistical processing.
HRQOL ScoresFirst, we compared the HRQOL results —according to the HUI3 and SF-8 measures—of all respondents
with the national norm. According to Shiroiwa et al.,the average HRQOL scores for males and females intheir 70s was .807 and .818, respectively; our results
were lower than these values. [13] A possible reason forthis difference is that Shiroiwa et al. used a face-to-facesurvey, while our study used a web-based survey. They
also reported that the ePRO survey showed lower scoresthan the paper-based survey, which may be related tosame factors. [14] However, it has been reported that

Asian J Occup Ther 18: 1−8, 2022

Table 4

Kishimoto K et al.

5

Relation between HRQOL scores, characteristics and driving cessation
Variable

Coefficient

p value

95%Cl

Sex

0.063

<0.0010.036 to 0.090

Age–0.0040.001–0.006 to –0.002

Driving Cessation–0.0340.011–0.060 to –0.008<100,000–0.120<0.001–0.163 to –0.076

100,000-200,000–0.093<0.001–0.133 to –0.053

200,000-300,000–0.0430.052–0.087 to 0.000
0.042 to 0.148

HUI3

1 month incomeDistance

> 300,000

reference< 5 minutes

0.095<0.001

5-10 minutes

0.061

0.025

0.008 to 0.114

10-15 minutes

0.070

0.016

0.013 to 0.126

15-20 minutes

0.031

0.384

–0.039 to 0.101>20 minutes

reference

PCS
Sex

1.125

0.003

0.382 to 1.868

Age–0.1110.001–0.176 to –0.047

Driving Cessation–0.8320.024–1.553 to –0.110<100,000–1.5980.009–2.793 to –0.404

100,000-200,000–1.3030.021–2.407 to –0.199

200,000-300,000–0.6890.261–1.891 to 0.513

1 month incomeDistance

> 300,000

reference< 5 minutes

2.433

0.001

0.972 to 3.893

5-10 minutes

1.992

0.007

0.534 to 3.451

10-15 minutes

1.934

0.015

0.373 to 3.494

15-20 minutes

1.800

0.066

–0.121 to 3.720>20 minutes

reference

Sex–0.1350.702–0.829 to 0.558

Age

0.032

0.298

–0.028 to 0.092

MCS

Driving Cessation

0.093

0.787

–0.581 to 0.766<100,000–2.137<0.001–3.252 to –1.022

100,000-200,000–1.0570.044–2.087 to –0.027

200,000-300,000–0.2220.698–1.344 to 0.900

0.249–0.562 to 2.165

1 month incomeDistance> 300,000

reference< 5 minutes

0.801

5-10 minutes

0.704

0.311

–0.657 to 2.065

10-15 minutes

0.234

0.753

–1.223 to 1.690

15-20 minutes

0.393

0.667

–1.399 to 2.186>20 minutes

reference

Adjusted R2: 0.071 for HUI3, 0.039 for PCS, 0.028 for MCS. CI: confidence interval.

there was no significant difference between the ePRO
and paper-based surveys in other countries [15, 16];
therefore, the influence of Japanese characteristics needs
to be further examined. As for the SF-8 scores, the re-sults were higher than the adjusted thresh-old of 50 for
general health, and the difference in HRQOL indicatedby the HUI3 became apparent. This may be because
HRQOL is calculated by HUI3, a preference-based in-

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DRIVING CESSATION IN OLDER ADULTS

Table 5. Relation between HRQOL scores and issues related driving cessation
Variable

Coefficient

p value

95%Cl

HUI3
Sex

–0.0340.049–0.067 to 0.000

Age–0.0030.075–0.006 to 0.000

Years of Driving Cessation–0.005<0.001–0.007 to 0.003

Decided by myself

0.007

0.860

–0.073 to 0.087

Major illness–0.0560.007–0.096 to –0.015

Trouble–0.0170.347–0.019 to 0.053

Receive service–0.0050.771–0.030 to 0.041

Sex

0.372

0.478

–0.659 to 1.403

PCS
Age

–0.0450.336–0.138 to 0.047

Years of Driving Cessation–0.177<0.001–0.242 to 0.112

Decided by myself–0.3550.777–2.818 to 2.108

Major illness–1.7560.006–3.004 to –0.507

Trouble–0.9090.108–2.019 to 0.201

Receive service–0.1870.739–0.912 to 1.286

Sex–1.0790.014–1.943 to 0.215

MCS
Age

–0.0650.100–0.143 to 0.013

Years of Driving Cessation–0.0050.847–0.049 to 0.060

Decided by myself–0.3320.752–2.396 to 1.733

Major illness–1.6760.002–2.723 to –0.630

Trouble–0.1960.678–1.127 to 0.734

Receive service

0.615

0.190

–0.306 to 1.536

Adjusted R2: 0.090 for HUI3, 0.103 for PCS, 0.042 for MCS. CI: confidence interval.

dex-type measure, which is more likely to show changes
than SF-8, which is a profile-type measure.
Comparison of HRQOL between Non-drivers andCeased Drivers
In the comparison of HRQOL between non-drivers
and those who ceased driving, the physical functioning,role physical, and PCS of the HUI-global score andSF-8 were lower for those who ceased driving.
Furthermore, our multiple regression analysis
showed that the factor of never driving or ceasing todrive was significantly associated with a decrease in
HRQOL, confirming the results of Edwards et al., whoreported that health deteriorated after driving cessation.
[4] The results of our multiple regression analysis
showed that the distance from the nearest public
transportation was significantly related to a decrease in
HRQOL, which we found meaningful. It is known thatdriving cessation decreases the level of activity outside
the home. [17,18] A study by Hirai et al. suggests thatolder adults may be at increased risk of functional

limitations if they cease driving, but that this risk may
be reduced to some extent if they are able to maintainindependent mobility by using public transportation orby bicycling. [8] Furthermore, it has been reported thatpeople are more likely to be homebound if the distanceto the closest retail store is farther. [19] We believe thatthe distance of public transportation from home is an
important factor of reduced HRQOL, for both non-drivers and for those who have ceased driving.
Comparison of HRQOL Before and After Driving
Cessation
Significant differences in HRQOL before and after
the driving cessation were found for two items: time
passed since driving cessation and whether the person
experienced any major illness or injury after cessation.
Although it is not clear whether the factors affecting
these items were due to driving cessation or to illness
after the cessation, it is worth noting that these results
are similar to those of Edwards et al. [4]In present study, people who stopped driving wereAsian J Occup Ther 18: 1−8, 2022

Kishimoto K et al.

7

asked to recall the time before they stopped driving andto fill in their HRQOL at that time. It is known, however,that a response shift often occurs in an HRQOL survey
over time [20,21]; therefore, we cannot deny that there
was an effect of this factor. Thus, it should be noted thata cross-sectional study such as ours cannot clarify thiscausal relationship, and we believe that future prospective studies are needed.
Currently, older people in Japan are more positive about the cessation of driving than ever before.
However, older adults are able to maintain independent
mobility and meet their daily needs by driving, using
public transportation, and bicycles. Therefore, we positthat older adults who have ceased driving should be
supported by introducing alternative transportation thatis convenient and safe to use. For the questionnaire item
asking whether they received any service after surrendertheir license, 349 out of 467 respondents answered thatthey did not receive any alternative transport services.
We were unable to determine whether the services are
not available, or whether they know about the services
but do not make use of them; regardless, we believe that
ensuring a full range of transportation for older adults
who have ceased driving is important for reducing thesubsequent decline in their HRQOL.

returning their driver’s license, 334 out of 467 respondents answered that they did not have any problems,suggesting that the reason for returning their driver’s
license may have been that some may no longer haveneeded a car. A follow-up study is necessary to examine
the details of the reasons for driving cessation and toclarify the relationship with HRQOL.

Relationship between occupational therapy and driving
cessation
Driving is not only a means of transportation, butalso a way to enjoy driving itself and to directly connect
driving with leisure and other activities that are meaningful to the person. Therefore, the loss of driving has
the potential to lead to the loss of meaningful occupation
itself. Occupational therapy should be actively involvedin the development of safe driving techniques and theprovision of alternative transportation in the community.

The authors have no conflicts of interest relevant tothis article.

Limitations
Despite its clear contributions, there are certain
limitations to this study. We used an online survey platform and asked people aged 65 and above to complete
the web-based questionnaire; therefore, we cannot
discount the possibility that there was a selection bias ofolder adults who are accustomed to using the Internet.
In addition, we set a maximum value for the number of
respondents recruited who are living in urban areas, tothereby reduce bias by region; however, as it was only
set for each prefecture, we could not strictly distinguishbetween urban and rural areas. As the effects of driving
cessation in urban and rural areas are expected to be
decisively different, it was thought important to set
the sample with this point in mind in the future. Furthermore, when asked if they had any problems after

Conclusion
This cross-sectional study using a web-based questionnaire among older adults aged 65 years or older who
did not hold a driver’s license showed that those whoceased driving had lower HRQOL than those who did
not drive. In addition, among older adults who surrendered their driver’s licenses, HRQOL was significantly
lower after driving cessation than before; moreover, thisfactor was affected by the number of years since driving
cessation and incidence of major illness. Although thecausal relationship between driving cessation and illness
could not be clarified, the results suggest that measures
such as securing transportation for older adults who
have ceased driving are necessary.

Conflicts of Interest Statement

Acknowledgements
We would like to thank Honyaku Center Inc. forEnglish language editing.

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Outcomes in Patients with Non-Small Cell Lung Cancer.
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55(6): S334 – S340.
[18] Shimada H, Makizako H, Tsutsumimoto K, Hotta R,
Nakakubo S, Doi T. Driving and Incidence of Functional Limitation in Older People: A Prospective Population-Based Study. Gerontology. 2016; 62(6): 636-643.
[19] Hirai H, Kondo N, Sasaki R, Iwamuro S, Masuno K,
Ohtsuka R, Miura H, Sakata K. Distance to retail storesand risk of being homebound among older adults in a city
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[20] Schmalz G, Garbade J, Kollmar O, Ziebolz D. Does oral
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Outcomes Among Cancer Patients: A Systematic Review.
Front Oncol. 2019; 9: 783.

■ORIGINAL ARTICLE

Factors Predicting the Use of Paralyzed Upper Limbs
in the Daily Life of Patients with Acute Stroke
Masato Ikegami1, 2, Hitoshi Mutai1, Yoshie Yuzawa2, Nobuko Sakai2
1
2

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

Abstract
Background and Purpose: In patients with stroke, predictors of the use of paralyzed upper limbs in each activity ofdaily life, including eating and toileting, are not clear. Therefore, we aimed to identify factors that predict the use ofparalyzed upper limbs in specific activities of daily life in patients with acute stroke.
Method: This prospective observational study enrolled 155 patients with acute stroke. We used the paralytic arm participation measure (PPM) to evaluate the use of the paralyzed upper limb in daily life. Eating and toileting were assessedat admission and discharge. Factors that predicted the use of the paralyzed upper limb at discharge were analyzed bybinomial logistic regression analysis.
Results: The predictors of the use of paralyzed upper limbs for eating at discharge were age [odds ratio (OR)=0.93,
p=.011], paralysis of the dominant hand (OR=3.75, p=.044), and motor function of the paralyzed upper limb (OR=2.16,
p<.001). For toileting, the predictors were motor function of the paralyzed upper limb (OR=1.75, p<.001), sensory
function of the paralyzed upper limb (OR=1.66, p=.004), and muscle strength of the quadriceps on the non-paralyzed
side (OR=3.65, p=.005).
Conclusion: These identified predictors may provide clues to interventions promoting the use of paralyzed upper limbs
in the daily life of hospitalized patients with acute stroke. Observation and evaluation of each activity by an occupational therapist using the PPM is potentially useful in encouraging patients to consciously use the paralyzed upper limbs indaily life.
Keywords: activities of daily living; acute phase; predictor; stroke; use of paralyzed upper limb

(Asian J Occup Ther 18: 9−16, 2022)

1. Introduction
Upper limb sensorimotor dysfunction due to stroke
sequelae adversely affects the performance of activities
of daily living (ADLs) in patients [1]. Improving upper
limb dysfunction in patients with stroke and enabling
the use of paralyzed upper limbs in ADL are importantroles of occupational therapists [2]. When consideringinterventions promoting the use of paralyzed upper
limbs, it is important to investigate factors associatedwith the use of the paralyzed upper limb in ADL first.
Received: 12 January 2021, Accepted: 16 November 2021
Corresponding to: Hitoshi Mutai, Department of Health Sciences,
Graduate School of Medicine, Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japane-mail: hitmutai@shinshu-u.ac.jp©2022 Japanese Association of Occupational Therapists

In previous studies on patients with acute stroke, theparalyzed upper limbs were significantly less-usedcompared to the non-paralyzed upper limbs [3, 4]. The
factors determining the use of the paralyzed upper limbs
are reportedly the following: age [5], severity of upper
limb motor paralysis [4, 6, 7], muscle strength [3, 5],motor functional independence measure (FIM) [3, 4],
and various upper limb function tests [3]. However, theabove studies investigated factors related to the total
movement of the paralyzed upper limbs in daily life,
not those related to each specific activity, such as eating
and toileting. We hypothesized that the factors related
to each ADL activity would be different because of thedifferent movements and tools involved in each ADL
activity. To help occupational therapists design interventions that can improve the usage of the paralyzed
upper limbs in functions of ADL, investigating the useof the paralyzed upper limb for each ADL is necessary.

10

USE OF PARALYZED UPPER LIMB IN STROKE PATIENTSIn addition, the acute phase is the period when paralysisof the upper limb improves the most [8]; thus, patientsshould be actively encouraged to use the paralyzed limb
in this period. It is also necessary to investigate thestatus of use of the paralyzed upper limb in the acutephase to examine the method of intervention that will beappropriate for this period. Furthermore, eating and toileting are among the basic ADLs and are of the highest
priority for intervention in the acute phase, based on ourclinical experience.
Therefore, this study aimed to clarify the useof paralyzed upper limbs in actual activities of dailyliving, such as eating and toileting, and to identify thepredictors of the use of paralyzed upper limbs in theabove-stated activities at the time of discharge.

2. Materials and Methods
Design and settingThis prospective observational study was conducted in a regional core general hospital. The STROBE
guidelines for observational studies were followed [9].
Patients with stroke were admitted to the hospital andreceived acute medical care. After the doctor’s examination, rehabilitation along with full-risk management
and control was provided to patients from the day ofadmission or the next day. In occupational therapy, earlyintervention is required to achieve functional recovery of
the affected upper limb and to improve the performanceof ADLs. At our institution, the patients underwent rehabilitation for 20 or 40 minutes a day, 7 days a week, fortotal of approximately 240 minutes. Upper limb function
training included the following exercises, which were
performed alone or in combination: instrument manipulation training, neuromuscular facilitation training, andtherapeutic electrical stimulation.
Participants
Patients ≥20 years old, who were diagnosed withstroke, and admitted to the hospital between October
2018 and October 2019 were enrolled in this study. A
diagnosis of stroke was confirmed by a physician basedon clinical symptoms and findings on computed tomography, magnetic resonance imaging, and other diagnostic
imaging techniques. The exclusion criteria of this study
were (1) patients diagnosed with transient ischemic attacks; (2) patients with limited joint range of motion andmuscle weakness in the paralyzed upper limb before theonset of stroke. This information was obtained throughinterviews and from patients’ medical records at thetime of admission; (3) patients with a score of >100 in
the Japan Coma Scale (score of >100 in the Japan Coma
Scale indicates “unarousable by any forceful stimuli”);(4) patients who could not provide informed consent; (5)patients with recurrent stroke during hospitalization; and(6) patients with ataxia.
Clinical characteristics
The following patient characteristics were obtained
from their medical records: age, sex, length of hospitalstay, disease type, affected dominant hand, presence of
ADL support before stroke onset, Glasgow coma scalescore, National Institutes of Health Stroke Scale (NIHSS)
score, and FIM score at admission. We used FIM toevaluate the actual continuous performance of ADLs in
the ward. Additionally, the stroke impairment assessment set (SIAS) was used by occupational therapists
to comprehensively assess the severity of the stroke.
The SIAS is classified into the following nine types of
impairments [10]: motor function (upper limb: 0–10,
lower limb: 0–15), muscle tone (upper and lower limbs:
0–6 each), sensory function (upper and lower limbs:
0–6 each), range of motion (upper and lower limbs: 0–3
each), pain (0–3), trunk function (0–6), visuospatial
function (0–3), speech (0–3), and non-paralyzed limb
function (grip and muscle strengths of quadriceps: 0–3
each). A higher score indicates better function.
Assessment
The use of the paralyzed upper limb in daily life
was assessed using the paralytic arm participation measure (PPM). Normally, motor activity log (MAL), [11,12] and accelerometers [13, 14] are commonly used toevaluate paralyzed upper limb use. MAL is a self-assessment performed through interviews; thus, it is not very
suitable for assessing patients with cognitive dysfunction or aphasia. Accelerometers can assess the amount ofcontinuous activity, but they cannot be used to evaluate
the specific type of activity performed. In this study, weused the PPM to observe and evaluate the actual performance of a particular ADL. This assessment measure
was developed at Fujita Health University Nanakuri
Memorial Hospital, and its reliability and validity are
guaranteed [15, 16]. It consists of the following 15
items: dressing (8 items), toileting (2 items), shaping/cleaning (4 items), and eating (1 item). Each item wasassessed using a 4-point scale from 0 to 3 points. The
scoring criteria was as follows: 3 points, the paralyzed
upper limb can smoothly perform the desired movement;
2 points, movement can be performed till the end, but isawkward and takes longer; 1 point, the limb is partiallyused; 0 point, totally not used. The criteria were basedon the quality and extent of use of the paralyzed upper
limb [15, 16]. We investigated the patients’ eating andtoileting, which are high-priority activities in the acutephase. Eating was evaluated based on either holding aAsian J Occup Ther 18: 9−16, 2022

Ikegami M et al.

11

Table 1. Characteristics of the patients at admission
Characteristics

Total(n=155)Use(n=72)

EatingNo use(n=83)

P-value

Toileting (lowering pants)
Use
No useP-value(n=60)(n=95)

Toileting (pulling up pants)
Use
No useP-value(n=59)(n=96)

AgeMedian years
(IQR)

77
(67–84)73(63–79.25)

80(71–85)

0.001

71.5
(63.75–78.25)

79(70.5–85)

0.001

71
(63.5–78.5)

79(70.75–85)

0.001

Sex

Male/Female(%)

93(60)/
62(40)

47(65.3)/25(34.7)

46(55.4)/
37(44.6)

0.251

41(68.3)/
19(31.7)

52(54.7)/
43(45.3)

0.12940(67.8)/
19(32.2)

53(55.2)/
43(44.8)

0.132

Length of
hospital stayMedian days
(IQR)

23
(12–32.5)

12.5(9–21.5)

29(22–37.5)<0.001

11.5(8.75–17.25)

30(22–36.5)<0.00111(8.5–16.5)

29.5(22–36.25)<0.001

Disease type

Lacunarinfarction/other(%)

28(18.1)/
127(81.9)23(31.9)/49(68.1)

5(6)/78(94.0)<0.00126(43.3)/
34(56.7)2(2.1)/
93(97.9)<0.00126(44.1)/
33(55.9)2(2.1)/
94(97.9)<0.001Affected hand

Right/Left (%)

81(52.3)/
74(47.7)

41(56.9)/31(43.1)

40(48.2)/
43(51.8)

0.33434(56.7)/
26(43.3)

47(49.5)/48(50.5)

0.413

33(55.9)/26(44.1)

48(50)/
48(50)

0.511

Dominant hand

Right/Left (%)

151(97.4)/4(2.6)

69(95.8)/3(4.2)

82(98.8)/1(1.2)

0.338

57(95.0)/3(5.0)

94(98.9)/1(1.1)

0.299

56(94.9)/3(5.1)

95(99)/
1(1)

0.155

Paralysis of thedominant hand

Yes/No (%)

81(52.3)/
74(47.7)40(55.6)/32(44.4)

41(49.4)/
42(50.6)

0.52

33(55)/
27(45)

48(50.5)/
47(49.5)

0.623

32(54.2)/
27(45.8)

49(51)/
47(49)

0.742

Premorbid
dependence

Independence/
Dependence (%)

139(89.7)/
16(10.3)

69(95.8)/3(4.2)

70(84.3)/
13(15.7)

0.032

59(98.3)/
1(1.7)

80(84.2)/
15(15.8)

0.005

58(98.3)/
1(1.7)

81(84.4)/
15(15.6)

0.005

GCS

Median (IQR)

15(13–15)

15.00(14.75–15.00)

14(11–15)<0.00115(15–15)

14(11–15)<0.00115(15–15)

14(11–15)<0.001NIHSSMedian (IQR)

4(2–11)2(1–4)

9(4–16.5)<0.0012(1–3)

8(4–16)<0.0012(1–3)

8(4–16)<0.001

FIM

Median (IQR)

Motor

17(13–45)

45.50(25.50–49.00)

13(13–17)<0.00148(40–49)

13(13–16.5)<0.00148(41–49)

13(13–17)<0.001

Cognitive

18(7–29)

29(21–35)

7(5–17.5)<0.00129(25–35)

8(5–20.5)<0.00129(25–35)

8(5–20.25)<0.001

Toilet transfer

1(1–5)

5(1–5)

1(1–1)<0.0015(4–5)

1(1–1)<0.0015(4–5)

1(1–1)<0.001

Upper limb motor
function8(3–10)10(8–10)3(0–8)<0.00110(8–10)4(0.5–8)<0.00110(8–10)4(0.75–8)<0.001

Lower limb motor
function12(6–15)

15(12.75–15)

7(1–12)<0.00115(13–15)

9(2–14)<0.00115(13–15)

9(2–14)<0.001

Upper limb
sensory function

5(2–6)

6(5–6)

2(1–5)<0.0016(5–6)

2(1–5)<0.0016(5–6)

2(1–5)<0.001

Lower limb sensory function

5(2–6)

6(5–6)

3(1–6)<0.0016(5.75–6)

3(1–6)<0.0016(5.5–6)

3(1–6)<0.001

Trunk function

4(1–6)

6(5–6)

2(0–4.5)<0.0016(5–6)

2(0–5)<0.0016(5–6)

2(0–5)<0.001

Visuospatial
function3(1–3)

3(3–3)

1(1–3)<0.0013(3–3)

2(1–3)<0.0013(3–3)

2(1–3)<0.001

Muscle strength ofquadriceps on the
non-paralyzed side3(2–3)

3(3–3)

2(1–3)<0.0013(3–3)

3(1–3)<0.0013(3–3)

3(1–3)<0.001

Grip strength on
the non-paralyzedside

2(1–2.5)2(2–3)

1(1–2)<0.0012(2–3)

1(1–2)<0.0012(2–3)

1(1–2)<0.001SIAS

Median (IQR)

IQR, interquartile range; 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; Use, PPM 1-3 points; No use, PPM 0

12

USE OF PARALYZED UPPER LIMB IN STROKE PATIENTS

0

1

2

3

100%
90%
80%
70%
60%
50%

44(28)
85(55)
23(15)

20%

5(3)
11(7)
6(4)

83(54)

89(57)

11(7)95(61)

Admission

Discharge

Ea�ng

7(5)

3(2)

96(62)

55(36)

Admission

89(57)4(3)8(5)

53(34)

10%
0%

8(5)
6(4)

40%
30%

44(28)

46(30)

55(35)

Discharge

Lowering the pants
to the knees

4(3)Toile�ng

Admission

Discharge

Pulling the pants up
to the waist

Fig. 1. Number and percentage of patients with paralytic arm participation measure scores at admission and discharge for each item
3: the paralyzed upper limb can smoothly perform the desired movement, 2: movement can be performed throughout the entire
activity, but awkwardly or/and slowly, 1: the limb can perform part of an activity, 0: does not perform the activity at all Eating
was evaluated based on either holding a bowl or operating chopsticks or a spoon. Toileting was evaluated based on the following
two items: lowering the pants to the knees and pulling the pants up to the waist.

bowl or maneuvering chopsticks or a spoon. Toileting
was evaluated based on two items: lowering the pants to
the knees and pulling the pants up to the waist.
Statistical analysis
Normal distribution was assessed using the Shapiro-Wilk test, according to which, our data were notnormally distributed. Patients with mild-to-no motor
paralysis were considered as having an SIAS motor
function score of ≥8 points in the paralyzed upper limb.
The Wilcoxon signed-rank test was used to compare the
PPM score at admission with that at discharge. Regarding the use of the paralyzed upper limb, 1–3 points of
PPM was defined as “use” and 0 point as “no.” Binomial
logistic regression analysis was conducted to identify
predictors associated with the use of the paralyzed upper
limb at discharge. The explanatory variables common
for eating and toileting were: age, sex, premorbid dependence, paralysis of the dominant hand, stroke type(lacunar infarction/other), cognitive FIM at admission,
PPM at admission, and SIAS sub-items at admission(including motor function of the paralyzed upper limb,
sensory function of the paralyzed upper limb, trunk
function, and visuospatial function); variable uniqueto eating was: grip strength on the non-paretic side;and variables unique to toileting: toilet transfer FIM at
admission and muscle strength of the quadriceps on the
non-paretic side. Since motor function of the paralyzed
lower limb had a multicollinearity problem with motor
function of the paralyzed upper limb, we prioritized
the upper limb and used it for the analysis. However,
we also performed the analysis using motor function of
the paralyzed lower limb, since it is also an important
predictor.
For the extracted factors, a receiver-operating characteristic curve was drawn, and the cutoff value and area
under the curve were calculated.
P-values of <0.05 were considered statisticallysignificant. All statistical analyses were performed using
EZR ver. 1.37 software (Saitama, Japan) [17]．
EthicsThis study was conducted following the ethicalstandards of the Declaration of Helsinki and the ethicalguidelines for medical and health research involving
human subjects. This study was approved by the Ethics
Review Committee of our hospital (approval number:
2; approval date: 2018/9/19). All patients in this study
provided written informed consent.

Asian J Occup Ther 18: 9−16, 2022

Table 2.

Ikegami M et al.

13

Predictors associated with the use of the paralyzed upper limb at discharge and their cutoff values (n=155)

Explanatory variables

OR

95% CI

P-value

Cutoff value

AUC

Age (years)

0.93

0.89–0.99

0.011

80

0.682

Paralysis of the dominant hand

3.75

1.03–13.60

0.044

1

0.582

Motor function of the paralyzed upper limb

2.16

1.71–2.73<0.0015

0.949

Motor function of the paralyzed upper limb

1.75

1.36–2.25<0.0017

0.959

Sensory function of the paralyzed upper limb

1.66

1.17–2.37

0.004

4

0.915

Muscle strength of the quadriceps on the
non-paralyzed side

3.65

1.45–9.18

0.005

3

0.810

EatingToiletingOR, odds ratio; CI, confidence interval; AUC, area under the curve

3. Results
Altogether, 164 patients were enrolled in this study.
In the analysis, 155 patients were included, as four
patients who had recurrent stroke, three patients who
had ataxia, and two who died after providing informed
consent were excluded. The patients’ characteristics andthe median interquartile range values for Glasgow Coma
Scale, NIHSS, FIM, and SIAS are shown in Table 1.
The median PPM values for eating and toileting
improved significantly (p<.001) from 0 (interquartile
range: 0–3) at admission to 3 (interquartile range: 0–3)
at discharge. Figure 1 shows the number and percentageof patients with specific PPM scores at admission anddischarge. Nearly 60% of the patients were able to use
the paralyzed upper limb normally at discharge for each
item. The following was the distribution of patients with
mild-to-no motor paralysis who did not use the paralyzed upper limbs: eating, 8 (8%); lowering pants to theknees, 9 (9%); and pulling pants up to the waist, 9 (9%).
The predictors and cutoff values that predicted theuse of paralyzed upper limbs while eating and toiletingat discharge, as revealed by binomial logistic regression
analyses, are shown in Table 2. For eating, the independent predictors of the use of paralyzed upper limbs
at discharge were age, paralysis of the dominant hand,and motor function of the paralyzed upper limb. For
toileting, the results of logistic regression analyses forlowering the pants to the knees and pulling pants up to
the waist were the same because patients who used theparalyzed upper limbs at discharge were matched. The
independent predictors of the use of paralyzed upper
limbs at discharge were upper limb sensory function andquadriceps muscle strength on the non-paralyzed side.
The results obtained by substituting the motor functionof the paralyzed lower limb for the motor function of theparalyzed upper limb were as follows: motor function of
the paralyzed lower limb (odds ratio = 1.73, 95% confidence interval = 1.37–2.18, p<.001).

4. Discussion
Use of the paralyzed upper limb in patients with acutestrokeThe PPM scores for eating and toileting weresignificantly higher at discharge than that at admission,indicating an improvement in the use of the paralyzed
limbs. Additionally, the proportion of patients who
used the paralyzed upper limb normally in daily life
increased from nearly 30% at admission to nearly 60%
at discharge. Since improvement in upper limb functionin the acute phase is expected, upper limb function
training and ADL training are important. However, theproportion of patients who did not use the paralyzed
side upper limbs at discharge, despite mild to almost no
motor paralysis, was 8% and 9% for eating and toileting,respectively. In the future, it is necessary to explore interventions to encourage the use of these limbs in thesepatients.
Factors predicting the use of paralyzed upper limb indaily life
With regard to eating, the predictors of the use of
the paralyzed upper limbs at discharge were age, paralysis of the dominant hand, and motor function of the paralyzed upper limb. A previous study also reported thatolder age is a factor inhibiting the use of the paralyzed
upper limb at discharge in the acute stroke phase [5].
Additionally, elderly patients with stroke have poorer
functional recovery compared to younger patients [18].
The cutoff value for age obtained in this study was 80
years, suggesting that poor functional recovery due to14

USE OF PARALYZED UPPER LIMB IN STROKE PATIENTS

advanced age may further affect the use of the paralyzed
upper limbs. Patients >80 years old face difficulty recovering the ability to perform ADL during the acute phase;thus, long-term rehabilitation and changing hand dominance should be considered. With regard to paralysis of
the dominant hand, in a previous study, the paralyzed
upper limbs of the dominant and the non-dominant sides
were used almost equally in the daily life of patientswith stroke [19]. However, our study results were different. Eating is an activity that is strongly influenced
by the dominant hand. In Japanese eating etiquette, thedominant hand is used to hold spoons, chopsticks, andother devices, while the non-dominant hand holds thebowl. When the non-dominant hand is paralyzed, thefood can be eaten with only the dominant hand because
the bowl is fixed using a self-help bowl or a non-slip
mat. Therefore, it is possible that patients with paralysisof the non-dominant hand eventually stop using that
hand at all to eat, while patients with paralysis of thedominant hand try to use it to manipulate spoons andchopsticks. With regard to the paralyzed upper limb
function, several reports have shown that the paralyzed
upper limbs are not used by patients with severe motor
paralysis [4, 6, 7], which is similar to our results. In thisstudy, the cutoff value of the paralyzed upper limb function was 5 in all patients. The severity of motor paralysis
in the early stage is a predictive factor for recovery frommotor paralysis [20]. Patients with scores <5 points havepoor motor function recovery, which may affect the useof the paralyzed upper limbs. Meanwhile, the sensory
function of the fingers associated with fine manipulationof tableware was not extracted as a predictor of the useof the paralyzed upper limb for eating. It is possible thatthe sensory impairment of the upper limbs was compensated by the visual sense and the nature of the self-help
tableware.
As for toileting, predictors of the use of the paralyzed upper limbs at discharge were motor function of
the paralyzed upper limb at admission, motor functionof the paralyzed lower limb at admission, sensory
function of the upper limb, and muscle strength of thequadriceps on the non-paralyzed side. The severityof proprioceptive deficit of the paralyzed upper limb
inhibits the use of the paralyzed upper limb in daily life[21]. Sensory impairment of the upper limb is associatedwith difficulties in fine manipulation [22]. Upper limb
sensory impairment inhibits the use of the paralyzed
upper limb in toileting because the sensory function of
the fingers is required to lower and pull up the pants,
especially because the part of the pants that is behindand the part that is hidden by the shirt cannot be visuallyconfirmed. Regarding lower limb function, no studies
have examined the relationship between quadriceps

muscle strength on the non-paralyzed or paralyzed
lower limb and the use of the paralyzed upper limb
in toileting. When pulling up and lowering pants, it isnecessary to maintain a stable standing position to exert
the paralyzed upper limb function. Therefore, since thequadriceps muscle strength on the non-paralyzed sideand the degree of paralysis of the lower limb on the paralyzed side affect the maintenance of a stable standing
position, they were extracted as predictors in this study.
In the future, in order to promote the use of theparalyzed upper limb, it is necessary to examine occupational therapy approaches for the early stage of stroke
using the predictors revealed in this study. For eating,interventions, such as those that enhance the motor
function of the paralyzed upper limb and positive ADL
instructions for using the paralyzed upper limb when
the non-dominant hand is on the paralyzed side, are also
important. For toileting, interventions that improve thestability of the patient while standing are necessary. A
few effective interventions for sensory disorders havebeen reported [23, 24]; nonetheless, actively adopting
them is important.
Limitations
This study has several limitations. First, it was
conducted at a single institution and included only
patients who provided consent to participate. Therefore,
selection bias might have occurred. Our results should
be cautiously generalized and interpreted. Second, we
did not consider psychological factors, such as patients’motivation or attention, as predictors. Therefore, a study
with inclusion of psychological factors as assessment
variables is warranted. Third, since there are other activities involved in toileting such as handling toilet paper
and wiping the buttocks, it is necessary to investigate
the use of paralyzed upper limbs for these activities in
the future. Fourth, ADL activities such as cleaning anddressing are also important in the acute phase and areincluded in the PPM. However, implementing all PPM
items within the therapy duration was difficult. Studies
investigating the use of paralyzed upper limbs in the
future should include these activities. Finally, this study
was conducted in the acute phase. Long-term follow-up
of the use of paralyzed upper limb is required for patients who did not use the paralyzed upper limb in theacute phase.
In conclusion, the use of paralyzed upper limbs ineating and toileting in patients with acute stroke wassignificantly improved at discharge. Factors that predicted the use of the paralyzed upper limb while eating
and toileting at discharge were also identified. The
results of this study suggest that occupational therapy

Asian J Occup Ther 18: 9−16, 2022

promotes the use of paralyzed limbs while performing
these activities. The predictive factors at admission andtheir cutoff values obtained in this study can be used to
predict the use of the upper extremities on the paralyzed
side at discharge in real life, and can be used to formulate treatment strategies. Evaluations using PPM, which
is a movement-evaluation tool for real-life situations,can guide occupational therapists to encourage patients
to consciously use their paralyzed upper limbs during
activities of daily life. This may improve the frequency
and quality of the patients’ use of their paralyzed upper
limbs in daily life.

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

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

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■ORIGINAL ARTICLE

Community-based Peer Support Programs to Improve
Quality of Life for Cancer Survivors: A Systematic Review
Katsuma Ikeuchi1, Yuki Yasuda2, Ryuichi Saito3, Seiji Nishida1,
Yasushi Orita1, Chiaki Sakamoto1
1

Prefectural University of Hiroshima
Kaseikai Medical Corporation, Vingt-cinq Porte
3
Department of Rehabilitation, Saiseikai Toyoura Hospital2

Abstract: Introduction: Peer support programs are mainly studied by hospitals and medical professionals, and further
research is needed on their impact on quality of life (QOL). The purpose of this study was to investigate the type ofcommunity-based peer support program that is effective for improving the QOL of cancer survivors.
Method: A systematic review was performed using the following procedures: (1) randomized controlled trials aimed
at improving QOL were searched from PubMed and Igaku Chuo Zasshi, (2) papers that met the inclusion criteria wereselected, and (3) the papers were assessed for quality by using the revised Cochrane risk-of-bias tool for randomized
trials.
Results: Results showed that four studies met the eligibility criteria, and three of them showed statistically significant
improvements in QOL. The peers instructed in programs were breast cancer survivors who had been diagnosed one tothree years earlier. Furthermore, peers received special training for approximately eight hours per session for a total of
two to seven days before providing support to the participants.
Conclusion: Few programs have been fully applied in Japan. In terms of program effectiveness and risk of bias, programs that include obtaining support and managing activities that affect mood may be effective. Furthermore, the importance of taking enough time to help cancer survivors trust each other and provide support according to the patient’s
wishes and available community resources was demonstrated.
Keywords: cancer, community, peer support, quality of life, systematic review(Asian J Occup Ther 18: 17−23, 2022)

1. Introduction
In Japan, it is estimated that 1.52 million people
need cancer treatment [1], and the period of survival for
those affected by cancer has been increasing [2]. Baxter
et al. [3] reported that cancer treatments have beensaving lives. However, survivors were often left withresidual physical and psychosocial complications thatprevented them from fully engaging in their everyday
lives. These complications subsequently result in acompromised quality of life (QOL). Furthermore, thenumber of cancer patients who receive treatment or die
Received: 21 May 2021, Accepted: 10 November 2021
Corresponding to: Katsuma Ikeuchi, Prefectural University of Hiroshima, 1-1 Gakuen-cho, Mihara-city, Hiroshima-ken 723-0053, Japane-mail: ikeuchi@pu-hiroshima.ac.jp©2022 Japanese Association of Occupational Therapists

at home is expected to increase because of policies suchas the shortening of the admission period and promoting
home medical care [4].
Many cancer patients undergo chemotherapy, radiation therapy, and surgery; experience side effects andcomplications from these treatments; and often live inthe community with cancer recurrence, financial uncertainty, and pain. For the reasons mentioned above, it ispresumed that a cancer survivor may find it difficult toperform well in daily life after discharged from the hospital. Peer support is one of the most effective supports
in such cases. Peer support can be defined as the processof giving and receiving nonprofessional, nonclinicalassistance from individuals with similar conditions or
circumstances to achieve long-term recovery [5]. Furthermore, peer supporters often work with patients and/or healthcare providers to address system-level barriers,
such as fragmented care, financial constraints, other

18

COMMUNITY-BASED PEER SUPPORT PROGRAMS FOR CANCER SURVIVORS

practical challenges (e.g., transportation, employment
concerns, and childcare), and communication difficulties[6]. In Japan, there are two types of associations thatprovide peer support: hospitals and patient groups. In
some cases, hospitals commission patient groups toprovide peer support at the hospital [7]. Currently, theactual situations and effectiveness of peer support are
being examined by the Ministry of Health, Labor andWelfare in Japan [8]. We believe that it is important forcancer survivors living at home to be able to receive
peer support comfortably and securely in order to improve their QOL, whether the associations providing the
support is hospitals or patient associations.
Several studies on peer support programs for cancer
survivors have shown that such programs increase
participant satisfaction and improve psychological adjustment [9, 10]. In Japan, Ikeuchi et al. [11] conducteda systematic review of community-based occupational
therapy programs to improve the QOL of cancer
survivors and reported that it is important to provide
programs with peers who have the same disease. Furthermore, in the nursing field, the effect of peer support
has been explained using the direct effect model [12],that is, the following are reported to have positive impacts on health- related outcome measures: (a) decreasing isolation and feelings of loneliness, (b) deterring
maladaptive behavior or responses, (c) promoting
positive psychological states and individual motivation,and (d) providing information regarding access to medical services or the benefits of behavior that positively
influence health and well-being. On the other hand, peer
support also has aspects that can have adverse outcomes,
for example, criticism, reinforcement of poor behaviors,and diminished feelings of self- efficacy [12].
In terms of QOL, in general, randomized controlled
trials (RCTs) did not find significant effects of participation in peer support programs on QOL [9]. However,further research is needed because of the impact of
methodological issues such as a small sample size, lackof long-term follow-up, and limited outcome measures,
as well as social resource issues such as the relatively
high abundance of support (peer and professional) already available because the study participants only hadbreast cancer (BC). Furthermore, the study participants
were recruited primarily by hospitals and specialists. In
general, it is thought that cancer survivors have fewer
opportunities to contact peers in the community thanin hospitals admission; thus, we believe that further research is needed on the degree of peer support provided
in the community. In summary, peer support programs
are mainly studied by hospitals and medical professionals, and further research is needed on their impact on
QOL.

Therefore, it is necessary to examine the effects ofpeer support programs that aim to improve QOL in community settings. This study aimed to identify an effective
community-based peer support program to improve the
QOL of cancer survivors. This study has the potential
to promote mutually supportive relationships amongcancer survivors when they live in the community. To
investigate effective peer support programs, this study
focused on RCTs with a higher level of evidence.

2. Methods
2.1 Study Design
This study was a systematic review and was conducted by following the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA)
statement [13, 14].
2.2 Data Sources and Searching Strategies
PubMed and Igaku Chuo Zasshi [15] were the databases used in the current study. Igaku Chuo Zasshi contains bibliographic citations and abstracts from more than
2,500 biomedical journals and other serial publicationsin Japan. A hand search was also performed. The searchterms in English were ((community) OR (home)) AND(peer) AND (cancer) AND (quality of life), and thosein Japanese were ((tiiki) OR (zaitaku)) AND (pia) AND(gan) AND ((seimei-no-shitsu) OR (seikatsu-no-shitsu)).
The last date of the search was December 3, 2020, forboth Japanese and English.
2.3 Inclusion Criteria
The inclusion criteria were as follows: (1) the program was conducted in the community or at home, (2)the program participants were cancer survivors aged 18
years or older, (3) the program participants were not in
the terminal stage, (4) the program was conducted withpeers, (5) the program was peer- reviewed, (6) the study
design was an RCT, (7) the language was English or
Japanese, and (8) the full text was available for ordering.
2.4 Papers Extraction
Identification, screening, eligibility, and included were performed according to the PRISMA Flow
Diagram [14] for research inclusion (Figure 1). In thescreening stage, we excluded papers that clearly would
not meet inclusion criteria (1) to (8) on the basis of theirtitles and abstracts. Papers that could not be judged by
the title and abstract or in which the title and abstract
met the inclusion criteria were carefully reviewed after
a thorough reading of the full text at the eligibility stage.
After paper extraction was completed, an abstract table
was created for the studies included in the qualitativeNo. of records identified bydatabase searching (n = 120)
・PubMed (n = 119)・Igaku Chuo Zasshi (n = 1)

Ikeuchi K et al.

No. of additional records identified
via other sources (n = 4)

No. of records screened (n = 124)

No. of records excluded (n = 101)

Eligibility

No. of full-text articles assessed for eligibility (n = 23)

No. of studies included in the qualitative synthesis (n = 4)
Included19

No. of records after duplicates were removed (n = 124)

Screening

Identicication

Asian J Occup Ther 18: 17−23, 2022

No. of studies included in the quantitative synthesis (meta-analysis) (n = 0)

No. of full-text articles excluded, withreasons (n = 19):
・Research protocol papers (n = 2)
・No quality of life as an outcome (n = 2)
・Participants are inpatients (n = 1)
・Peers are not participating in (n = 1)
・Not RCTs (n = 13)

FigureFig.1．PRISMA
1. PRISMAFlow
FlowDiagram
Diagram
The processof
identifying
papersto adopting
themis shown.
The processof identifying
papersto adopting
themis shown.

synthesis (Table 1).
2.5 Evaluating the Quality of Papers
After the eligibility stage, two or more authors
assessed the quality of the included articles according to
the manual described in the Cochrane risk-of-bias toolfor RCTs (RoB 2.0) [16, 17] in the Cochrane Handbook.
Two of the authors had experience with systematic
reviews. There were five types of bias risk: bias arisingfrom the randomization process, bias due to deviations
from intended interventions, bias due to missing outcome data, bias in the measurement of the outcome, andbias in the selection of the reported result. To determine
the risk of bias, we had to check the manual and thenanswer two to six signaling questions corresponding toeach bias (Table 2). For example, when bias arises fromthe randomization process, we answered signaling questions such as “1.1 Was the allocation sequence random?”and “1.3 Were there baseline imbalances that suggest
a problem with the randomization process?.” Whenanswering signaling questions, respondents selected yes,probably yes, no, probably no, no information, and not
applicable. After answering these signaling questions,five types of bias risk could be classified as “low risk,”“some concerns,” and “high risk” (Table 3).

3. Results
3.1 Process of Adopting Papers (Figure 1)
After searching the database, 120 articles werelisted (119 articles in PubMed and 1 article in Igaku
Chuo Zasshi). We screened 124 papers, including 4
papers collected by hand searching. In the screening,
101 papers that clearly would not meet inclusion criteria(1) to (8) on the basis of their title and abstract were
excluded. Nineteen papers were excluded in terms ofeligibility. In other words, four papers [18–21] were
included. Nineteen papers were excluded for eligibility
because 2 papers were research protocol papers withunknown results, 2 papers did not have QOL as an
outcome measure, 1 paper had inpatients as participants,
1 paper had cancer survivors who did not participate
in programs with peers, and the other 13 papers were
not RCTs. There have been no studies on the process ofquantitative integration (meta-analysis).
3.2 A Review of Accepted Papers (Table 1)
Among the four articles that were accepted, allstudy participants were women with BC. Furthermore,
QOL was significantly improved in three of the papers[18, 20, 21]. The peers instructed in programs were BC
survivors who had been diagnosed one to three years
earlier, and some studies required peers to be free ofrecurrence for several years or more. Peers also received
special training of approximately eight hours per session
for a total of two to seven days before providing support
to the participants. The programs of the intervention
groups in the three papers that significantly improved
QOL are described below.
Nápoles et al. [18] evaluated a community-based,

20

COMMUNITY-BASED PEER SUPPORT PROGRAMS FOR CANCER SURVIVORS

Table 1. An abstract table for accepted papers
Information on the adopted papers (n = 4) are organized.
No.

First author,
Year(Country)

DesignCancer type
Number ofParticipants

Intervention contents(Number of Participants)

QOL outcomeswith significant
improvements

Main outcome measure

18

Nápoles, 2015
(USA)

RCT

BC
n = 151

Intervention: Nuevo Amanecer(n = 76)Control: Usual care (n = 75)

QOL: FACT-B, General distress
Emotional wellsymptoms: BSI, Breast cancer- spe- being of FACT-B
cific distress: a subscale of the IES-R

19

Nápoles, 2020
(USA)

RCT

BC
n = 153

Intervention: Nuevo Amanecer-Ⅱ QOL: FACT-B, General distress(n = 76)
symptoms: PHQ-8, PSS, BSI andControl: usual care (n = 77)
MOCS-A

None

20

Giese-Davis,
2016
(USA)

RCT

BC
n = 104

Intervention: peer‐counseling(n = 52)
Control: usual care (n = 52)

QOL: BSW and TOI in FACT-B,
Cancer ‐ related trauma symptoms:
PCL-C, Cancer self-efficacy: CBI,
Marital interaction: LWMAT,
Depression symptoms: CES-D, BC
resources: BCRQ

BSW in FACT-B

21

Toija AS, 2019
(Finland)RCTBCn = 260

Intervention: usual care and peer
support via telephone (n = 130)
Control: usual care (n = 130)

Generic state of health: 15D, QOL:EORTC QLQ-C30, EORTC-QLQBR23

Sexual function in
EORTC QLQ-C30
and EORTC-QLQBR23

RCT: Randomized Controlled Trial, BC: Breast Cancer, QOL: Quality of Life, FACT-B: Functional Assessment of Cancer Therapy- Breast, BSI:
Brief Symptom Inventory, IES-R: Impact of Event Scale-Revised, PHQ-8: eight-item Patient Health Questionnaire depression scale, PSS: thePerceived Stress Scale-10, BSI: Brief Symptom Inventory, MOCS-A: Measure of Current Status part A, BSW: Breast Cancer-Specific Well-being,
TOI: Trial Outcome Index, PCL-C: Posttraumatic stress disorder (PTSD) CheckList-Civilian, CBI: Cancer Behavior Inventory, LWMAT: The
Locke-Wallace Marital Adjustment Test, CES-D: Center for Epidemiologic Studies- Depression, BCRQ: Breast Cancer Resources Questionnaire,
15D: a generic, preference-based instrument for measuring health- related QoL, EORTC QLQ-C30: The European Organization for Research
and Treatment of Cancer Quality of Life Questionnaire Core 30, EORTC-QLQ-BR23: The European Organization for Research and Treatment ofCancer Quality of Life Questionnaire-Breast23
Table 2. Answering signaling questions
Answers to signaling questions are described.
Bias arising from theReference randomization process
number1.1
1.2
1.3

Bias due to deviations from
intended interventions

Bias due to missing
outcome data

Bias in measurement Bias in selection ofof the outcome
the reported result

2.1

2.2

2.3

2.4

2.5

2.6

3.1

3.2

3.3

4.1

4.2

5.1

5.2

18

Y

Y

N

PY

PY

PN

PN

N

NA

Y

NA

NA

Y

PY

N

N

19

Y

Y

N

PY

PY

PN

PY

N

NA

PY

NA

NA

Y

Y

N

N

20

NI

PY

N

PY

PY

PY

PY

N

PN

N

N

N

Y

Y

N

N

21

Y

Y

N

PY

PY

PN

PN

N

NA

Y

NI

NA

Y

Y

PN

PY

Y: Yes, PY: Probably yes, N: No, PN: Probably no, NI: No information, NA: Not applicable
Signaling questions are as follows:
1.1 Was the allocation sequence random?
1.2 Was the allocation sequence concealed until participants were recruited and assigned to interventions?
1.3 Were there baseline imbalances that suggest a problem with the randomization process?
2.1 Were participants aware of their assigned intervention during the trial?
2.2. Were carers and trial personnel aware of participants’ assigned intervention during the trial?
2.3 Were there deviations from the intended intervention beyond what would be expected in usual practice?
2.4 Were these deviations from intended intervention unbalanced between groups and likely to have affected the outcome?
2.5 Were any participants analysed in a group different from the one to which they were assigned?
2.6 Was there potential for a substantial impact (on the estimated effect of intervention) of analysing participants in the wrong group?
3.1 Were outcome data available for all, or nearly all, participants randomized?
3.2 Are the proportions of missing outcome data and reasons for missing outcome data similar across intervention groups?
3.3 Is there evidence that results were robust to the presence of missing outcome data?
4.1 Were outcome assessors aware of the intervention received by study participants?
4.2 Was the assessment of the outcome likely to be influenced by knowledge of intervention received?
5.1 Multiple outcome measurements (e.g. scales, definitions, time points) within the outcome domain?
5.2 Multiple analyses of the data?

Asian J Occup Ther 18: 17−23, 2022

Ikeuchi K et al.

21

Table 3 Rating quality of papers
Results of the assessment of the five types of bias risk; the five biases are answered with “low risk,” “some concerns,” and “high risk.”
Reference
numberBias arising from the Bias due to deviations fromrandomization processintended interventions

Bias due to missing
outcome data

Bias in measurement of
the outcome

Bias in selection of thereported result

18

Low risk

Low risk

Low risk

High risk

Low risk19

Low risk

Low risk

Low risk

High risk

Low risk20

Low risk

High risk

High risk

High risk

Low risk21

Low risk

Low risk

Low risk

High risk

High risk

translational stress management program called Nuevo
Amanecer (NA) to improve health-related QOL in
Spanish-speaking Latinas with BC. The specifics of
the NA involved managing the initial impact of cancer,
finding cancer information, obtaining support, identifying helpful and unhelpful thoughts, managing thoughts
and mood, stress management techniques, managing
activities that affect mood, and goal setting. The NA was
conducted once a week for a total of eight sessions of 90
minutes each.
Giese-Davis et al. [20] conducted an RCT of peer
counseling for patients with newly diagnosed BC. Peernavigators provided support during medical treatment,
made connections to community resources, recognizedtrauma symptoms, and helped sojourners know whether
to seek professional help for distress. The pair could
meet weekly by telephone, email, or in person for up to
six months.
Toija et al. [21] explored the effectiveness ofa simple and low-cost peer support program on thehealth-related QOL of patients with BC. This peer support was provided by trained volunteer BC survivors via
telephone, thus enabling newly diagnosed BC patientsto get in contact with survivors in a simple and uncomplicated manner to ask questions and receive emotional
support when needed. Moreover, it was continued
according to the patients’ preferences as long as it wasnecessary, with approximately one call per week.
3.3 Evaluating the Quality of Papers
The results of the responses to the signaling questions (Table 2) guided the evaluation of the quality ofthe papers (Table 3). For example, in a study by Nápoles
et al. [18], the answer to signaling question 1.1 “Was the
allocation sequence random?” was “Yes.” In answering
the other signaling questions, four items of the article
quality rating were “low risk” and one item was “highrisk.” The studies with the lowest risk of bias were thoseof Nápoles et al. [18, 19], followed by Toija et al. [21].
The study with the highest risk of bias was that of Daviset al. [20].

4. Discussion
4.1 Reported Programs
Three studies [18, 20, 21] showed significant enhancements in QOL, among which the study by Nápoles
et al. [18] had the lowest risk of bias, followed by thestudies by Toija et al. [21] and Giese- Davis et al. [20].
The following describe the details of the three papers [18,20, 21] that showed significant improvements in QOL.
The NA conducted by Nápoles et al. [18] showeda statistically significant improvement in emotional
well-being in FACT-B at six months. Their sample consisted mostly of Mexican and Central American Latinas,
and participant cancer survivors with low educationaland economic status were included in the NA. Therefore, this study may not be generalizable to Japanesegroups. On the other hand, it may be useful for Japanbecause NA has contents that are strongly related to thecommunity life of cancer patients, such as searching forcancer information; good skills when communicatingwith health professionals, family, and friends; managing
activities that affect mood; and goal setting [22].
Giese-Davis et al. [20] reported that peer counselingperformed for a maximum of 6 months showed a statistically and clinically significant difference in FACT-B
BSW at 12 months. The content of this program, whichhelps peers talk about their experiences, make connections with community resources, and decide whether
to seek professional help, is likely to be applicable inJapan. However, it should be noted that the risk of bias
was the highest among the four papers adopted in thisstudy.
Toija et al. [21] reported a small but statisticallysignificant improvement in sexual function in EORTC-QOL30 and EORTC-QLQ-BR23 at six months follow-up. Unfortunately, there are many limitations to thisstudy: the number of phone calls made differed between
participants; data on participants’ disease stage and treatment were not reported; and data on sexual function in
the EORTC- QOL30 and EORTC-QLQQ-BR23, whichshowed statistically significant improvements, were not

22

COMMUNITY-BASED PEER SUPPORT PROGRAMS FOR CANCER SURVIVORS

shown. Therefore, generalizing this program is difficult.
The three studies [18, 20, 21] that showed significant improvements in QOL all incorporated a follow- up
period of more than six months into their study design.
This finding is consistent with that of Hoey et al. [9],who stated that an extended period of time may be required before people can develop relationships and build
sufficient rapport to enable them to gain benefits frompeer support. When running a peer support program in
the community, it is also necessary to support cancer
survivors so that they can take time to fully build trusting relationships with each other.
By contrast, Nápoles et al. [19] found no significant
improvement in QOL. This program for Latinos living
in rural areas is a revision of the NA [18, 22] for Latinos
living in urban areas. As a result of revisions, NA-II was
expanded from 8 to 10 sessions, the use of audiovisualmaterials was increased, and a handout for family members providing information on the program was created.
Nápoles et al. [19] stated that the reason for the lack ofsignificant improvement in QOL with NA-II was that all
women who received NA were enrolled mostly within
three months of diagnosis or within one year, whereas
women who received NA-II were enrolled farther fromthe date of their initial diagnosis (within 2.5 years on
average). This may be due to the longer time since thediagnosis and that the baseline levels of QOL among
women in the NA-II were better than those in their prior
RCT, thus leaving less room for improvement. Thisis similar to what Hong-Li et al. [23] reported when
following the QOL of nonmetastatic BC patients after
initial treatment with surgery and chemotherapy for one,
two, and five years; they found that the QOL at one year
was the lowest. Therefore, it is important to concentrateon providing QOL support to BC survivors within thefirst year after diagnosis or initial treatment.
From the above four studies, there was a scarcity of
programs that could be fully applied in Japan because
every study has its advantages and limitations.
4.2 W
 hat Kind of Support Should A Specific Peer
Provide?
Peers in the four studies were BC survivors who
had been diagnosed one to three years previously
and had received several specific training sessions ofapproximately eight hours each. Therefore, educatedpeers provided support to the participants. By contrast,
Petruseviciene et al. [24] conducted a program in which
untrained BC survivors formed groups to knit, makepaper cranes, and attend lectures by an occupational
therapist. As a result, participants reported a significant
improvement in QOL, which was suggested to be
due to the mental well-being of women with the samedisease doing the same program. As shown above, peer
support can be provided by trained cancer survivors
or by a group of untrained individuals. Furthermore, a
study showed that programs [25] provided by healthcare professionals, not peers, have improved QOL. As
mentioned above, there are hospitals and patient groups
that provide peer support in Japan. These two typesof peer support programs have their advantages anddisadvantages. For example, although the peer support
provided at hospitals is for any cancer survivor and theirfamily members, some patients may feel burdened toparticipate because they have to go to the hospital. In
addition, while the provided information is highly reliable as medical staff oversees, services focused on thepatient’s life are less likely to be provided [26]. On theother hand, peer support provided by patient groups isless difficult to participate and can provide support thatis more relevant to the patient’s life, yet it is necessary
to consider whether or not the information provided isreliable. Therefore, it is essential to educate peers because peer support programs provided by hospitals andpatient groups have advantages and disadvantages. Also,
it is important that peer support provided by hospitals
and patient groups complement each other and provide
services so that cancer survivors can use peer support
comfortably and securely, taking into consideration thewishes of cancer survivors and the community resourcesthat should be provided when providing communitybased support to improve QOL.
4.3 Limitations and Prospects
A limitation of this study is that the small numberof RCTs that met the inclusion criteria did not allow
for a meta-analysis to be performed. Given that there
were only three programs that showed significant improvements in QOL, research that includes QOL as an
outcome measure should be conducted in the future.
This systematic review should be updated when newand more effective studies are published or when approximately three to five years have passed.

5. Summary and Conclusion
A systematic review was studied with the aim ofinvestigating community-based peer support programsfor improving QOL. The results showed that four studies met the eligibility criteria, and three of them showedstatistically significant improvements in QOL. However,few programs can be fully applied in Japan. In terms ofprogram effectiveness and risk of bias, programs that
include obtaining support and managing activities that
affect mood may be effective. Furthermore, the importance of taking enough time to help cancer survivors

Asian J Occup Ther 18: 17−23, 2022

trust each other and provide support according to thesurvivors’ wishes and available community resources
was demonstrated.

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go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000196975.pdf.
［9］Hoey LM, Ieropoli SC, White VM, Jefford M. Systematic
review of peer-support programs for people with cancer.
Patient Educ Couns. 2008; 70(3): 315-37.
［10］Meyer A, Coroiu A, Korner A. One-to-one peer support
in cancer care － a review of scholarship publishedbetween 2007 and 2014. European journal of cancer care.
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［11］Ikeuchi K, Seiji N. Community-based occupational therapy programs to improve quality of life for cancer survivors - a systematic review (in japanese). Sagyouryouhou.
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［12］Dennis CL. Peer support within a health care context: aconcept analysis. Int J Nurs Stud. 2003; 40(3): 321-32.
［13］Moher D, Liberati A, Tetzlaff J, Altman DG, The
PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses － The PRISMAStatement. PLoS Med. 2009; 6(7): e1000097.
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PC, Ioannidis JPA, et al. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanationand Elaboration. PLoS Med. 2009; 6(7): e1000100.
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Reviews of Interventions [online]. Cochrane [cited 2021
March 08]. Available from: https://training.cochrane.org/
handbook/current.
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Cochrane risk-of-bias tool for randomized trials (RoB 2.0)
[online]. [cited 2021 March 08]. Available from: https://drive.google.com/file/d/0B7IQVI0kum0kX0dLblBJd2ltSzg/view.
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Gregorich S, Lee HE, et al. Nuevo Amanecer: resultsof a randomized controlled trial of a community-based,
peer-delivered stress management intervention to improve quality of life in Latinas with breast cancer. Am J
Public Health. 2015; 105(Suppl 3): e55-63.
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Samayoa C, Torres-Nguyen A, et al. Nuevo Amanecer-II:
Results of a randomized controlled trial of a community-based participatory, peer-delivered stress management
intervention for rural Latina breast cancer survivors.
Psychooncology. 2020; 29(11): 1802-14.
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Star P, Zhong L, et al. Peer-counseling for women newly
diagnosed with breast cancer: A randomized community/
research collaboration trial. Cancer. 2016; 122(15): 2408-17.
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Roine RPA. Effectiveness of peer support on health-related quality of life in recently diagnosed breast cancer
patients: a randomized controlled trial. Support Care
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Lee HE, Duron Y, et al. Randomized controlled trial of
Nuevo Amanecer: a peer-delivered stress management
intervention for Spanish-speaking Latinas with breast
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W. Quality of life in patients with breast cancer and theirrehabilitation needs. Pak J Med Sci. 2014; 30(1): 126-30.
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Support for survivors by cancer survivors (peer support)(in Japanese). MB Med Reha. 2015; 191: 19-24.

■ORIGINAL ARTICLE

The Effect of Cognitive Function on Imitation Skills in
Patients with Schizophrenia.
Makoto Tanaka1, Takao Osanai1, Takuhiko Kato1,
Hisako Ogasawara2, Kazumaru Wada1
1
2

Graduate school of Health Sciences, Hirosaki University
Fuse Hospital

Abstract: The purpose of this study is to identify how cognitive functions such as attention and cognitive processes,
such as the retention process to maintain an image needed in the learning by imitation process, are related to the ability to convert this into action (imitation) in patients with schizophrenia. Many people with schizophrenia have a lower
imitation ability compared to healthy persons. Those with low imitation ability had lower scores for cognitive functions such as MMSE and visuospatial cognitive functions such as the number of correct answers in MRT. As describedabove, reduced imitation ability in patients with schizophrenia is caused by problems in information processing which
temporarily retains and manipulates visual information during the performance of a task.
Keywords: schizophrenia, imitation, cognitive function(Asian J Occup Ther 18: 25−30, 2022)

Introduction
Patients with schizophrenia have difficulty in dailyliving activities, such as dressing, taking medication,
money management, communication, and using social
resources [1]. Among these, difficulty grooming andcommunication lead to further isolation from society [2].
Normally, these skills are acquired by recognizing andimitating the actions and behaviors of people around us
during the growth process. Consequently, among difficulties in daily life by patients with schizophrenia, those
involving lifestyle-related routines are considered to becaused by a failure to learn through experience while
growing up. Learning by imitation includes observing
the detailed actions of another person as a target of imitation, converting the action into a visual image or concept, retaining that image, and then converting it into an
action [3]. In previous studies on imitation by patientswith schizophrenia, patients with lower imitation skills
were shown to have difficulty understanding the feelings
Received: 26 March 2020, Accepted: 8 November 2021
Corresponding to: Makoto Tanaka, 66-1, Hon-cho, Hirosaki-shi, Aomori, 036-8564, Japane-mail: tanakam@hirosaki-u.ac.jp©2022 Japanese Association of Occupational Therapistsof other people and properly expressing their own emotions [4-6]. Matthews, et al. [7] stated that when patientswith schizophrenia were instructed to mimic images,
such as hand and mouth shapes and facial expressions
which were displayed on a monitor, many could not imitate the images compared to healthy subjects. Park, etal. [8] analyzed the relationship between imitation skills,
psychiatric symptoms, and social functions using thesame method, and found that those with poor imitation
skills had more negative symptoms and decreased social
function. In addition, patients with schizophrenia are
known to have an impaired working memory, attention
deficiency, and lower information processing ability[2]. Although previous studies have reported that poor
imitation skills in patients with schizophrenia are related
to mental symptoms and a reduction in emotional cognition and social function, the studies provide insufficientdetails regarding the relation between imitation ability
and cognitive function, and no correlation between
poor imitation skills in patients with schizophrenia andreduced cognitive ability has been clearly identified.
Consequently, the purpose of this study was to
identify how cognitive functions such as attention, andcognitive processes such as the retention process tomaintain an image (needed in the learning- by- imitation
process), are related to the ability to convert this into

26

COGNITIVE FUNCTION AND IMITATION IN SCHIZOPHRENIA

action (imitation) in patients with schizophrenia.
This study was conducted with the approval of the
Ethics Committee of the Hirosaki University Graduate
School of Health Sciences (Ref. No. 2016-029).

Anchor points for each item were set as matching (twopoints), partially matching (one point), and not matching(zero points), and the higher the score, the higher theimitation ability .

Methods

2) Cognitive function
The Mini-Mental State Examination (MMSE) [11]was used to assess cognitive function. 11 assessment
items were set, including “Time orientation”, “Location
orientation”, “Instant recall”, “Calculation”, “Delayed
reproduction”, “Object naming”, “Sentence repetition”,“Verbal instruction”, “Writing a complete sentence”,“Spontaneous writing”, “Figure copying”. Total score(0-30 points) was calculated. The higher the score, thehigher cognitive function.

I. Subjects
The participants (Schizophrenia group) were 59
adult patients (29 outpatients and 30 inpatients) withschizophrenia, as confirmed by the Structured ClinicalInterview for DSM-V. All participants were clinicallystable and recruited from Fuse Hospital in Aomori,Japan. Patients were excluded if they had a neurologicaldisease, were mentally retarded, or had suffered an acute
psychotic episode in the last six months.
For comparison, 40 healthy persons (Healthy group)
were also included in the study. These (18 males, 22
females) were recruited from local residents, to match
the patient group in age, gender distribution, and formal
education. All subjects were informed of the purposeof the survey, that they could refuse to answer, and that
refusal would not result in disadvantage. After explanation, consent to participate in the study was obtained.
II. Survey contents
A survey was carried out by individual interview
for each participant during the survey period (October
4-14, 2016). Survey contents are as follows.

3) Visuospatial cognitive function
The Mental Rotation Test (MRT) was used toassess the visuospatial cognitive function. MRT is
a visuospatial cognitive task to assess the ability toimagine how an object will appear when rotated in 2- or
3-dimensional space. We created the original evaluation
scale with reference to the method of Yamada, et al. [12].
Subjects were shown 10 photographs of hands and feettaken from various angles on a 11.6 inch display, one ata time. Subjects were then asked to answer right or left,
as quickly and accurately as possible. The number ofcorrect answers and total time were used to assess total
visuospatial cognitive function.

Assessment

III. Statistical analysis

1) Imitation ability
The Standard Performance Test for Apraxia(SPTA)[9] was used to assess imitation ability. SPTA is a test
to detect apraxia as well as various behavioral and fine
motor dysfunctions that cannot be explained by motor
paralysis, ataxia, involuntary movement and generalmental dysfunction in persons with brain injury. The test
was created to detect, differentiate, and analyze higher
order dysfunction. The purpose of this study is to assess
the imitation ability of patients with schizophrenia.
Seven assessment items were set. For imitation of theupper limb (one hand) finger configuration “Chin handof Ruria”,”I, II, IV ring”,”I,V ring”. For imitation of
motion of the upper limb (both hands) without an object,“Figure 8”, “Butterfly “,”Paper/Rock Interaction Test”.
And for continuous upper limb (one hand) motion “Ruria
and Stretch Fist”. In addition, “Reverse fox” was used toscreen for mild dementia [10].
Total score (0-16 points) of the eight items wascalculated. Subjects sat facing the investigator, andwere asked to mimic the movement of the investigator.

The a priori hypothesis was that cognitive function
and imitation skills would differ for the Schizophrenia
group versus the Healthy group. Accordingly, comparison was made using a Mann-Whitney U test and t-test.
The Mann-Whitney U test was used to compare the total
MRT, MMSE, and imitation test scores, between the
Schizophrenia group and Healthy group. The normal
distribution of total MRT time was examined using theShapiro-Wilk -test (p = .000). Next, the respective total
MRT times of the Schizophrenia and Healthy groups
were compared using Welch’s t-test. Spearman’s rankcorrelation coefficient was used to analyze the total imitation test scores and MMSE scores, number of correct
MRT answers and total time in the Schizophrenia group.
Significant difference was set as P < 0.05. The analysis
was performed using Excel -Toukei version 2010 (Social
Survey Research Information Co., Ltd.).

Results
Basic attributes of the Schizophrenia group and theAsian J Occup Ther 18: 25−30, 2022

Tanaka M et al.

27

Table.1 Participants
Schizophrenia group(n 59)
M (SD)

Healthy group(n 40)
M (SD)

p-value

59 (8.3)

57.1 (11.5)

.356
.101

Age (years)
GenderMale
Female

37
22

18
22

Diagnosis

Schizophrenia

59―

Form of treatment

Out patients
In patients

30
29

―
―

Age (years) : t test

Gender: Fisher’s exact test

.000*

.000*
30

16
14

25
Total score

Total Score

12
10
8
6
4

15
10
5

2
0

20

Schizophrenia
group （n＝59）

Healthy group（n＝40）*：p＜.01 Mann-Whitney U test0

Schizophrenia
group（n＝59）

Healthy group（n＝40）*：p＜.01 Mann-Whitney U test

Figure 1： Total imitation test scores for the Schizophrenia Group and the Healthy Group
Fig. 1. Total imitation test scores for the Schizophrenia
Fig. Figure2：
2. Total MTotal
MSE scoresfor scores
the Schizophrenia
Group andMMSE
for the Schizophrenia
Group andGroup and the Healthy Groupthe Healthy Group

Healthy group are described in Table 1. Average age
and gender of the Schizophrenia group and the Healthygroup were 59 years (SD 8.3) and 37 males and 22
females; and 57.1 years (SD 11.5) and 18 males and 22
females, respectively. Treatment regimen for the Schizophrenia group was 30 outpatients and 29 inpatients. No
statistical significant difference between the two groups
regarding age and gender was observed. Total scores forthe imitation test for the Schizophrenia group and the
Healthy group are shown in Figure 1. The median total
score of the imitation test for the Schizophrenia groupwas 11.0 points, which is significantly lower (p=.000)
than that of the Healthy group at 16 points.
Total MMSE scores for the Schizophrenia groupand the Healthy group are shown in Figure 2. The
median total MMSE score for the Schizophrenia groupwas 23.0 points, which was significantly lower (p=.000)
than that of the Healthy group at 30 points.

Comparison of results of the number of correct
MRT answers for the Schizophrenia group and the
Healthy group are shown in Figure 3. Median MRTscore for the Schizophrenia group was 8.0 points, which
was significantly lower than that for the Healthy groupat 10.0 points (p=.000).
Total MRT time for the Schizophrenia group andthe Healthy group are shown in Figure 4. Median total
MRT time for the Schizophrenia group was 28.7 sec,
and no significant difference with the Healthy group at
29.0 secs was observed.
Results of correlation between total scores of theimitation test and MMSE/MRT for the Schizophrenia
group are shown in Table 2. A moderate positive correlation between the imitation test total score and thetotal MMSE score (r = .55, p = .000), “Calculation” (r =.46, p = .000), “Sentence repetition” (r= .47, p = .000),

28

COGNITIVE FUNCTION AND IMITATION IN SCHIZOPHRENIA

.000*

.922
50

9

45

8

7

Total time (second)

Number of correct answers

10

6

5
4
3
2
1
0

40
35
30
25

20
15

10
5

Schizophrenia
group （n＝59）

0

Healthy group（n＝40）

Schizophrenia
group（n＝59）*：p＜.01 Mann-Whitney U test

Healthy group（n＝40）

Welch t-test

3： Numbercorrect
MRT
answers
in theFigFigure
3 Numberof correctofMRT
answers
in theSchizophrenia
Schizophrenia
andthe Healthy group
group and thegroup
Healthygroup

Fig 4. Total MRT time for the Schizophrenia group and the
Healthygroup Total MRT time for the
Figure4：

Schizophrenia group and the Healthy
group

Table 2. Correlation between Total Imitation test scores, MMSE and MRT
Items

r

p-value

MMSE

Total Score
Time orientation
Location orientation
Instant Recall
Calculation
Delayed reproduction
Object naming
Sentence repetition
Verbal instruction
Writing a complete sentence
Spontaneous writing
Figure copying

.55
.00
.25
.23
.46
.22
.19
.47
.22
.35
.24
.41

.000
.966
.053
.055
.000
.099
.220
.000
.090
.063
.063
.002

MRT

Number of correct answers
Total time

.38
.29

.005
.036

Spearman’s rank correlation coefficients“Figure copying” (r = .41, p = .002) was observed. A
weak positive correlation between total imitation testscore and number of correct MRT answers (r = .38, p =.005) was observed.

Discussion
Imitation is a series of motor learning exercises thatcan change a person’s movement to match a targeted
model and reproduce it [13]. Learning by imitation includes a cautionary process to pay attention to the clues
and features of the target, a retention process to maintaina representation form, and then a process to reproduce
the movement by physical motion. An image of task

implementation is said to be formed and these tasks arecarried out by the normal functioning of these elements[14]. In this study, the correlation between cognitive
functions such as attention, and cognitive processes,
such as the retention process to maintain an image(needed in the learning- by- imitation process), and theability to convert this into action (imitation) in patientswith schizophrenia was analyzed.
In the comparison of imitation ability between the
Schizophrenia group and the Healthy group, the total
imitation test scores in the Schizophrenia group weresignificantly lower. These findings agree with the resultsfrom the study by Matthews, et al. [7] that many patientswith schizophrenia have a more difficult time imitating

Asian J Occup Ther 18: 25−30, 2022

than healthy subjects do. This difficulty in imitation
ability in schizophrenia patients is considered to affectguidance in occupational therapy. Since difficulty in imitation ability in patients with schizophrenia is related to
impairment in social cognition and behavior [8], further
examination is considered necessary.
In the comparison of cognitive functions between
the Schizophrenia group and the Healthy group, thetotal MMSE score in the Schizophrenia group wasshown to be significantly lower. Previous studies havealso reported that total MMSE scores for patients withschizophrenia were lower than those for healthy peopleof the same age regardless of type of treatment, such as
hospitalization or outpatient care [15,16]. The cognitive
function is considered to be an essential function when
performing various tasks [17]. Major cognitive dysfunction in person with schizophrenia is thought to be due
to information processing problems. In the comparisonof the number of correct MRT answers in the Schizophrenia group and the Healthy group, the MRT scoresfor the Schizophrenia group were significantly lower.
In the MRT, subjects were asked to perform tasks suchas differentiating visual images while rotating them, inorder to compare them with the displayed visual stimuli.
These visuospatial cognitive functions are necessary tounderstand spatial positioning relationships such as rightside, left side, and depth of an object, and are thought tobe related to the ability to perform various tasks. In order
to assess visuospatial cognitive function in patients withschizophrenia, Vignemont et al. [18] displayed picturesof letters and numbers on a screen and asked the subject
to identify whether they were mirrored characters, thenrecorded the total time for response and the number ofcorrect answers. From the results, patients with schizophrenia showed a significantly longer time than healthy
subjects, and subjects with more severe psychiatric
symptoms had fewer correct responses. In the present
study, even the results by MRT to differentiate between
left/right limbs were similar to those in previous studies.
These results suggest that mental rotation in patientswith schizophrenia is weaker when maintaining andmoving their own limbs during physical exercise.
A moderate positive correlation between total imitation test scores and MMSE total scores, “Calculation”,“Sentence repetition”, “Figure copying” was observed.
A weak positive correlation between total imitation testscores and “Writing a complete sentence” was observed.
”Calculation” and “sentence repetition” require the ability to pay attention to numbers, sentences, and figures,and to temporarily retain information during processing.
In observational learning by imitation, the main function
involved is the attention process that selects the most
relevant event from the stimulus, accurately perceives

Tanaka M et al.

29

clues, and then retains the stimulus as a symbol [14].
Consequently, a positive correlation between the itemsof “calculation” and “sentence repetition” can be considered. In addition, although imitation and figure copying
differ in terms of body, graphics and expression methods,
both have the same actions in terms of matching tasks,
which is considered to suggest a positive correlation.
When instructed to “Write a complete sentence”, thesubject was told “Please close your eyes” and required
to close their eyes. To do so, subjects were required
not only to understand the intent of the sentence, butalso to perform the exercise with closed eyes. Since theprocess of understanding intention is based on linguistic
information and converting this into movement, this isa point in common with imitation learning, where theintention is understood based on visual information andconverted to movement [19]. A positive correlation between “imitation” and “writing a complete sentence” issuggested. Regarding information processing ability inpatients with schizophrenia, it has been pointed out thatthe ability to maintain attention and selectivity, as wellas the control function, is reduced [20,21]. Therefore,
careful consideration as to how information processing
ability is related to imitation ability, in connection withcognitive dysfunction which is unique to schizophrenia,
is needed.
From the analysis of the correlation between total
imitation test scores in the Schizophrenia group andnumber of correct MRT answers and total time, MRTscores showed a weak positive correlation. Visuospatial
cognitive function required for MRT is necessary forrecognizing the spatial positional relationship between
an object and the subject’s own body [12]. If the visuospatial cognitive function is impaired, it becomesdifficult to recognize top, bottom, left, and right ofmultiple objects and the positional relationship between
objects. Because the imitation test used in this study wascomposed of techniques such as alternately turning both
hands and shifting the positional relationships between
front and back, a positive correlation between total imitation test scores and total MRT scores was suggested.
Because the ability to understand spatial positional
relationships between an object and the subject’s bodyis weak, it is difficult to learn different left and rightmovements and complicated movements. This problem
is thought to hinder patients with schizophrenia fromacquiring new abilities. Therefore, when occupational
therapists provide movement guidance instructing
patients with schizophrenia to imitate a movement,
dividing complicated movements into several individual
steps and keeping in mind that instead of providing instructions face to face, providing instructions alongside
the patient so the right and left are more easily distin-

30

COGNITIVE FUNCTION AND IMITATION IN SCHIZOPHRENIA

guished, is important.

Conclusion
Many people with schizophrenia have a lower
imitation ability compared to healthy persons. Thosewith low imitation ability had lower scores for cognitive
functions such as ”calculation”, ”sentence repetition”,”figure copying”, and ”writing a complete sentence”,
and visuospatial cognitive functions such as the numberof correct answers in the rotational test, etc. As described above, reduced imitation ability in patients withschizophrenia is caused by problems in information
processing which temporarily retains and manipulates
visual information during the performance of a task.
Therefore, when learning movement by imitation,
it is necessary to consider things such as simplifying the
movement at the position facing in the same direction.

Limitation
MMSE is commonly used in medicine to screen for
dementia. Therefore, it does not accurately represent theactual state of cognitive function in schizophrenia. In the
future, it will be necessary to use a cognitive function
test specialized for patients with schizophrenia.

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■ORIGINAL ARTICLE

Comparison of Forearm Muscle Activation and Relationship with Pressure Distribution in Various Grip Patterns
Keisuke Irie1, Junpei Yokota2, Masakatsu Takeda2, Kohei Mukaiyama2,
Yuji Nishida3, Masaru Sato4, Yasuyoshi Mishima4, Noritaka Yamamoto4,
Momoko Nagai-Tanima2, Tomoki Aoyama2
1

Department of Occupational Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
3
Technical Research Department, Marketing & Technology Research Division, ITO Co. Ltd., Japan
4
Sensing System Research Center, National Institute of Advanced Industrial Science and Technology (AIST), Japan
2

Abstract: Introduction: In racket sports, it is necessary to devise a gripping method that facilitates both the efficienttransmission of power and injury prevention. This study quantified grip pressure distribution (PD) in the hand using
various gripping methods and investigated the relationship between these distributions and muscle activation.
Methods: In a laboratory setting, a grip sensor was used to measure hand PD in 15 healthy adults during each task.
Participants gripped the sensor device using three grip patterns with simultaneous electromyography (EMG) recordings
from the extensor digitorum communis (EDC), extensor carpi radialis, flexor digitorum superficialis (FDS), and flexor
carpi ulnaris (FCU). The device’s hand-contact area was assigned anatomical regions, and the percentage PD of eachregion was calculated for each task. We compared the EMG in each grip pattern and analyzed the correlation between
grip force and EMG.
Results: The main outcomes measured were EMG and PD. For radial and power grips, there was a significant relationship between EDC and grip force (r = 0.52, 0.47). For the ulnar grip, there was a significant relationship between FDS
and grip force (r = 0.55). Furthermore, the ulnar grip’s EDC activity was significantly lower than that of the power grip,
and FCU activity was significantly higher than that of the radial grip (p < 0.05).
Discussion: The ulnar grip had significantly lower EDC activity than the power grip and higher FCU activity, which is
involved in the elbow joint’s stability, than the radial grip. The ulnar grip may be effective in preventing injuries.
Keywords: pressure distribution, muscle activation, racket sports, grip patterns, guidance(Asian J Occup Ther 18: 31−37, 2022)

1 Introduction

With the development of the sports and healthindustry, the number of recreational tennis players has
increased internationally. [1-3] The incidence of tennis
injuries ranges from 0.05 to 2.9 per player per year, andupper limb injuries are more likely to become chronic
than lower limb injuries. [1] Therefore, it is importantto prevent recurrence by providing treatment andguidance, especially for upper limb disorders. Lateral
Received: 6 May 2021, Accepted: 8 November 2021
Corresponding to: Keisuke Irie, Department of Occupational Therapy,
Human Health Sciences, Graduate School of Medicine, Kyoto University, 53 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japane-mail: irie.keisuke.8n@kyoto-u.ac.jp©2022 Japanese Association of Occupational Therapists

epicondylitis (tennis elbow), a typical tennis disorder, isa painful condition of the extensor tendons attached to
the lateral condyle of the humerus. The extensor carpi
radialis brevis (ECRB) muscle is the affected tendon
in almost 90% of cases. [4-5] Over 30 treatments aredescribed for the tennis elbow; therefore, many of them
are used routinely such that there is no single optimum
treatment. [6] Patient education is provided as part of
the treatment, [7] including instructions on using theelbow band and gripping the racket. The four traditional
single-handed hand grip positions are the continental,
Eastern, semi-western, and Western. [8] Tagliafico et al.
investigated the grip styles of tennis players and foundthe damage caused by different grip styles. It has beenreported to be related to the Eastern grip with radial-sided injuries and the Western or semi-western grip with

32

COMPARISON OF FOREARM MUSCLE ACTIVATION AND RELATIONSHIP WITH PRESSURE DISTRIBUTION IN VARIOUS GRIP PATTERNS

ulnar-sided injuries. [9] In addition to the grip position,
information on the pressure distribution (PD) of thefinger being applied is important. Studies using grip
strength devices have reported that the involvement of
the ulnar fingers, such as the ring finger and little finger,
was useful for exerting grip strength. [10] Furthermore,
the force of the index finger before impact reportedly
affects the force after impact. [11] It was suggested thata weaker index finger is desirable to suppress excessive
contraction. However, the relationship between forearmmuscle activation and the grip pressure distribution has
not been clarified.
As there have been studies examining the PD ofeach finger using various test devices (cylinder of various sizes with sensors, [12] dynamometer with pulleyassembly, [13] and digital dynamometer[14] with force
sensor), it was found that the PD of the index finger andthe middle finger is more involved in the grip strength.
Recently, qualitative and quantitative data on the wholehand PD have been reported using a cylinder withsurface-pressure sensors. Mühldorfer et al. measured
the load in each anatomical hand region during a grip
task and reported similar results in previous studies. [15]Similarly, the same authors studied changes in load distribution that accompanied changes in grip strength anduse for wrist fusion patients. [16] Since these techniques
can quantitatively confirm information on gripping andPD, converting qualitative information, such as guidance on gripping, into quantitative information for comparison has become possible. It is necessary to consider
whether the flexor grip (centered on the index finger andmiddle finger) or the ulnar grip (centered on the index
finger and little finger) is better to transmit force andprevent injury efficiently. Our research question was
how PD relates to forearm muscle activation when theradial or ulnar fingers are predominantly gripped (radialgrip or ulnar grip) during a power grip compared towhen all fingers are gripped evenly (power grip).
Surface electromyography (EMG) is commonlyused as a non-invasive tool for evaluating muscle function in clinical settings and research institutions. Several
studies have used EMG to document muscle activation
during a power grip task to assess the relationshipbetween grip strength and activity in forearm muscles,[17-18] while others have documented muscle activation in styles other than the power grip. [19-20] Theselatter studies only observed the relationship between
muscle activation and total grip strength, and no study
has examined the simultaneous relationship between
regional forces in the hand and the activity of muscles
involved in the grip task. Understanding the regional

distribution of forces during hand grasping and theirrelationship with the activity of the muscles responsible
for the task will lead to a better overall understandingof grasping and its disorders. In a systematic review
of EMG studies of the tennis elbow, representative ofboth the extensor carpi radialis (ECR) brevis and longus
combined or selective for the ECRB alone, extensor
digitorum communis (EDC), flexor carpi ulnaris (FCU),
flexor carpi radialis, flexor digitorum superficialis (FDS),
pronator teres, and triceps brachii have been selected.
[21] Since we focused on the main movement of thewrist joint and finger muscles during grip, we acquired
the muscle activities of the EDC, ECR, FDS, and FCU
muscles. This study aimed to: (1) quantify the load
distribution in the hand during various styles of thegripping task and (2) investigate the relationships ofthese distributions with muscle activation. We hypothesized that the grip force of the radial grip is associatedwith the activity of the extensor muscles, such as the
ECR and EDC, and the ulnar grip is associated with theactivity of the flexor muscles such as the FDS and FCU.
Furthermore, we predicted that ECR activity in the
flexor grip was significantly higher than that in the ulnar
grip.

2 Methods
2.1 Participants
The participants of this cross-sectional study were
15 healthy students from a national university. They
were all informed about the experiments, and those who
provided informed consent were included. The exclusion
criteria were as follows: (1) persistent pain that leads
to an inability to grip, (2) a history of musculoskeletal
disorders, (3) severe neurological or cardiovascular disease, and (4) hand deformity. The study was approvedby the Ethics Review Committee of University Graduate
School and Faculty of Medicine (approval number
R2018). Written informed consent was obtained fromthe patients for the publication of their anonymized
information in this article.
2.2 Equipment
2.2.1 Measurement of grip force and load distribution
Grip force and load distribution were measured
using a cylinder-shaped device with an embeddedpressure sensor, allowing the capture of qualitative andquantitative data during grip tasks. The sensor sheet(200 × 300 mm) with an embedded pressure sensor (173× 288 mm, pitch 1.2 mm) was wrapped around a hardcylinder (60 mm diameter) to record the load in various
hand regions. Pressure sensor data were transferred to
a computer at a frequency of 10 Hz (Figure 1). This

Asian J Occup Ther 18: 31−37, 2022

Irie K et al.

33

Fig. 1. The grip sensor system
The grip sensor is a cylindrical device (60 mm in diameter) with a sensor sheet (200 × 300 mm), wherein the pressure sensor wasembedded (173 × 288 mm, pitch 1.2 mm). The pressure information of the contact area is sent from the grip sensor to the personal computer, and the colored pressure distribution can be viewed on the screen.

technology is useful for printing high-definition andhigh-precision electronic circuits on a flexible sheet substrate and the PD system incorporated into the sensor.
This device exhibits high sensitivity and selectivity
against various types of pressure. [22-24]
2.2.2 EMG
Muscle activities were recorded using the TeleMyo
2400 system (Noraxon, Scottsdale, AZ, USA) witha sampling rate of 1000 Hz. Surface electrodes wereplaced to record from the EDC, ECR, FDS, and FCU
muscles of the forearm. These muscles were strategically selected because they represent key extrinsic handlocations and for their ease of accessibility to surface
EMG recordings. We confirmed the crosstalk between
each EMG recording in advance and visually confirmedthat individual muscle activation did not affect othermuscle activations. The skin at the electrode sites was
shaved and cleaned using scrubbing gel and alcohol.
Bipolar surface electrodes (Ambu A/S, Ballerup, Denmark) were placed with a 2 cm interelectrode distanceon these muscles.
2.3 Experimental protocol
The participants performed the following three grip
tasks using the cylindrical device: a radial grip, a power
grip, and an ulnar grip, as described previously. They

gripped the cylindrical device (placed vertically on aplatform) with their right hand while sitting on a chair,with both shoulders in a neutral position, their rightelbow flexed at 90°, and their right wrist dorsiflexed at
0° to 15°, similar to a conventional grip test. [25] They
were given verbal instructions and demonstrations ongripping the device as follows: for the radial grip: holdit primarily with the index and middle fingers; the power
grip: hold it around all your fingers; and the ulnar grip:
hold it primarily with the ring and little fingers. Before
starting each task, the participants practiced how tograsp. Subsequently, looking at the data displayed, they
performed a maximum force grip of 3 seconds twiceon the device. Load distribution and EMG data wererecorded while gripping the device.
2.4 Data analysis
The sensor loads within the sensor matrix are
displayed as a two-dimensional raster diagram. This
distribution map represents the contact regions of thehand grasping the cylinder. After calculating the force
value from each sensor in the sheet, their values weresummed to determine the total force of the hand-contact
area. The forces were calculated based on seven anatomical regions (thumb, index finger, middle finger, ring
finger, little finger, thenar, and hypothenar) as previously
described to analyze load distribution. [16] Setting the

34

COMPARISON OF FOREARM MUSCLE ACTIVATION AND RELATIONSHIP WITH PRESSURE DISTRIBUTION IN VARIOUS GRIP PATTERNS

Fig. 2. Scale of hand-contact forces during a grip task
The left side of the figure shows a grey pressure distribution map of the entire hand. The right side shows the division of thoseareas as follows: (1) thumb, (2) index finger, (3) middle finger, (4) ring finger, (5) little finger, (6) thenar, and (7) hypothenar.

force applied across the entire contact area to 100%,
each region’s percentage contribution was calculated(Figure 2).
For EMG data, a 10 Hz high-pass filter and a 450
Hz low-pass filter were applied, and the root meansquare method was used for signal rectification. After
this waveform processing, the average amplitude (during
the 3-second task) for each muscle was calculated, andthe average values from two trials of each grip task
were calculated for all parameters. Normalization was
performed by dividing the average amplitude data by the
amplitude at the time of maximum muscle strength (%maximum voluntary contraction= %MVC).
2.5 Statistical analysis
All statistical analyses were conducted using IBM
SPSS Statistics version 26 (IBM, Armonk, NY, USA).
The data were normalized to analyze the relationshipbetween grip forces applied from each grip patternand EMG, and Pearson’s correlation analysis was performed. In addition, the relationships between extensors
and flexors due to different grip patterns were evaluatedusing repetitive one-way analysis of variance (ANOVA),
with post hoc comparisons performed when significancewas determined using ANOVA. Furthermore, the partial

Table 1. Muscle activities and pressure distribution in each grip style
Variable

Radial grip

Power grip

Ulnar grip

Thumb

2.6 (0.6)

2.0 (0.8)

2.1 (1.0)

Index finger

7.0 (2.2)

4.5 (1.8)

1.3 (0.7)

Middle finger

7.6 (3.8)

5.3 (3.9)

0.9 (0.8)

Ring finger

1.1 (1.1)

4.4 (2.7)

3.6 (1.7)

Little finger

0.6 (0.7)

2.7 (1.5)

5.0 (2.4)

Thenar

3.9 (2.0)

2.4 (1.4)

2.1 (1.1)

Hypothenar

0.2 (0.5)

0.5 (1.0)

0.4 (0.7)

EDC

100.6 (31.7)

111.4 (33.5)

91.0 (28.2)

ECR

78.5 (19.7)

83.8 (11.66)

71.4 (16.5)

FDS

67.1 (21.6)

51.9 (14.94)

56.1 (15.1)

FCU

61.1 (40.4)

76.4 (34.8)

94.8 (27.5)

Grip force (kgf)Normalized (%MVC)

Variables are expressed as mean standard deviation (SD).
Abbreviations: EDC, extensor digitorum communis; ECR, extensor carpi radialis; FDS, flexor digitorum
superficialis; FCU, flexor carpi ulnaris; and %MVC, % maximum voluntary contraction.

Asian J Occup Ther 18: 31−37, 2022

Irie K et al.

35

Fig. 4. Results of comparing %MVC with different grip patterns
White, radial grip; grey, power grip; and black, ulnar grip.
* p < 0.05. % MVC=% maximum voluntary contraction

Fig. 3. The percentage contribution of the seven anatomical areas ineach grip type
The (A) radial grip, (B) power grip, and (C) ulnar grip areshown in order from the top. The left side of the figure in eachgrip style shows the contribution of each anatomical area on
the total pressure. The right side shows the pressure distribution in grey scale, wherein the darkening of color indicates theincrease in pressure.

η square (ηp2) was calculated to investigate the effectsize.

3 Results
Of the participants, eight were female, the mean
age was 27.8 ± 8.2 years, and all participants wereright-handed. Table 1 shows the EMG and PD data
for each of the three grip patterns. The forces applieddiffered with grip patterns in each of the anatomical

regions; however, almost no force was observed in the
hypothenar region using any grip. Figure 3 shows therelative contributions of the seven anatomical regions ofeach grip pattern. For the radial grip, the contributionsof the index finger (31.6 ± 6.0%) and the middle finger(31.9 ± 9.1%) were larger than for the other grips.
Forces during the power grip were distributed across thefingers as follows: index finger (23.4 ± 11.1%), middle
finger (22.5 ± 9.6%), ring finger (18.7 ± 6.7%), and little
finger (12.3 ± 5.0%). For the ulnar grip, the ring finger(23.2 ± 7.6%) and little finger (33.4 ± 9.8%) regions
tended to have stronger grips than the other grips. The
relationships between the grip forces and EMG areshown in Table 2. Grip force was correlated with EDC
in both the radial grip (r = 0.52, p = 0.03) and power
grip (r = 0.47, p = 0.04), while it was correlated with
FDS activity in the ulnar grip (r = 0.55, p = 0.02). Figure
4 shows the comparison results of %MVC with different
grip patterns. As a result of repeated one-way ANOVA,
the EDC was less activated in the ulnar grip than in the
power grip (p = 0.007, 95% confidence difference inter-

Table 2. The relationship between the grip pressure and electromyography in each grip style
Radial grip

Power grip

Ulnar grip

EDC

0.52*

0.47*

0.23

ECR

0.15

-0.1

0.04

FDS

0.31

0.32

0.55*

FCU

0.09

0.14

0.37

Abbreviations: EDC, extensor digitorum communis; ECR, extensor carpi radialis; FDS, flexor
digitorum superficialis; and FCU, flexor carpi ulnaris.
* p < 0.05.

36

COMPARISON OF FOREARM MUSCLE ACTIVATION AND RELATIONSHIP WITH PRESSURE DISTRIBUTION IN VARIOUS GRIP PATTERNSval [CI] = 6.0-34.9, ηp2 = 0.44). Furthermore, the FCU
was activated to a greater extent in the ulnar grip thanin the radial grip (p = 0.004, 95%CI = 10.6-56.8, ηp2 =0.49). The ECR showed a similar trend to the EDC, but
no significant difference was found (p = 0.08).

4 Discussion
Our study findings showed that grip force wascorrelated with the EDC in both the radial grip andpower grip, while it was correlated with FDS activity inthe ulnar grip. The EDC was less activated in the ulnar
grip than in the power grip. Furthermore, the FCU was
activated to a greater extent in the ulnar grip than in theradial grip. This study found that the PD changed due tothe differences in grip patterns. This information on PD
confirms that the participants properly performed thegrip patterns based on our purpose.
In the present study, the index and middle finger
PDs were large during the power grip. Additionally, aprevious study reported that when using a glove withembedded pressure sensors, the contribution of the
middle finger was the largest in lifting a metal object
from a desk. [26] Power grip studies of load distribution
have similarly reported the index or middle finger contributions to be the largest, followed by the ring finger
and little finger forces. [16] Finger length is involvedin the PD of the hand, and it is reasonable that the PDof the middle finger is the largest in healthy adults. [15]Correlation analysis showed that the power grip andradial grip were associated with EDC activity, and theulnar grip was associated with FDS activity. In a pathological autopsy of the tennis elbow, the abnormal regionof the elbow contains the lateral ECRB-EDC complex,
and the EDC also originates from the lateral epicondyle, which is considered a factor in the developmentof tennis elbow. [27] Both the radial and power grips
have a large PD between the index and middle fingers,
suggesting that extensor muscle activation increases
when the radial side fingers are dominant. Moreover,unless the participants were instructed to grip with theulnar fingers, the power grip tended to have a high-PD
on the index and middle fingers, similar to the radialgrip. Therefore, the EDC may be excessively active inamateur players who do not receive proper guidance.
Furthermore, when the radial grip is performed, theracket’s tip is raised more than when the ulnar grip isused; therefore, a compensatory action is required tocorrect it. The ECR showed a tendency to show similar
muscle activity as the EDC, but there was no correlation
with grip strength. Previous studies have reported that
the ECR shows higher activity during the groundstroke[28]. However, in this study, the participants performed
the task of gripping the device without changing the dorsiflexion angle of the wrist joint, which may have resulted in force adjustments occurring mainly in the fingers.
Therefore, we considered that there was no differencein the ECR activity. The PD of the ring finger and little
finger was high in the ulnar grip, suggesting that thisis related to the flexor muscle groups such as the FDS
and FCU. The FCU has been reported to be a major
stabilizer for elbow valgus stability, [29] and the ulnar
grip may be of teaching significance. Furthermore, ourresults suggest that the ulnar grip can increase the FCU
activity and decrease the EDC activity and is consideredan effective teaching method to prevent the developmentof tennis elbow. However, excessive flexion poses a riskof injury to the lateral wrist ulna; therefore, the degree
should be considered. This study's characteristic is thatthe qualitative index of the difference in grip was quantified using the grip sensor. By quantification, the valuesof the PD of the index finger and middle finger in the
power grip and radial grip were both high. Therefore, intreating tennis elbow, in addition to physical treatment,such as massage, teaching the patient how to hold theracket and properly applying force are necessary.
This study had some limitations that should
be noted. First, the number of muscles was limited.
Representative muscles involved in finger movements
were selected based on previous studies. However,this muscle selection may be biased owing to the setup
requirements. Second, there are limitations to the shapeand size of the equipment used to analyze the PD. Here,the size of 60φ was adopted to prevent finger overlap.
Previous studies have confirmed that different racket
sizes do not affect muscle activity. [30] However, theinfluence of the shape and weight of the racket is predicted. Thus, in future studies, it will be necessary tomeasure PD and muscle activation during groundstroke,such as wrapping a sensor around a tennis racket. Moreover, the number of target muscles, such as the ECU
and FCR, should be increased while focusing on muscle
crosstalk. Finally, the age of onset of tennis elbow is
between the 30s and 50s, and muscle activity characteristics during this period may be different than that inyounger individuals. Therefore, future studies that takeage into account are needed.

5 Conclusions
This quantitative study revealed different load
distributions during various grip patterns, and it wasclarified that the pressure distribution of the index andmiddle fingers was associated with the EDC activity.

Asian J Occup Ther 18: 31−37, 2022

Moreover, the pressure distribution in the ring finger
and the little finger, such as in the ulnar grip, is related
to flexor muscle activity such as that of FDS and FCU.
Considering these results, the ulnar grip may be usefulfor preventing lateral epicondylitis.

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■ORIGINAL ARTICLE

Effects of Single-handed and Dual-handed Tasks on
Myoelectric Hand Prosthesis Operability of Unilateral
Transradial Amputees
Jumpei Oba1, Sumiko Yamamoto2, Kengo Ohnishi3,
Isamu Kajitani4, Yaeko Shibata5, Koki Asai6
1

Kobe Gakuin University
International University of Health and Welfare
3Tokyo Denki University
4
National Institute of Advanced Industrial Science and Technology
5
Hyogo Rehabilitation Center
6
Kobe City Medical Center General Hospital2

Abstract: Objective: The influence of myoelectric hand training on the ability of amputees to operate a prosthetic hand
has not been fully verified. This study aimed to investigate the effects of single-handed and dual-handed tasks on theability of amputees to use a myoelectric prosthetic hand in training.
Method: The subjects were unilateral transradial amputees (n=12). The training effects of each task were measured byassigning the myoelectric hand prosthesis users to two groups and conducting a crossover study: one group performed
the single-handed task first followed by the dual-handed task, and the other group did the opposite. The Southampton
Hand Assessment Procedure (SHAP) score was used to assess the subjects’ ability to control the myoelectric prosthetic
hand.
Results: The training effect differed significantly between the single-handed task, SHAP score: 6.3 (5.8-8.5) points,
and the dual-handed task, SHAP score: 10.3 (8.8-14.2) points; however, the effect was insufficient (p = 0.008, r = 0.20).
Conclusion: The dual-handed task improved the subjects’ ability to accurately operate a myoelectric hand more effectively than the single-handed task. This suggests that the dual-handed task is more effective at developing control of
opening/closing movements and object handling with a myoelectric hand than the single-handed task.
Keywords: myoelectric hand prosthesis, single-handed task, dual-handed task, unilateral transradial amputees(Asian J Occup Ther 18: 39−46, 2022)

1. Background
Myoelectric prostheses were reported to be practical and effective by Hermansson et al. based on their
myoelectric prosthesis usage survey of myoelectric
prosthesis users (n=75) [1]. Moreover, there are reports
affirming that myoelectric prostheses play an importantrole in achieving rehabilitation goals [2-4]. However,this previous research involved survey-based retrospective studies. Therefore, while these studies support theReceived: 21 February 2021, Accepted: 8 November 2021
Corresponding to: Jumpei Oba, Kobe Gakuin University, 518, arise
ikawadani-cho, nishi-ku, Kobe 651-2181, JAPANe-mail: j-oba@reha.kobegakuin.ac.jp©2022 Japanese Association of Occupational Therapists

usefulness of myoelectric prostheses, their findings are
not based on firm scientific evidence [1]. Furthermore,
Resnik reported that the effects of myoelectric prosthesis training on the ability of amputees to operate upper
limb prostheses are unclear [5]. Hence, it is necessary to
clarify the effects of myoelectric hand operation training
based on objective data.
Myoelectric prosthesis operation training was
proposed by Atkins in 1992 [6], and associated guidance
was formulated by Johnson et al. in 2015 [7]. The training was organized into single-handed and dual-handedtasks, and it was recommended that dual-handed tasks
should be performed after practicing single-handedtasks [6,7]. However, there are no objective data toverify how single-handed and dual-handed tasks affectamputees’ ability to operate myoelectric prostheses. The

40

TRAINING METHOD OF MYOELECTRIC HAND PROSTHESIS

same applies to the relationship between the results ofsingle-handed and dual-handed task [8]. In a study inwhich able-bodied subjects practiced operating a myoelectric prosthesis using a simulated myoelectric prosthesis, it was reported that dual-handed tasks resulted ingreater improvements in object manipulation skill thansingle-handed tasks [8].
The aim of this study was to clarify the effects ofsingle-handed and dual-handed tasks on myoelectric
prosthetic hand training among transradial amputees,
and the differences between the effects of the tasks. Our
hypothesis was that dual-handed tasks are more effective
than single-handed tasks.

2. Methods
2-1. Subjects
The subjects were unilateral transradial amputees
with no experience of myoelectric prosthesis use ortraining. The inclusion criteria were being a unilateraltransradial amputee, who is over 20 years of age, does
not have difficulty donning prosthetic arms due to muscular weakness or a limited range of motion, and has no
history of rehabilitation. The exclusion criteria were an
amputated limb length of <10 cm, skin conditions thatmake it difficult to collect myoelectric signals, having
difficulty donning prostheses due to cognitive dysfunction or intellectual disability, experience of myoelectric
prosthetic use, and refusal to consent to the experimental
conditions. Twelve unilateral transradial amputees met
the above criteria and participated in this study. The subjects’ attributes were as follows: 8 males and 4 females,mean age: 42.9 ± 13.9 years, mean height: 162.8 ± 7.0
cm, mean weight: 58.9 ± 6.5 kg, mean residual lengthof the amputated forearm: 18.2 ± 5.7 cm, mean residual

percentage length of the amputated forearm: 66.3 ±
18.9%, mean maximum circumference of the amputatedforearm: 22.8 ± 2.6 cm, side of amputation: 9 right and3 left. In the experiment, none of the subjects had impaired proprioception due to diabetes or other diseases.
The subjects were randomly divided into twogroups, a group in which the dual-handed task was
performed after the single-handed task (group A) andanother group in which the single-handed task was
performed after the dual-handed task (group B). The
significance of differences between the groups was analyzed using Fisher’s exact test for sex and the amputatedside and Mann-Whitney’s U test for age. Height, bodyweight, residual amputated forearm length, residual
percentage amputated forearm length, and maximum
amputated forearm circumference were analyzed using
the Student’s t test. No significant intergroup differenceswere found for any of the examined background factors(p>0.05) (Table 1).
This research complied with the tenets of the
Declaration of Helsinki and was conducted with the approval of the institutional review board of Kobe Gakuin
University (approval code: HEB101207-4).
2-2. Design and Protocol
This study involved a crossover design. In thebaseline period, the subjects practiced controlling the
opening and closing movements of a virtual myoelectric
hand using a software program on a personal computerfor 20 minutes per day for 5 days as practice before
donning the myoelectric prosthesis. Next, groups A and
B performed both tasks. Group A performed the dual-handed task after performing the single-handed task,
and group B performed the single-handed task after performing the dual-handed task. Each task was conducted

Table 1. Group A and Group B profile

Sex [M/F]
Age [year]
Body height [cm]Body weight [kg]Side [R/L]
Stump length [cm]
Stump ratio [%]Stump max girth [cm]Amputation history [month]etiology [trauma/congenital]
Body prosthesis history [mo nth]Group A
n=6

Group B
n=6

p値

3/3
43.8 ± 12.8
161.0 ± 7.3
56.2 ± 6.6
5/1
17.3 ± 52
66.3 ± 17.5
22.8 ± 1.9
112.0 ± 250.8
5/1
4.0 ± 2.6

5/1
42.0 ± 16.1
164.5 ± 6.9
61.7 ± 6.7
4/2
19.0 ± 6.5
66.3 ± 21.8
22.8 ± 3.4
140.2 ± 236.3
4/2
4.0 ± 5.2

n.s
n.s
n.s
n.s
n.s
n.s
n.s
n.s
n.s
n.s
n.s

Notes. Sex and amputation ratios in both groups were determined using Fisher's exact test, age was determined using Mann-Whitney's U test, Body height, Body weight, Stump length, ratio, and maximum girth using Student's t
test. n.s.: not significant

Asian J Occup Ther 18: 39−46, 2022

Oba J et al.

41

Fig. 1. Protocol
Notes. The design of thi s study adopted a crossover test method. In the baseline period of this study design, participants practiced opening and closing control using a myoelectric hand in a monitor for 20 minutes a day for 5 days as a practice before wearing myoelectric
prosthesis.

for 20 minutes per day for 5 days, for a total of 10 days.
The washout period was set to 2 days. Both groups
underwent a myoelectric hand operation test before andafter each period (Figure 1).
The myoelectric hand used in this study was the
Ottobock MyoBock electric hand (8E38 = 6 DMC plus
7.1 / 4). The electrodes for opening and closing the
myoelectric hand were positioned on the extensor carpi
radialis longus and flexor carpi ulnaris of the residual
forearm.
The single-handed and dual-handed tasks selected
as training methods for this study were based on thoseused in clinical practice and previous myoelectric prosthesis studies [7-9]. The single-handed task involved
picking up and placing (holding, moving, and releasing) a block (a cube; side length: 1 to 3 cm) or a disk
(diameter: 1 to 3 cm) on a desk and was performed for
20 minutes a day for 5 days [9]. Each day, the subjects
were asked to perform the task 50 times at their own
pace. The subjects were also instructed not to assist the
myoelectric prosthesis with their intact hand. The dual-handed task was also a 5-day assignment. In this task,
macrame was performed for 20 minutes, twice a day.
Specifically, the subjects were required to create 20 flatknots on a desk [9]. They were instructed to use theirintact hands as they would in a normal dual-handed task.
We pilot-tested the macrame task to confirm whether it
had direct effects on the outcome measure of this experiment. The results showed that it had no recognizableinfluence. The assessment procedure did not involve
string manipulation or repeated hold-and-release operations; therefore, we concluded that the macrame task
was an independent task and would not interfere withthe assessment procedure.
2-3. Outcome measure
The Southampton Hand Assessment Procedure(SHAP) score [9,10] was used as the outcome measurein this study. The SHAP test’s credibility and validity
for measuring the controllability of opening/closing
myoelectric hand movements and the ability of subjects
to manipulate objects using a myoelectric hand during
daily activities were confirmed by Hill et al. [9,11]. The
capability to manipulate objects represents the ability1) to appropriately manipulate an object as intended, 2)
to adjust the contact position and force applied so thatthey are appropriate for the target object, 3) to hold andmove the object without dropping it, and 4) to accurately release the object at the target location [9-11]. The
SHAP test consists of 6 abstract objects and 14 activities
of daily living. Each task is timed by the subject andrecorded on an assessment sheet by the assessor. The
score is computed from the time and normalized to a
100-point scale [12] (Figure 2).
As for the experimental environment, the subjects
donned the myoelectric hand and sat in front of a desk.
The height of the desk was adjusted so that the angle ofthe elbow joint was 90 degrees during the performance

42

TRAINING METHOD OF MYOELECTRIC HAND PROSTHESIS

Fig. 2 The Southampton Hand Assessment Procedure (SHAP)
Notes. This test evaluates the ability to control the opening and closing of the myoelectric hand and the ability to operate items. It consistsof six types of object tasks for manipulating the object whose shape is to be grasped and 14 types of daily life movement tasks [11-13]of the task [13]. Prior to the test, each task was practiced
only once by the subjects to confirm that the prosthetic
hand could be used to execute the task. An occupational
therapist, other than the primary researcher, with experience of training amputees to operate myoelectric
prosthetic hands performed the examinations.
2-4. Statistical analysis
In this study, we used the crossover method toinvestigate the differences in the changes in myoelectric
prosthetic hand operation ability between the single-handed and dual-handed tasks.
The carryover effect was examined by assessing
whether the results obtained in the first half of theintervention were carried over to the beginning of thesecond half of the intervention. The carryover effect was
analyzed by comparing the median of the sum of thescores for the first and second interventions between thegroups. When the difference was insignificant (p> 0.10),
we judged that there was no carryover effect, and tested
the timing effect and training effect. The timing effectis the potential effect of conducting the intervention ata particular time. In this study, the timing effect wascalculated by subtracting the results for the second intervention from those for the first intervention in groupA, and subtracting the results for the first intervention
from those for the second intervention in group B. The
training effect is the difference between the effects of
two or more tests [14,15]. We compared the change
seen in the single-handed task with that seen in the
dual-handed task in the first half of the intervention,and the change seen in the single-handed task withthat seen in the dual-handed task in the second half of
the intervention. The effect of the task was determinedbased on which task’s change value was significantly
higher [14,15]. The difference in the effects of thesingle-handed and dual-handed tasks was considered torepresent the training effect in this study. We analyzed
the results of groups A and B with the Mann-Whitney U
test. The statistical significance level was set at 0.1 forthe carryover effect test and 0.05 for the timing effectand training effect. The results obtained before and after

Asian J Occup Ther 18: 39−46, 2022

Oba J et al.

3. Results

the single-handed and dual-handed tasks were analyzed
with the Wilcoxon signed rank test, using the results forthe first half of the intervention. This was done in order
to exclude the effects of prior training experience [14,15].
The significance level was set at 0.05. In each test, theeffect size ( r ), which indicated the magnitude of theeffect, was calculated in addition to the significance ofthe difference in the training effect.
Statistical analyses were conducted by performing
the Mann-Whitney U test and Wilcoxon signed rank test
using statistical analysis software (IBM SPSS Statistics
ver.24.0). The effect size was calculated with Microsoft
Excel ver.16.0, using the Z-value obtained from theMann-Whitney U test and Wilcoxon signed rank test.

The results of this study are shown in Tables 2, 3,
and 4.
Table 2 shows the SHAP scores for each subject ingroups A and B. The results for the first to fourth tests
are represented as median and interquartile range values.
In group A, the scores for the first, second, third andfourth tests were 43.5 (40.0-44.5) points, 47.0 (45.547.0) points, 46.0 (43.0-47.5) points, and 55.0 (54.356.7) points, respectively. In group B, the scores for the
first, second, third, and fourth tests were 41.5 (38.0-43.5)
points, 53.0 (52.0-54.8) points, 51.0 (49.3-52.0) points,
and 60.0 (58.5-60.0) points, respectively.
Table 3 shows the results of comparisons of
the SHAP scores obtained before and after the single-handed task and those obtained before and after the

Table 2. Result of SHAP of all subjects (A group and B group)
I

II

III

IV

Group A

43.5 (40.0-44.5)

47.0 (45.5-47.0)

46.0 (43.0-47.5)

55.0 (54.3-56.7)

Group B

41.5 (38.0-43.5)

Single-handed task

Dual-handed task

53.0 (52.0-54.8)

51.0 (49.3-52.0)

Dual-handed task

60.0 (58.5-60.0)

Single-handed task

Notes. The results of SHAP for each subject in Groups A and B.
Data are represented as median (interquartile range), SHAP score.

Table 3. Results of statistical analysis in the SHAP crossover test method
median (IQR)
Group A

13.5 (11.3-15.8)

GroupB

21.0 (16.3-25.8)

first half of the mterventlon-1.8 (-4.3-0.4)

second halfo f the mtervenhon

0.8 (0.5-3.3)

carryover effecttimmg effecttraining effect43

sigle-handed task

6.3 (5.8-8.5)

dual-handed task

10.3 (8.8-14.2)

effect size ( r )p-value
0.421
0.31

0.20†

0.008**

Notes. Comparison of SHAP score GroupA and GroupB was conducted using the Mann-Whitney U test. Comparison of SHAP firsthalf of the intervention and second half of the intervention was conducted using the Mann-Whitney U test. Comparison of SHAP single-handed task and dual-handed task was conducted using the Mann-Whitney U test and the effect size.
*p<.05. **p<.01. ***p<.001. † r ≧ .01. ‡ r ≧ .03. § r ≧ .05.

Table 4. Comparison of SHAP before and after single-handed task and before and after dual-handed task
Beforemedian (IQR)

Aftermedian (IQR)

p-valueeffect size ( r )single-handed task

44 (40-45)

47 (45-48)

0.045*

0.59 §

dual-handed task

42 (38-44)

53 (52-55)

0.001***

0.78 §

Notes. C omparisono f SHAP score before and after single-handed task and dual-handed task was conducted usmg Wilcoxon signed ra11k test and the effect size.
*p<.05. **p<.01. ***p<.001. † r ≧ .01. ‡ r ≧ .03. § r ≧ .05.

44

TRAINING METHOD OF MYOELECTRIC HAND PROSTHESIS

dual-handed task. There was no significant difference inthe carryover effect between groups A (13.5 (7.0-28.0)
points) and B (21.0 (8.0-26.0) points) (p = 0.421). There
was no significant difference in the timing effect between the first (-1.8 (-4.3-0.4) points) and second halves(0.8 (0.5-3.3) points) of the intervention (p = 0.310).
There was a significant difference in the training effectbetween the single-handed task (6.3 (5.8-8.5) points)
and the dual-handed task (10.3 (8.8-14.2) points), but
the effect size was small (p = 0.008, r = 0.20). The scorechange seen in the dual-handed task was larger than thatobserved in the single-handed task.
The comparison between the results obtained before
and after the training showed a significant difference(Table 4). The result obtained before the single-handedtask was 44 (40-45) points, and that obtained after the
single-handed task was 47 (45-48) points, and the effectsize was moderate (p = 0.045, r = 0.59).
There was a significant difference between the
results obtained before the dual-handed task (42 (38-44)
points) and those obtained after the dual-handed task (53(52-55) points). The effect size was large (p <0.001, r =0.78).

4. Discussion
This study adopted a crossover design due to thelimited number of subjects, which was affected by thefact that it targeted unilateral transradial amputees andthe conditions for the myoelectric hand training would
have discouraged some potential subjects from taking
part.
As for the results, the SHAP score increased during
both the single-handed and dual-handed tasks. Furthermore, statistical analyses showed that 1) the changes
seen after both the single-handed and dual-handed tasks
were significant; 2) the effect of the single-handed task
was moderate, and that of the dual-handed task waslarge; and 3) the dual-handed task had a greater effect on
myoelectric hand operation than the single-handed task.
Therefore, the implementation of single-handed task anddual-handed task training based on clinical experience
is justified, but it is important to carefully consider thedetail of such tasks.
Furthermore, when comparing the single-handedtask and the dual-handed task, the carryover effect andtime effect were not significant, while the training effectwas significant. This indicates that the dual-handed task
had a superior training effect compared with the single-handed task.
Hill reported that the aim of such dual-handedtasks is to acquire cooperative dual-handed movement
between the myoelectric prosthesis and intact hand [10].

The dual-handed task required the opening and closingof the myoelectric hand to be controlled more precisely
than the single-handed task and involved cooperation
with the intact hand. The significantly higher score seenin the dual-handed task implies that the dual-handedtask was effective at helping the subjects to acquire
the ability to grasp objects accurately, adjust their grip
properly, and grasp and release objects. Also, the purpose of such dual-handed tasks is to enhance the speed,
accuracy, and hand-eye coordination of the myoelectric
prosthesis hand [8, 9]. Hand-eye coordination, which
is often referred to as visuomanual pursuit tracking,requires coordination between various areas of the central nervous system [17]. Visuomanual pursuit tracking
involves controlling the movement of the upper limb
by capturing positional information about the target
object and the upper limb [18]. It was reported that theposition of the target object is an important factor, which
affects the distance and direction of the object, body,shoulder, and hand, and that gazing at the target affects
the speed of movement during reaching movements [18].
Therefore, the dual-handed task increased the movement
speed of the myoelectric hand when grasping the target
object. In the future, we would like to examine the possibility that the dual-handed task may have affected thesubjects’ ability to gaze at the target object and adjust
the direction of the appropriate hand as compared withthe single-handed task. In addition, the dual-handed task
requires cooperation with the intact hand and accurate
control of opening and closing movements of the myoelectric hand, appropriately timed directional movement
coordination of the myoelectric hand toward the object,and grasping and releasing the target object accurately.
Presumably, the somatosensory senses of the residual
limb improve accordingly. The dual-handed task may
involve more effective loops for controlling the opening
and closing of the myoelectric hand and the manipulation of the target object operation than the single-handed
task.
Macrame was used for the dual-handed task in thisstudy. It is necessary to consider whether the macrametask affected the results of the SHAP test; i.e., whether
the macrame and SHAP tasks were similar. Macrame
involves repeatedly performing an operation involving
the gripping of string, but none of the tasks in the SHAP
test involved string, and repeating a gripping operation
is not a hindrance. Therefore, the similarities between
the macrame and SHAP tasks were minimal, and any
direct effect was considered to be weak.
The results of this study demonstrated that boththe single-handed and dual-handed tasks are effective
tools for learning how to control the opening/closing
movements of a myoelectric hand and use a myoelectricAsian J Occup Ther 18: 39−46, 2022

hand to perform daily activities. Compared with thesingle-handed task, the dual-handed task was more
effective. In occupational therapy, we recommend
implementing dual-handed tasks in the early stagesof training. By performing dual-handed tasks more
frequently than single-handed tasks, patients’ ability tooperate myoelectric prosthetic hands can be expected
to improve more quickly. This should also reduce thelength of the training period.

5. Limitations and future work
The number of subjects in this study was 12, andthe number of samples was small. Therefore, the resultsof this study cannot be used as definitive proof of theuniversal effects of myoelectric prosthesis training.
The results should be investigated for their reliability
in a larger pool of transradial amputees. Also, Whether the amputation measurement is a dominant handmeasurement can affect effectiveness and learning.
Therefore, the study group need to control the dominant
hand on the amputee. However, in the clinical setting,the number of upper limb amputees is small, and it isextremely difficult to obtain research cooperation fromunilateral upper limb amputees who have no experienceof myoelectric prosthesis training. Therefore, this study
was conducted with the cooperation of 12 transradial
amputees.
Regarding the study design, the two-day washout
period was short. It would be desirable to employ a oneweek washout period between the intervention periods.
The two-day washout period was recommended by theinstitutional review board to reduce the stress place on
the subjects.
In this study, the Ottobock MyoBock electric hand
was the only myoelectric hand used. It is recommended
that our results should be verified with other myoelectric
hands, e.g., the Össur i-Limb quantum and Ottobock
bebionic hand.

6. Acknowledgements
The authors thank the subjects of this study. The
authors also thank the occupational therapists who performed the myoelectric prosthesis training and assistedwith the measurement of the SHAP scores.

7. Authors’ contributions
All of the authors contributed equally to the preparation of this manuscript.

Oba J et al.

45

8. 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.

9. Funding
The authors disclosed receipt of the following
financial support for the research, authorship, and/or
publication of this article: This research was supported
by JSPS KAKENHI Grant Number 18K12156 and21H03858.

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prostheses. Journal of Prosthetics and Orthotics. 2012;24(2): 56–64[4] Carey L. Stephanie, Derek J. Lura, M. Jason. Differencesin myoelectric and body- powered upper-limb prostheses:
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■ORIGINAL ARTICLE

The Immediate Effects of a Knee-Ankle-Foot
Orthosis on Standing Reach in Individuals with
Subacute Stroke
Tomohiro Ota1, Hiroyuki Hashidate2, Natsuki Shimizu1, Mitsunobu Yatsunami2
1
2

Hatsudai Rehabilitation Hospital
Department of Physical Therapy, School of Health Science, Kyorin University

Abstract: Background and Objectives: A knee-ankle-foot orthosis (KAFO) has been clinically used for individuals
with stroke, but its effect is still unclear. This study was to evaluate the immediate effects of a KAFO on the standing
reach of individuals with subacute stroke.
Method: This study adopted a cross-sectional experimental design. A total of 31 inpatients with subacute stroke (meanage, 66.5 ± 14.4 years; mean poststroke interval at admission, 26.2 ± 10.1 days) were enrolled in the study. The functional reach test (FRT) was used to measure the standing reach of the participants with or without a KAFO. The participants were divided into the following groups on the basis of the results of FRT without a KAFO: group 1 comprised patients who were unable to reach without a KAFO (n = 22), and group 2 comprised patients who had the ability to reach
without a KAFO (n = 9).
Results: In group 1, the proportion of participants who could reach with a KAFO significantly increased (p = 0.002). In
group 2, the mean standing reach with a KAFO (25.4 ± 6.7 cm) was significantly longer than that without a KAFO (20.3± 7.0 cm) (p = 0.021).
Conclusion: The use of a KAFO may immediately improve the standing reach of individuals with subacute stroke.
Results show that a KAFO may be an effective device for improving standing reach and can be used to develop rehabilitation programs for individuals with subacute stroke.
Keywords: stroke, hemiplegia, rehabilitation, orthotic devices, postural balance(Asian J Occup Ther 18: 47−54, 2022)

Introduction
Stroke is a leading cause of long-term disability [1],and the primary goal of stroke rehabilitation is to regain
independence in performing activities of daily living(ADLs). The improvement of standing balance is an
essential factor of ADL performance because activities
while standing, such as transferring, walking, climbing
stairs, toileting, and dressing, are frequently performedin daily life. Standing balance is also important in preventing falls in individuals with stroke [2].
The clinical guidelines of the Stroke Foundation
Received: 27 June 2020, Accepted: 30 November 2021
Corresponding to: Tomohiro Ota, Hatsudai Rehabilitation Hospital,
3-53-3 Honmachi, Shibuya-ku, Tokyo 151-0071, Japane-mail: d2107003@gmail.com©2022 Japanese Association of Occupational Therapists

suggested that the task-specific practice of standingbalance is recommended for individuals with stroke whohave difficulty standing [3]. Furthermore, performing
standing practice early after stroke onset is essential
for improving stroke care effectiveness [4, 5]. The current concepts of biological recovery after brain injury
suggest that early task-specific intensive practice hasa crucial contribution in improving stroke recovery[6]. To prevent or minimize secondary changes to themusculoskeletal and cardiorespiratory systems due toimmobility, performing standing practice early after
stroke onset is essential [7]. In individuals with severe
stroke, standing and walking activities are affected bysevere impairments, and balance recovery and independent walking are limited. Therefore, improving standing
abilities, such as standing reach, early after stroke onset
is required for individuals with severe stroke.
In the clinical setting, lower limb orthoses, such

48

THE IMMEDIATE EFFECTS OF KAFO ON STANDING REACH IN STROKE

as ankle-foot orthoses (AFOs) and knee-ankle-footorthoses (KAFOs), have been used to improve standing abilities by compensating for the stability of theparetic lower limb. The therapeutic effects of lower
limb orthoses are differentiated into immediate effects
by wearing lower limb orthosis [8-15] and fixed-term
effects by wearing and training with lower limb orthoses
over a certain period [16]. The immediate effects referto changes in performance that immediately occur after
wearing lower limb orthoses. The fixed-term effects
refer to the changes in performance that occur when individuals use lower limb orthoses over a specific period,
and these effects include immediate effects. Therefore,
to verify the fixed-term effects of using lower limb orthoses, the immediate effects need to be evaluated.
AFOs have been used to compensate for the stability of the paretic lower limb by stabilizing the ankle
joint. Previous studies have shown that AFOs immediately improved walking abilities, such as walking
independence [8], walking speed [9], walking endurance[10], and stride length [11], and standing abilities, suchas weight bearing on the paretic lower limb [12] andbody sway [13] in static standing. Furthermore, the useof AFOs improved walking speed over time [16].
Conversely, KAFOs have been used to compensate
for the stability of the paretic lower limb by stabilizing
the knee and ankle joints and improve the walking abilities of individuals with severe stroke [17]. However,
little information has been reported on the immediate
and fixed-term effects of KAFOs on the standing balanceof individuals with stroke. Standing balance is divided
into static and dynamic standing balance abilities [18,19]. Previous study reported that KAFOs immediately

improved the static standing of individuals with subacutestroke [15]. However, the immediate effects of KAFOs
on the dynamic standing of individuals with subacutestroke have not been clarified. Dynamic balance isdefined as the ability to maintain stability during weightshifting [19] and is assessed by performing reachingtasks while standing. A recent report showed that AFOs
immediately improved reach distance while standing[14]. Although KAFOs are used for individuals withsevere stroke instead of AFOs, KAFOs immediately
improved static standing [15] similar to AFOs [12, 13].
Therefore, KAFOs can be one of the beneficial interventions for stabilizing unstable paretic lower limb and for
improving the disabilities of individuals with stroke [17];hence, the authors hypothesized that wearing KAFOs
immediately improves the standing reach of individuals
with stroke, similar to AFOs [14], by compensating forthe stability of the paretic lower limb.
This study was to evaluate the immediate effectsof KAFOs on the standing reach of individuals withsubacute stroke. Identifying the immediate effects of
KAFOs on standing reach could be useful for the establishment of therapeutic and rehabilitation programs with
KAFOs that are designed to improve the standing reachof individuals with severe stroke.

Methods
Study design
A cross-sectional experimental design was adopted.
This study was approved by the ethics committee ofKyorin University (28-4) and Hatsudai Rehabilitation
Hospital (H27-85).

Table 1. Characteristics of participants.
Group 1 (n = 22)aAge, year

Group 2 (n = 9)72.3 (11.8) [67.1, 77.5]
bStatistic

52.4 (9.8) [44.9, 60.0]

p

-3.31

d

< 0.001
0.534

0.39

e

Stroke type (hemorrhage/infarction), nc

7 (32) /15 (68)c

8 (89) /1 (11)

8.33

e

0.004

Affected side (right/left), nb

10 (45)/12 (55)

5 (56)/4 (44)

0.26e

0.609

-1.72

d

0.085

-1.72

d

0.085

e

0.001

Gender (male/female), n

12 (55)/10 (45)bcaPeriod from stroke onset to admission, dayc28.2 (10.0) [23.8, 32.7]
aPeriod from stroke onset to KAFO prescription, dayb

6 (67)/3 (33)37.6 (12.9) [31.9, 43.3]
cc21.2 (8.9) [14.4, 28.0]
29.1 (12.5) [19.5, 38.7]cc

BRS of the paretic lower limb (II/III/IV), n

16 (73) /6 (27)/0 (0)1 (11) /5 (56)/3 (33)

13.20

SIAS knee extension strength item (2/3), nb

6 (27)/16 (73)0 (0)/9 (100)

3.04e

0.081

9 (100)/0 (0)

e

0.349

Type of KAFO (1/2), nb

20 (91)/2 (9)0.88

Note. BRS = Brunnstrom recovery stage; SIAS = Stroke impairment assessment set; KAFO = knee-ankle-foot orthosis. Type of KAFO, 1 =KAFO with spring assisted extension knee joint and Klenzak ankle joint, 2 = KAFO with ring lock knee joint and Klenzak ankle joint.
aContinuous variables were analyzed with Mann-Whitney U test, and the data were shown as M (SD) [95% confidence interval]. bNominal variables were analyzed with chi-square test, and the data were showed as n (%). cAdjusted residual > |1.96|. dZ-score was based on Mann-Whitney U
test. eχ2-score was based on chi-squared test.

Asian J Occup Ther 18: 47−54, 2022

Ota T et al.

49

Figure1. Measurement
method of the
FRT withor without
KAFOor without KAFO.
Figure1. Measurement
methodof the
FRT with
		 FRT = functional reach test; KAFOs = knee-ankle-foot orthoses.

FRT = functional reach test; KAFOs = knee–ankle–foot orthoses.

ParticipantsThis study enrolled 31 patients with subacute stroke(mean age, 66.5 ± 14.4 years; mean poststroke interval
at admission, 26.2 ± 10.1 days) admitted to a rehabilitation hospital (Table 1). The inclusion criteria were as
follows: (1) patients who have stroke for the first time,(2) those whose poststroke intervals at admission were
within 60 days, (3) those not using lower limb orthoses(KAFOs were provided for the first time after stroke
onset), and (4) those who can follow simple verbal commands or instructions. All participants provided written
informed consent.
Experimental protocol
The demographic and physical characteristics ofthe participants were recorded within 1 week before
receiving KAFOs (Table 1). Demographic characteristics, such as age, sex, stroke type, lesion side, time fromstroke onset to admission or KAFO provision, and typeof KAFO were investigated. As physical characteris-

tics, paretic and nonparetic lower limb function wereassessed by physical therapists. The motor paralysis
severity of the paretic lower limb was evaluated using
Brunnstrom recovery stage [20]. The BRS is classified under six categories (from I [flaccidity with nomovement] to VI [individual joint movement with little
awkwardness]) as per the motor recovery process ofhemiparalysis after stroke. The nonparetic lower limb
function was evaluated using the quadriceps muscle
strength item of the unaffected side function subcategory
in stroke impairment assessment set (SIAS) [21]. This
1 0 (severely impaired) to 3 (normal).
item is rated fromAll participants were provided with KAFOs after
admission for the first time. A doctor, physical therapist,and prosthetist determined whether to provide inpatientswith KAFOs after early admission. KAFOs were provided on the basis of standing and walking performances and the presence or absence of knee collapse while
standing and walking with or without the use of lower
limb orthoses. Specifically, lower limb orthoses were50

THE IMMEDIATE EFFECTS OF KAFO ON STANDING REACH IN STROKE

FigureTwo groups
groups formed
dependingon the on
results
the FRTof
without
KAFOs.
Figure2.2.Twoformeddependingtheofresults
the FRT
without KAFOs.
		 FRT = functional reach test; KAFOs = knee-ankle-foot orthoses.

FRT = functional reach test; KAFOs = knee–ankle–foot orthoses.

provided when the participants (1) could undergo standing or walking training but have unstable knee and ankle
joints due to severe motor impairments, (2) exhibited
spasticity patterns predominantly in the flexor muscles
and could not keep a knee extension position while
standing or walking, and (3) displayed insufficient knee
control or instability or have an AFO that inadequately
controlled knee instability [22]. All participants were
provided with traditional KAFOs equipped with bilateral
metal struts that could be used as AFOs by removing theparts for the knee joint and thigh (Kawamura Gishi Co.,
Ltd., Osaka, Japan; MEDX. Co., Ltd., Tokyo, Japan).
For standing balance, the maximal forward reaching distance was measured using the functional reachtest (FRT) [23] with and without a KAFO on the paretic
lower limb (Fig. 1). A tape measure was placed at thelevel of the participants’ acromion process. Before thereaching movement, the measuring tool was leveled sothat it was horizontal to the floor. Reaching was performed using the nonparetic arm because it is difficultfor individuals with stroke to maintain the paretic arm
above shoulder level. The participants lifted their outstretched nonparetic arm to shoulder height, paused for
initial reading, and reached as far forward as possible.
They were instructed to “reach as far forward as they
can without moving their feet or taking a step and to try
keeping their hands along the tape measure.” The startand end positions of the index finger of the outstretchedhand were recorded, and the positional difference represented the total reach for that direction. During theexamination, the participants stood in a comfortable upright posture without physical assistance and raised theirunaffected arm to the height of the acromion process.
Their feet were maintained flat on the floor, and the test
was discarded and repeated if the feet were moved. The

FRT was performed on the same day within 1 week after
providing KAFOs. In tests with and without KAFOs,
participants wore shoes on their nonparetic lower
limb and were barefoot, respectively. In this study, the
KAFOs used were those that were provided to the participants after admission. The FRT was performed threetimes, and the maximal reach distance was adopted as
the representative value.
To assess whether the participants can perform
standing reach, the “reaching forward while standing”
item of the functional balance scale (FBS) [24, 25] wasscored on the basis of the FRT results. The FBS is a 14item scale that assesses the balance of individuals withstroke and has good reliability and validity [25]. The
items are scored from zero points to four points. A scoreof zero points represents an inability to complete thetask, and a score of four points represents the ability to
independently complete the task. In the present study,
the “reaching forward while standing” item of the FBS
was scored from zero points to four points.
Data analysis
To evaluate the immediate effects of KAFOs on the
FRT results, the participants were divided into the following groups on the basis of the results of the “reaching forward while standing” item of the FBS without
KAFOs: participants who were unable to undergo the1
FRT or require assistance (zero points) were categorized
as participants who were unable to reach (group 1),
whereas participants who were able to undergo FRTwith or without supervision (≥1 point) were categorized
as participants who were able to reach (group 2) (Fig. 2).
The Mann-Whitney U test was performed to compare age and time from stroke onset to admission or
KAFO provision between groups. The chi-squared test

Asian J Occup Ther 18: 47−54, 2022

Ota T et al.

51

Table 2. Comparisons of the proportion of participants who were able to reach with KAFOs among participants who were unable to reach without KAFOs.
Unable to reachAble to reachn (%)

Adjusted residualn (%)

Adjusted residual

Without KAFOs

22 (100)

3.13

0 (0)

-3.13

With KAFOs

14 (64)-3.13

8 (36)

3.13

Note. KAFOs = knee-ankle-foot orthoses.
χ2 = 9.78. p = 0.002. effect size (Cramer’s V) = 0.47.

Figure 3. 	Comparison of reach distance during the FRT with and without KAFOs
Figure 3.
Comparison
reachduring
FRT with and without KAFOs among
among
participantsof
whowere distanceable to reach
withoutthe
KAFOs.
		
FRT =who
functional= knee-ankle-footparticipants
werereachabletest;
to KAFOsreach without
KAFOs.orthoses.
		*p < 0.05.

FRT = functional reach test; KAFOs = knee–ankle–foot orthoses.
*p < 0.05.
was also performed to compare sex, stroke type, lesionside, the BRS of the paretic lower limb, quadriceps
muscle strength items of the SIAS, and type of KAFO
between groups. In group 1, the chi-squared test wasused to compare the proportion of participants who wereable to reach with KAFOs. In group 2, the data of reachdistance during the FRT with or without KAFO followed normal distribution. However, the Wilcoxon ranksum test was used to examine the differences in reachdistance with and without KAFOs, because sample sizein this study was small.
The significance level was set at p ≥ 0.05, and all
analyses were conducted using Statistical Package for
the Social Sciences version 23.0 (IBM Corp., Chicago,
IL, USA).

Results
The results of the “reaching forward while standing” item of the FBS without KAFOs showed that the

numbers of participants in groups 1 and 2 were 22 and 9,
respectively.
The Mann-Whitney U test showed that group
2 was significantly younger than group 2 (Table 1).
The chi-squared test showed that the proportions ofparticipants who had infarction or BRS IV in group 2
were higher than those in group 1 (Table 2). In addition,
the chi-squared test also showed that the proportion ofparticipants who had BRS II in group 2 was lower thanthat in group 1. There were no significant differences ingender, affected side, quadriceps muscle strength itemsof the SIAS, type of KAFO, period from stroke onset toadmission, and period from the stroke onset to KAFO
prescription between groups.
The chi-squared test showed that the proportionof participants in group 1 who were able to reach significantly increased with KAFO use (Table 2). Amongthe participants in group 1 who were able to reach with
KAFOs, the mean reach distance in the FRT was 11.0 ±6.2 cm.

1

52

THE IMMEDIATE EFFECTS OF KAFO ON STANDING REACH IN STROKE

In group 2, mean reach distance during the FRTwith KAFOs and without KAFOs were 25.4 ± 6.7 cm,
95% confidence interval (CI) [20.2, 30.5] and 20.3 ± 7.0
cm, 95% CI [14.9, 25.7]. The Wilcoxon rank-sum test
showed that the mean reach distance during the FRTwith KAFOs was significantly longer than that during
the FRT without KAFOs, p = 0.021, Z = -2.31, effectsize (r) = 0.77, mean amount of change = 5.1 ± 4.6 cm,
95% CI for the difference [1.6, 8.7] (Fig. 3).

Discussion
This study evaluated the immediate effects of
KAFOs on the standing reach of individuals withsubacute stroke. There was a significant improvement
in standing reach when the participants wore KAFOs.
Among the participants who were unable to reach
without KAFOs, the proportion of those able to reachsignificantly increased after wearing KAFOs. Furthermore, among the participants who were able to reach
without KAFOs, standing reach significantly improved
after using KAFOs. To the best of our knowledge, thisis the first study to evaluate the immediate effects of
KAFOs on the standing reach of individuals with subacute stroke. Regarding orthotic treatment for improving
the standing reach of individuals with severe subacutestroke, this study provides information on the estimatedeffects of KAFOs on standing reach.
Among the participants who were unable to reach
without KAFOs, the number of participants who wereable to reach increased immediately after wearing
KAFOs. Among the participants who were able to reach
without KAFOs, wearing KAFOs improved the reachdistance in the forward direction. Duncan et al. [21]reported that the reach distance during the FRT was
highly correlated with the center of pressure (COP) displacement, which determines the limit of stability (LOS)[26]. The LOS of people with stroke is narrow because
of instability of paretic lower limb affected by motor paralysis, and the upright standing of people with stroke ischaracterized by weight-bearing asymmetry with moreweight on the nonparetic lower limb [27]. Narrow LOS
restricts the COP displacement in the anterior-posterior
and medial-lateral directions and makes it more difficult
to control the COP movement and to perform the FRT.
Participants in group 1 might be unable to reach because
motor paralysis of paretic lower limb was more severe
and the LOS was narrower than those of group 2. Ingroup 2, most participants had moderate motor paralysis
of paretic lower limb, and motor paralysis of paretic
lower limb might decrease the LOS and reach distanceduring the FRT. In each group, the use of KAFO might
increase the LOS by compensating for the stability ofthe paretic lower limbs, and make it easier to control
the COP movement, resulting in immediately improvement of the FRT. On average, KAFO use increased theforward reach distance by 5.1 cm. In best of our knowledge, there were no previous studies on minimal clinically important change for FRT in people with severe
stroke to compare the change of the forward reachdistance in this study. However, in recently systematic
review, exercise training improved the forward reachdistance, and the mean difference in the forward reachdistance before and after training was 3.1 cm in individuals with stroke [28]. The results of this study indicatedthat KAFOs immediately made positive changes in theforward reach distance equivalent to exercise training.
In addition, the effect size r calculated for the change ofthe forward reach distance was large. Therefore, wearing
KAFOs may lead to the considerable improvement forstanding reach of individuals with subacute stroke.
Individuals with severe stroke have impaired abilities to perform standing activities and have decreased
physical activity overall because of the severe impairments and disabilities. Decreased physical activity can
induce secondary changes in the musculoskeletal [29]and cardiorespiratory systems [30] and may be harmful
for rehabilitation. The early use of KAFOs in these
individuals after stroke onset may improve the ability
to perform standing activities and increase physical activity by immediately improving standing balance. Additionally, task-specific balance exercises improved thestanding balance of individuals with stroke [31]. KAFOs
can be used anywhere and allow individuals to performtask-specific standing exercises. Performing practicalstanding exercises with KAFOs during daily living
may be useful for adaptations to the living environment
and the reorganization of the brain after stroke. Further
studies are needed to verify the fixed-term effects ofadditional exercises with KAFOs on standing reach thatexceeds the immediate effects of KAFOs.
Limitation
This study used a small convenience sample.
Caution is required when interpreting the results of thisstudy for generalization and application.

Conclusion
The standing reach of individuals with subacutestroke can be improved immediately by wearing
KAFOs.

Asian J Occup Ther 18: 47−54, 2022

Funding statement or Declaration of
conflicting interests
The authors received no financial support for the
research, authorship, and/or publication of this article.

Author contributions
All authors contributed equally in the preparationof this manuscript.

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■ORIGINAL ARTICLE

Effects of Visual Impairment After Acute Stroke on
Activities of Daily Living
Kaori Ito1, Keisuke Hanada2, 3, Kayoko Yokoi4, Kazutaka Sakamoto5,
Kazumi Hirayama4
1

Department of Rehabilitation, Japanese Red cross Society Omori Red Cross Hospital
Department of Rehabilitation, Kinsyukai Hanwa Memorial Hospital
3
Osaka Prefectural University Graduate School of Comprehensive Rehabilitation
4
Department of Occupational Therapy, Graduate School of Health Sciences, Yamagata Prefectural University of Health Sciences
5
Department of Neuropsychiatry, Aizu Medical Center, Fukushima Medical University, Fukushima
2

Abstract: Objective: In stroke patients with visual impairment, it is unclear which activities of daily living (ADL) are
affected or how they are affected. This study aimed to determine the effect of the type and prevalence of visual impairments on ADL in acute stroke patients.
Method: We interviewed stroke patients without severe movement disorder, aphasia, general inattention, or hemispatial
neglect who were admitted to our hospital between September 2018 and May 2020 for lesions in the cortical and subcortical white matter posterior to the central sulcus. The patients were asked via a questionnaire whether they had ADL
impairments related to 13 types of visual impairments, and to provide specific examples. We determined the types ofvisual impairments, the prevalence of each impairment, and what effect they exerted on daily life.
Results: Sixteen participants were included. Fifteen participants had defective visual search, 14 had hemianopic dyslexia, 9 had walking trajectory deviations, and 6 had difficulty in recalling the place where they were seeing right before.
In addition, there were defective visual counting, difficulty in judging distance, and pure alexia.
Conclusion: Even in cases without severe movement disorder, aphasia, general inattention, and hemispatial neglect, cerebral infarction in the posterior half of the cerebrum causes problems in ADL due to visual impairment. It is important
to interview patients from the acute stage with visual impairment in mind.
Keywords: visual impairment, acute stroke, symptom, questionnaire, defective visual search(Asian J Occup Ther 18: 55−64, 2022)

Introduction
Approximately 30% of all stroke patients experience post-stroke visual impairment [1]. Hemianopia
is the most prominent symptom in these patients, but
in a survey of visual disorders after stroke, patients
reported issues with visual-spatial perception, object andspace recognition, contrast sensitivity, etc. [2]. These
impairments are more complicated to diagnose but canReceived: 10 December 2020, Accepted: 15 November 2021
Corresponding to: Kaori Ito, Department of Rehabilitation, Japanese
Red Cross Society Omori Red Cross Hospital, 4-30-1, Chuo, Ota-ku,
143-8527 JAPANe-mail: kao.ito.1972@gmail.com©2022 Japanese Association of Occupational Therapists

be debilitating in regard to daily activities [3]. Specificinterviews are critical to detecting such symptoms. The
prevalence of visual problems is approximately 48%
during the acute phase of stroke [4]. Often, the central
aim of acute phase rehabilitation for stroke is to improve
activities of daily living (ADL) related to movement
disorders. Therefore, if their movement disorder is mild,
patients are often discharged in the acute phase. As aresult, that visual impairment that has been overlooked
may have a detrimental effect on ADL. Several studies
have reported effective rehabilitation, such as saccadic
eye movement training in field defects, training ofsystematic visual search, and eye movement training
for reading, for various visual impairments arising after
strokes [2, 5]. We believe, therefore, that systematicallyexamining patients for visual impairments in acute care

56

VISUAL IMPAIRMENT AND ACTIVITIES OF DAILY LIVING AFTER STROKE

hospital wards is vital to improving patients’ quality oflife. However, to the best of our knowledge, this has
not yet been attempted in a research setting. Further,many ADL assessments relating to movement disorders
in patients in acute care wards utilize reference criteriaother than the bowels and bladder in the Barthel Index(BI). We believe, however, that in some cases, activities
covered as BI criteria become difficult to perform due tovisual impairment. However, it is not clear which activities are affected or how they are affected.
If patients, in addition to visual impairment, haveaphasia, general inattention, or hemispatial neglect, it
is possible that their vision disorder will be masked.
Vision-related symptoms occur due to damage to the
occipital, temporal, and parietal lobe of the cerebral
cortex, but not when the damage is anterior of thecentral sulcus. In cases of cerebral infarctions there iscomparatively good mapping between the location of
the abnormality on brain images and the damaged area;
thus, they are suitable for the study of responsible lesions. Therefore, this study aimed to determine the type
and prevalence of visual impairments and the effect on
ADL in acute stroke patients with lesions in the corticaland subcortical white matter posterior to the central
sulcus, and without severe movement disorder, aphasia,
general inattention, or hemispatial neglect.

Materials and participantsThis study was conducted at the acute care hospital,
Omori Red Cross Hospital. The participants comprised
consecutive stroke patients who were admitted to thehospital between September 2018 and May 2020. We
wished to include acute patients with infarctions in posterior cerebral regions, and without severe movement
disorder, aphasia, general inattention, and hemispatial
neglect. The inclusion criteria were as follows: Patientsfor whom stroke onset occurred within 20 days of thestart of the survey, head diffusion magnetic resonanceimaging during hospitalization indicated new changes
in lesions in the cortical and subcortical white matter
posterior to the central sulcus, a score of ≥70 on theBI, an auditory comprehension score of ≥8/10 in theWestern Aphasia Battery, a digit span of ≥5, a score of≤2 on the Catherine Bergego Scale, and no bilateralvisual field loss. Patients with residual dysfunction fromocular diseases, orthopedic maladies, or neurological or
psychiatric illness were excluded.
This study was approved by the ethical committeeof Yamagata Prefectural University of Health Scienceand conducted in accordance with the Declaration of
Helsinki. All participants provided written informed
consent after receiving a detailed description of thestudy.

Methods
Measurement of the visual field
The visual field was measured using a tangent
screen at a visual angle of 25° from the gazing point. A
hole was made in the gazing point of the screen and thetest was performed from there while the participant’s
gaze was confirmed.
Subjective awareness of visual field loss
Before the above-mentioned visual field measurement, participants were asked whether there wasanything in their visual field that they found difficult tosee. They were asked again after the visual field measurement. If the patient remained unaware of their visual
field loss even after the measurement, we consideredthat the patient had anosognosia for hemianopia [6].
Questionnaire
The symptoms discussed in question items and thecontent of the questions themselves were cooperatively
decided upon by a total of five occupational therapists
and neurologists well-versed in the diagnosis of poststroke visual impairment. First, after searching the literature to find all possible symptoms that can occur after
a stroke, we eliminated very rare symptoms and very
salient symptoms like Bálint syndrome or environmental
agnosia, whose presence need not be confirmed withquestions: this left a total of 13 symptoms. Next, we extracted information from the literature on how these 13
symptoms cause problems to affected people, considered
how and where those problems may affect a patient’s
life after being hospitalized, and designed our questions.
The literature used in these investigations has been citedthroughout this text and in Table 2. Finally, questions
related to two symptoms not described in the literature,
but which the aforementioned five specialists frequently
encountered in the past (detailed later) were also added.
The questionnaire is provided in Table 1. Some of thequestions related to the BI items are transfer, feeding,grooming, dressing, toilet use, bathing, mobility, andstairs (Table 1A), and the other questions related to ADL
in other situations (Table 1B). The questions described
problems that might occur due to some kind of visual
impairment and asked participants whether or not they
had experienced these problems after their strokes. If thepatient replied that they had experienced these problems,
they were asked to provide further details, which werecross-referenced with the academic literature, and thevision impairment was confirmed. After each question,
we asked “Have your nurses or rehabilitation staff orAsian J Occup Ther 18: 55−64, 2022

Ito K et al.

57

Table 1 Questions relating to activities of daily living
What activities do you have trouble within your daily life? We would like you to tell us about activities you have trouble within your daily life. Which of thefollowing activities are you able to perform adequately? Please tell me what problems you are having and how you are compensating for them.
A. Questions Relating to the Barthel Index
Transfer (bed to chair and back)1. Can you lie down to sleep in bed in the correct position (with your head on the pillow and your body positioned along the bed)?
→ Disability of body orientation
2. Can you sit correctly in a chair (if the chair has a back, with your back against the back)? → Disability of body orientation
Feeding
1. Can you eat on your own?
2. Have others told you that you have left food on the plate after you finished eating, or have you noticed it afterwards? → Defective visual search
3. Can you reach for dishes correctly and smoothly? → Visuomotor ataxia or difficulty in judging distance
4. Have you ever missed your cup when pouring tea? → Visuomotor ataxia or difficulty in judging distance
5. Please tell us about any other difficulties you have with eating.
Grooming
1. Can you perform grooming activities (hand-washing, face-washing, brushing teeth, shaving, makeup, etc.) on your own? → Ideational apraxia
After you thought you had finished these activities, have others told you that you had missed some places, or have you noticed it afterwards?
→ Personal neglect or defective visual search
2. Are you easily able to find the correct grooming items if there are many items around the washbasin? → Defective visual search
3. Please tell us about any other problems you have with movements around the washbasin.
Dressing
1. Can you change clothes or shoes by yourself? What do you need help with?
2. Can you quickly and correctly put on your clothes? → Dressing apraxia
3. Please tell us about any other difficulties you have with dressing and putting on shoes.
Toilet use
1. Can you manage all toileting activities from entering the bathroom to exiting the bathroom by yourself?
What do you find difficult?
Is it sitting on the toilet seat? → Disability of body orientation
Is it using toilet paper? Is it using the button to flush the toilet? → Ideational apraxia
Bathing
1. Can you manage bathing all by yourself?
2. Can you find the soap, shampoo bottle, etc. and pick them up smoothly? → Defective visual search
Can you use soap and shampoo correctly? → Ideational apraxia
3. Please tell us about any other problems you have with bathing.
Mobility (on level surface)
1. Can you walk in a straight line down the hallways of the ward? Do your trajectory deviate? → Walking trajectory deviation
Which side do your trajectory deviate?
2. When you are walking, do you sometimes bump into people or things? → Defective visual search
Which side are the things you bump into on? What part of your body do you bump the most?
3. Can you move around your room when it is dark in the morning, evening and after lights out? Why are you having difficulty moving around?
→ Defective contrast sensitivity
4. Can you get to the dining room or communal bath on the ward by yourself? Can you get back to your room from the ward without getting lost?
→ Heading disorientation
5. Do you sometimes have difficulty judging how far away people or things are? → Difficulty in judging distance
6.	Have you ever tried to sit in front of or behind a chair, or grasped an object in front of or behind where it was, or bumped into a wall thinking that there wasstill space between you and the wall? → Difficulty in judging distance
Stairs
1. Can you climb up and down stairs by yourself without any problems? If not, why not? → Difficulty in judging distanceB. Questions not relating to the Barthel Index
1. Can you read and write characters the same way you did before you got sick? → Agraphia, alexia
2. Can you read sentences the same way you did before you got sick? → Hemianopic dyslexia
3. Do you ever look at a familiar family member or friend and not know who they are? Do you know who they are if you hear their voice? → Prosopagnosia
4. Do you ever look at something and not know what it is? Do you know what it is if you touch it? → Visual object agnosia
5. Do you ever have trouble finding the things that you need that are around your bed? → Defective visual search
6. Do you ever have trouble finding the things that you need that are in your hospital room? → Defective visual search
7. Can you find your therapist in the rehabilitation room? → Defective visual search
8. Can you punch the buttons on a television remote control and the keys on a calculator without difficulty?
What do you find difficult about it? → Visuomotor ataxia
9. When you type on the keyboard of a PC, do you sometimes hit the wrong keys? → Visuomotor ataxia
10. Do you have difficulty in recalling the place where they were seeing right before? → Difficulty in recalling the place where they were seeing right before
11. Do you ever find it difficult to count objects?
Is it harder to count objects if they are scattered around? → Defective visual search
Is it harder to count objects if they are lined up? Is it when they are lined up vertically or lined up horizontally? → Defective visual counting
12. When you have trouble identifying things, is it when objects, pictures and characters are facing up, facing down, or on their sides?
→ Object orientation agnosia
13. Have other people pointed out to you that you are reading the newspaper or other reading material upside down? → Object orientation agnosia
C. Have you had other annoying experiences that we have not yet asked you about?
The name of the symptom after the arrow expresses the probable visual impairments and other neuropsychological symptoms if the patient answers that they
have problems with the questions that appear before the arrow.

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VISUAL IMPAIRMENT AND ACTIVITIES OF DAILY LIVING AFTER STROKE

Table 2 The types and characteristics of impairments
Types of impairments

Characteristics

A. Visual impairments
Disability of body orientation

Difficulty matching the axis of one’s own body and a viewed object correctly [7].

Defective visual search

Difficulty moving gaze to find objects [2, 5, 8].

Visuomotor ataxia

The hand reaching for the viewed object deviates up-down, left-right, or forward-back [9].

Difficulty in judging distance

Inability to visually judge depth distance [10, 11].

Defective contrast sensitivity

Inability to distinguish low-contrast objects [2, 5].

AlexiaBecoming unable to read characters [12].

Hemianopic dyslexia

Difficulty reading sentences, skipping words, and reading the same part of the text
repeatedly [2, 5].

Prosopagnosia

Seeing faces but being unable to recognize them [13].

Visual object agnosia

Seeing objects but being unable to determine what they are [14].

Object orientation agnosia

Unable to determine object orientation [15].

Defective visual counting

Difficulty counting items [16, 17].

B. Nonvisual neuropsychological symptoms
Personal neglect

Difficulty perceiving own body on the contralateral side of the lesion [18].

Ideational apraxia

The patient cannot use tools correctly despite knowing what they are [19].

Dressing apraxia

The patient can explain how to dress and can dress others, but cannot dress themselves properly [20].

Heading disorientation

The patient gets lost in a place where the scene cannot be viewed in its entirety [21].

Agraphia

The patient can no write characters [22].

your families pointed this out to you?” After the questionnaire was completed, we asked participants if they
had any concerns other than what they had been asked
about (Table 1C).
The visual impairments we assumed that could
affect ADL during hospitalization were as follows. Disability of body orientation [7], defective visual search[2, 5, 8], visuomotor ataxia [9], difficulty in judging
distance [10, 11], defective contrast sensitivity [2, 5],alexia [12], hemianopic dyslexia [2, 5], prosopagnosia[13], visual object agnosia [14], object orientation
agnosia [15], and defective visual counting [16, 17]. In
addition, the participants were asked about deviation ofwalking trajectory, and difficulty in recalling the place
where they were seeing right before, which are common
post-stroke impairments.
Furthermore, we asked about the following neuropsychological symptoms that are not visual impairments
but that might occur due to changes in the cortical andsubcortical white matter posterior to the central sulcus
that might affect ADL during hospitalization. These
were personal neglect [18], ideational apraxia [19],dressing apraxia [20], heading disorientation [21], andagraphia [22].
The type and characteristics of each of these visual
impairments and non-visual neuropsychological symptoms are shown in Table 2. The name of the symptom
after the arrow in Table 1 expresses the probable visual
impairment and other neuropsychological symptoms
if the patients answer that they have problems with thequestions that appear before the arrow.
From the interview results, we determined thetypes of visual impairments experienced by the patients,
and what effects they exert on the patients’ daily life.
To validate the questionnaire’s test-retest reliability,
similar questions were asked ≥1 week after. This second
interview was conducted by a different occupational
therapist blinded to the study details and the patients’initial responses. For all binary (Yes/No) questions inTable 1, Cohen’s kappa coefficient (κ) was calculated tomeasure the degree of agreement between the patients’first- and second-round responses.
Correspondence with rehabilitation and nursing records
We searched records compiled by physical ther-

Asian J Occup Ther 18: 55−64, 2022

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59

Table 3 Demographic and clinical characteristics
Patient Age
Sex
No. (years)

Symptoms on
admission

WAB
WAB
Auditory
Digit
BI
Namingcomprehension
span(max: 10)
(max: 10)

Right hemiplegia,
80
vertigoCBS(range:
0-30)

BIT
BIT
BIT
Line
Line
Star
bisection Cancellation cancellation(max: 9) (max: 36) (max: 54)

Lesions

10

10

6

1

6

30

53

Left LOinf, FUS, LIN,
and PLIC

100

10

10

9

0

9

36

54

Right LIN and PHIPfRight hemianopia,
100
right hemiplegia

10

10

9

0

9

36

54

Left PHIP, FUS, and
LOinf

68

m

Weakness in theleft lower limb

80

10

10

5

2

9

35

52

Right PostC, CUN.
Left SFG, CS, and IPS

5

75

m

Dysarthria,
left hemiplegia

95

10

10

5

1

9

35

50

Right ITG, MTG,
CR, PreC, PostC and
ANG; left IC

6

66

m

Collide with objects on the right

100

8.8

6.8

6

0

9

36

53

Left HIP, PHIP,LIN,
and LT

7

68m Vertigo

100

10

10

7

1

9

35

52

Right CCspl, LIN, and
PHIP

8

77

m Right hemianopia 100

10

10

8

1

9

36

54

Left LOsup, LIN,
PHIP, and FUS

9

63

f

Transient loss of
consciousness

95

10

9.2

7

2

9

36

53

Left IPS, right CR

10

70

f

Left hemianopia

100

10

10

7

0

9

36

52

Right FUS, LIN, andPHIP; left CERB

11

49m Right hemianopia 100

10

9.2

6

0

9

36

54

Light PHIP, LIN, and
MTG.

12

56

m Left hemianopia

100

10

10

7

0

9

36

54

Right LIN

13

88

f

80

10

10

5

1

9

34

50

Left STG, MTG, and
ANG

14

83

m Left hemiplegia

75

10

10

7

2

9

33

48

Right IPS, ANG, SMG,
TS, and PLT

1578

f Left hemianopia

100

10

10

7

0

9

36

54

Light LIN and PHIP

16

90

f

Left lower limb
paresthesia

85

10

10

5

0

9

34

48

Right IPS and CR

1

79

m

2

53

f Left hemianopia

3

43

4

VertigoMax: maximum; BI: Barthel Index; WAB: Western Aphasia Battery; CBS: Catherine Bergego Scale; BIT: Behavioral Inattention Test; CUN: cuneus; IPS: intraparietal sulus; CAL: calcarine sulcus; LOinf: inferior occipital gyrus; LOsup: superior occipital gyrus; FUS: fusiform gyrus; LIN:
lingual gyrus; PHIP: parahippocampal gyrus; PLIC: posterior limb of internal capsule; SFG: superior frontal gyrus; CS: central sulcus; ITG: inferior temporal gyrus; MTG: middle temporal gyrus; STG: superior temporal gyrus; CR: corona radiate; PreC: precentral gyrus; PostC: postcentral
gyrus; IC: insular cortex; HIP: hippocampus; PLT: posterolateral thalamus; CCspl: splenium of corpus callosum; CERB: cerebellum; ANG: angular gyrus; SMG: supramarginal gyrus; TS: temporal stem

apists and nurses during patient hospitalization for
descriptions corresponding to any of the 13 symptom
types detailed in our questions. If any records indicating
the problems we assumed could likely occur as a resultof the impairments were found, we determined that thesymptom in question had been recorded.

Results
Between September 2018 and May 2020, 447
patients were admitted to our hospital with cerebral
infarctions. Of them, 16 patients met the criteria forparticipation. Table 3 shows the demographic and clinical characteristics of each participant. The median time
between stroke onset and the survey was 3.5 days (range

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VISUAL IMPAIRMENT AND ACTIVITIES OF DAILY LIVING AFTER STROKE

Table 4 Patterns of visual field loss and visual symptoms corresponding to questions
Walking trajectory
Patient Homonymous Unawareness Defective Hemianopic
No awarenessdeviation to the sideNo.
field lossof hemianopia visual search dyslexia
of deviation
opposite to the lesion

Defective
visualcounting

Difficulty in recalling DifficultyPure
the place where theyin judging
alexiawere seeing right before distance1

Right HA

2

+

+

+

-

+

+

-

-

2

Left HA

0

+

+

+

+

-

-

-

-

3

Right UQ

0

+

+

-

-

+

-

-

4

Left LQ

1

+

+

+

+

-

-

+

-

5

-

+

+

+

+

-

-

-

-

6

Right UQ

2

+

+

-

-

+

-

-

7

Left UQ

0

+

+

+

+

-

+

-

-

8

Right UQ

0

+

+

+

-

-

+

-

-

9

-

+

+

+

+

-

-

-

-

10

Left UQ

1

+

+

+

+

-

-

-

-

11

Right UQ

0

+

-

-

-

-

-

+

12

Left UQ

0

+

+

-

-

-

-

-

13

-

+

+

+

-

-

-

-

14

Left LQ

2

+

+

-

+

-

-

-

15

Left UQ

1

-

+

-

-

+

-

-

16

-

+

-

-

-

-

-

-

+

0: Subjective awareness prior to visual field examination; 1: Subjective awareness after visual field examination; 2: No subjective awareness evenafter visual field examination; +: Symptom reported; -: Symptom not reported; HA: hemianopia; UQ: upper quadrantanopia; LQ: lower quadrantanopia

2-15 days), and the median hospital stay was 24 days
(range 13-72 days). All participants were right-handed,and their midpoint BI score was 100 (range 75-100).
Regarding visual field loss, two participants had
homonymous hemianopia, eight had upper quadrantanopia, two had lower quadrantanopia, and four did nothave visual field loss (Table 4). Among the 12 participants with visual field loss, six did not have subjective
awareness of the loss before visual field testing. Three ofthem became aware of the loss after the visual field testing while the other three remained unaware even after
testing. That is, three participants exhibited anosognosia
for hemianopia.
The following is a list of the visual impairmentsthat affected ADL during hospitalization. Fifteen participants (94%) had defective visual search, 14 (88%)
had hemianopic dyslexia, 9 (59%) had deviation ofwalking trajectory, 6 (36%) had difficulty in recalling
the place where they were seeing right before, 2 (13%)
had defective visual counting, 1 (6%) had difficulty in
judging distance, and 1 (6%) had pure alexia. All of the
9 participants who had deviation of walking trajectorycomplained of deviations toward the opposite side ofthe lesion, and 7 (78%) out of the 10 participants had no
subjective awareness of deviation and only describedhaving had it pointed out by nurses and rehabilitation
staff (Table 3). All patients had subjective awareness of
all other symptoms. None of the participants reported
difficulties related disability of body orientation, visuomotor ataxia, defective contrast sensitivity, prosopagnosia, visual object agnosia, or object orientation agnosia.
Correspondence between question answers andphysical therapist/nurse records was as follows. Of
the types of visual impairments discussed in our questions, one patient did not have any records from either
physical therapists or nurses indicating the impairment“difficulty in recalling the place they were seeing rightbefore,” despite the fact that question results indicatedthat an impairment was present. However, for all othervisual impairments, corresponding records by either aphysical therapist or nurse were found for all patients
whose question answers indicated an impairment. Further, when question results did not indicate that an impairment was present, neither form of record contained
the corresponding descriptions.
Among the impairments, defective visual search,

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61

Table 5 Voluntarily reported visual symptoms and non-visual symptoms corresponding to questions
Patient
Simple visual Complex visual
PhotophobiaNo.
hallucination hallucination

Cerebral
diplopia

Metachromatopsia Metamorphopsia

Agraphia
Acalculia Amnesia
for Kanji

1

-

-

-

+

-

-

-

-

-

2

+

+

-

-

-

+

-

-

-

3

-

-

-

+

-

-

-

-

-

4

-

-

-

-

-

-

-

-

-

5

-

-

-

-

+

-

-

-

-

6

-

-

-

-

-

-

-

-

+

7

-

-

-

-

-

-

-

-

-

8

-

-

-

-

-

+

-

-

-

9

-

+

-

-

-

-

-

-

-

10

-

-

-

-

-

-

-

-

-

11

-

-

-

-

-

-

+

+

-

12

-

+

+

-

-

-

-

-

-

13

-

-

-

-

-

-

-

-

-

14

-

-

-

-

-

-

-

-

-

15

-

-

-

-

-

-

-

-

-

16

-

-

-

-

-

-

-

-

-

+: Symptom reported; -: Symptom not reported

deviation of walking trajectory, and difficulty in judging
distance were reported in response to questions regarding BI. Defective visual search was reported in response
to questions relating to BI and questions relating to othervisual activities. Defective visual search was reported
as follows in response to questions relating to the BI. To
questions pertaining to “Mobility,” seven participants
answered that they “bumped into things,” or “people
suddenly appeared and startled me.” To questions related
to “Grooming,” five participants answered that “it takes
a long time to find my tools,” and to questions related to“Feeding,” four participants answered that they “noticed
that some of their food had been left on the plate.” Deviation of walking trajectory to opposite side of the lesion
and difficulty in judging distance were only reported
in response to questions relating to BI. To questions
regarding “Mobility” and “Stairs,” difficulty in judging
distance was reported, such as “I was surprised to findthat I was about to sit in front of the chair,” “I can’t tell
how far I am from objects and people when I walk,” and“when I go down the stairs I can’t tell the height of astep, so it’s scary.”
Concerning the answers to questions relating tononvisual neuropsychological symptoms, one participant reported agraphia of kanji characters, one reported

acalculia, and one reported mild amnesia (Table 5). No
other non-visual neuropsychological symptoms werereported.
To the final question, in which the participant was
asked about experiences that concerned them other thanwhat was asked in the interview, one participant (6%)
reported photophobia; three (19%) reported simple
visual hallucinations, such as “seeing stripes”; one (6%)
reported complex visual hallucinations, such as “seeing
people”; two (12%) reported cerebral diplopia, in which
the viewed object appears to be duplicated twice; one(6%) reported metachromatopsia, where the perceived
color is different from the actual color; and two (12%)
reported metamorphopsia, where the perceived shape isdifferent from the actual one (Table 5) [5, 23, 24].
The questionnaire had excellent test-retest reliability (κ = 0.952); specifically, the patients’ first- andsecond-round responses were in almost complete agreement [25].

Discussion
This study aimed to determine the effect of the type
and prevalence of visual impairments on ADL in acutestroke patients. Our results suggest that patients who

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VISUAL IMPAIRMENT AND ACTIVITIES OF DAILY LIVING AFTER STROKE

have had acute strokes with lesions in the cortical andsubcortical white matter posterior to the central sulcus
feel that they have problems in ADL due to various
visual impairments, even if they do not have impairments that clearly hamper daily life, such as movement
disorder, aphasia, general inattention, or hemispatial neglect. The symptoms frequently observed were defective
visual search, hemianopic dyslexia, deviation of walking
trajectory, and difficulty in recalling the place where
they were seeing right before.
According to Zihl [5], 61% of patients with homonymous hemianopia complained of ADL problems
due to defective visual search. The number of patients
who report ADL impairments decreases with time dueto the natural recovery process after stroke and because
patients consciously or unconsciously perform compensatory actions. Therefore, it is to be expected thatthe prevalence of ADL impairments is high in the acutephase, as was observed in our study. A subset of patients
report symptoms that do not improve over the long term;
these patients do not use compensatory mechanisms.
Such patients have lesions on the thalamus, parietal lobe
or the fibers connecting them [5].
It was previously thought that defective visual
search was caused by the patient being unable to makesufficiently large eye movements to compensate forthe missing part of the visual field and being unable toorganize visual information on the missing side. It is
now known that the severity of this impairment does
not correlate with the size of the remaining visual fieldor the patient’s subjective awareness of the visual field
loss [5]. It has become clear that in some cases, similar
impairments occur if lesions are present in the posteriorparietal area even without visual field loss [8]. Thus, it
is conceivable that this symptom can be present if homonymous visual field loss or posterior parietal lesions
occur in the acute period. As shown in Tables 3 and 4,
all of the patients presenting with this symptom met oneof these conditions. The fact that these symptoms wereobserved regardless of the patient’s subjective awarenessof visual field loss is in line with previous findings [8].
According to Zihl [5], 77% of patients with left
homonymous hemianopia and 90% of those with righthomonymous hemianopia complained of hemianopic
dyslexia. This is in line with our current findings.
Hemianopic dyslexia was previously considered to bea reading impairment caused by characters seeming
to abruptly appear and disappear from the boundary
between the healthy visual field and the blind visual
field. However, it has been reported that similar reading
difficulties can occur in the absence of visual field loss
if there are posterior parietal lesions [8]. Recently, theassociation between such difficulties and certain typesof visuospatial attention or eye movement control has
been proposed [26]. Therefore, it is conceivable thatthese symptoms can present if there is homonymous lossof visual field or posterior parietal lesions in the acuteperiod. As shown in Tables 3 and 4, all of the patients
presenting with this symptom met one of these conditions.
There are reports that the walking trajectory of patients with hemispatial neglect deviate to the same side
as the lesion [27]; however, we could not find any studies of patients with posterior lesions without hemispatial
neglect whose walking trajectory deviate to the side
opposite to the lesion. However, in one study, when patients were asked to point in the direction they believed
was straight ahead, patients with hemispatial neglect
but not homonymous hemianopia pointed to a spot thatdeviated from the exact center toward the lesion side,and patients with homonymous hemianopia but nothemispatial neglect pointed to a spot that deviated fromthe exact center toward the side opposite to the lesion[28]. It is prudent to assume that the latter patients, whenattempting to walk straight ahead, will exhibit walking
trajectory deviating to the side opposite to the lesion.
However, the study did not survey a patient group withposterior lesions but without neglect or hemianopia;
thus, it is unclear whether hemianopia is a requirement
for the symptom of tilting toward the side opposite to
the lesion. In this study, this symptom was also reported
in patients without visual field loss. This suggests thatthe mechanism of this symptom is unrelated to the stateof the visual field. This impairment differed from theother symptoms in that many patients were unaware of
its existence. Danger arises when patients have comorbid deviation of walking trajectory and defective visual
search, as they will approach obstacles without noticing
them. Hence, those caring for the patient should be alert
to the presentation of this symptom.
It is not uncommon for stroke patients to complainof difficulty in recalling the place where they wereseeing right before. However, we were unable to findany studies that investigated this problem directly. However, it can be anticipated that this impairment will cause
various problems with daily activities. For example,
Inoue et al. [17] theorized that this symptom underlies
defective visual counting.
While uncommon, some patients in our study had
defective visual counting, difficulty in judging distance,or pure alexia. Defective visual counting has come to bethought of as a manifestation of visual inattention [16].
In the cases with visual inattention, severe impairment,such as the inability to count four or fewer objects, isobserved. However, some patients are unable to countfive or more similar items even if visual inattention isAsian J Occup Ther 18: 55−64, 2022

not present [17]. This type of defective visual counting
occurs even if the items are lined up and not haphazard,
or if they are arranged vertically. Thus, this cannot be
explained by defective visual search or hemianopia.
There are reports of difficulty in judging distance withbilateral lesions [10], but this symptom can also occur
with unilateral legions [11]. It has been hypothesizedthat the lesions responsible for this symptom occur inthe cuneus [10]. The cuneus was involved in the lesionsof the patient who complained of difficulty in judging
distance in this study. It is assumed that the lesions
responsible for pure alexia are in the left lingual gyrus
and the parahippocampal gyrus [12]. Lesions in theseregions were observed in the patients who complainedof pure alexia in this study.
In response to questions relating to the BI, patients
reported defective visual search, deviation of walking
trajectory, and difficulty in judging distance. Thus, ourresults indicated that even within the activities assessedby the BI, under the categories of “Mobility,” “Grooming,” “Feeding,” and “Stairs,” patients had difficulties
with impairment of visual function, not with movement
function. Even if there is adequate improvement inmovement function, patients may not be able to succeedin the activities themselves if visual impairments are notaddressed.
To manage the various symptoms described above,effective rehabilitation strategies such as training,
compensation, and environmental adjustment havebeen reported [2, 5]. It has been reported that patients
who experience visual impairment following a stroke
whose impairment goes unnoticed by others, who do notreceive sufficient information, and who do not have theopportunity to receive systematic rehabilitation believethat the process of tackling their visual impairment is
not supported [29]. In order to improve patient qualityof life, we believe it is important to interview stroke
patients in the acute stage in order to identify potential
visual disorders, provide descriptions of symptoms, andconsider necessary measures such as rehabilitation.
Study limitations
This study had a number of limitations. The numberof participants was unfortunately small because we excluded patients with severe movement disorder, aphasia,
general inattention, and hemispatial neglect.
The correspondence between decisions madebased on question results and the presence or absenceof physical therapist/nurse records was good. However,these confirmatory methods are not objective evaluation
methods of the impairments themselves. In the future,
we must develop testing methods to quantify each
impairment, and investigate whether the results of theseIto K et al.

63

questions correspond to patients’ actual conditions ornot.
In this study, our questions were only administered
to hospitalized patients in the acute phase. Not understanding how the results obtained via these questions
are reflected in the various problems that might occur inhome/workplace ADLs after discharge, therefore limits
their usefulness. In the future, we will develop questions
that consider a home or workplace setting and investigate the relationship between those and questions implemented while patients were hospitalized. Thereby, we
believe we will be better able to predict problems that
may arise in the acute period and extend into post-discharge life, and better develop specific countermeasures.

Conclusion
The results of this study suggest that many patients
who have had acute strokes with lesions in the corticaland subcortical white matter posterior to the central
sulcus have visual impairments such as defective visual
search, hemianopic dyslexia, deviation of walking trajectory, and difficulty in recalling the place where they
were seeing right before, and that these impairments
caused difficulties with ADL. Therefore, we believethat is important to interview patients during the acutestage with visual disorders in mind, and if symptoms are
discovered, to conduct the necessary rehabilitation.

Conflicts of Interest
The authors have no conflicts of interest to declare.

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CP, Currie J. High incidence and prevalence of visualproblems after acute stroke: An epidemiology study
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[5] Zihl J. Rehabilitation of visual disorders after brain
injury. Hove: Psychology Press Ltd; 2000.
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VISUAL IMPAIRMENT AND ACTIVITIES OF DAILY LIVING AFTER STROKE

hemisphere: anosognosia for hemiplegia and anosognosia
for hemianopia. Neurology. 1985; 24(4): 471-82.
[7] Kase CS, Troncoso JF, Court JE, Tapia JF, Mohr JP.
Global spatial disorientation: clinico-pathological correlations. J Neurol Sci. 1977; 34(2): 267-78.
[8] Zihl J, Hebel N. Patterns of oculomotor scanning inpatients with unilateral posterior parietal or frontal lobe
damage. Neuropsychologia. 1997; 35(6): 893-906.
[9] Rondot P, De Reconde J, Ribadeau Dumas JL. Visuomotor ataxia. Brain. 1977; 100(2): 355-76.
[10] Houjou T, Funayama M, Nakagawa Y, Sano Y, Kato M.
Difficulty in judging distance following parieto-occipital
lobe damage (in Japanese). Higher Brain Function Research (koujinoukinoukennkyu). 2009; 29(4): 434-44.
[11] Takeda C, Notoya M, Shiota S. The process of rehabilitation for patients with impaired distance perception (inJapanese). Higher Brain Function Research (koujinoukinoukennkyu). 2015; 35(2): 225-32.
[12] Benito-Leon J, Sanchez-Suarez C, Diaz-Guzman J, Martinez-Salio A. Pure alexia could not be a disconnection
syndrome. Neurology. 1997: 49(1): 305-6.
[13] De Renzi, Faglionil EP, Grossi D, Nichelli P. Apperceptive and associative forms of prosopagnosia. Cortex.
1991; 27(2): 213-21.
[14] Riddoch MJ, Humphreys GW. A case of integrativevisual agnosia. Brain. 1987; 110: 1431-62.
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Neuropsychologia. 1997; 35(2): 153-63.
[16] Tamaru F, Mitani Y, Yamadori A. A case of Balint’s
syndrome (in Japanese). Japanese Journal of Neuropsychology (shinnkeishinrigaku). 1986; 2(1): 49-56.
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when similar shapes are lined up (in Japanese). Japanese
Journal of Neuropsychology (shinnkeishinrigaku). 2018;34(4): 329.
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WJ, et al. Personal neglect - A disorder of body represen-tation? Neuropsychologia. 2011; 46(5); 898-905.
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[25] Landis JR, Koch GG. The measurement of observer
agreement for categorical data. Biometrics. 1977; 33(1):159-74.
[26] Schuett S, Heywood CA, Kentridge RW, Zihl J. The
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[28] Ferber S, Karnath HO. Parietal and occipital lobe contributions to perception of straight ahead orientation. J
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■ORIGINAL ARTICLE

Kinetics of Visual Axis and Pupil Diameter during
Caregiver-assisted Eating
Atsuko Suzuki-Urayama1, 2, Yui Takahashi1, 3, Mitsuhiro Nito4,
Katsuhiko Suzuki5, Hiromi Fujii1, 6
1

Graduate School of Health Sciences, Yamagata Prefectural University of Health Sciences, Yamagata, Japan
Division of Rehabilitation, Yamagata Prefectural Central Hospital, Yamagata, Japan
3
Division of Rehabilitation, Yamagata Prefectural Mental Health Medical Center, Tsuruoka, Japan.
4
Department of Anatomy and Structural Science, Yamagata University School of Medicine, Yamagata, Japan
5
Department of Physical Therapy, Yamagata Prefectural University of Health Sciences, Yamagata, Japan
6
Department of Occupational Therapy, Yamagata Prefectural University of Health Sciences, Yamagata, Japan
2

Abstract: The purpose of this study was to examine the kinetics of the visual axis and pupil diameter during caregiver-assisted eating. The eating task was caregiver-assisted eating of twelve healthy volunteers. Visual axis position,
spoon bowl motion, and pupil diameter were recorded using an eye tracker and a digital video camera. All participants
indicated visual axis on a spoon or food during the motion of moving the spoon to the participant’s mouth in caregiver-assisted eating. Critical visual point (CVP) disappeared completely in all trials of all participants. The min-to-max
and max-to-min pupil diameters, differences and changing were divided to three patterns for caregiver-assisted eating inall participants. Most patterns showed decrease of pupil diameter. These data suggest that the participant looked carefully at the food or the spoon using an accommodation reflex and a convergence reflex. Caregiver-assisted eating is naturalin non CVP. A participant does not have somatosensory information during eating motion in caregiver-assisted eating.
Positional information of a spoon is obtained only from visual information. We speculated that participant anxiety wasstronger with caregiver-assisted eating than with unassisted eating. However, the causes of an increase and lack ofchange in pupil diameter remain unclear. Occupational therapists, who understands biological responses during eating
motion, must teach a caregiver-assistant methods that are suitable for a participant.
Keywords: caregiver-assisted eating, visual axis, pupil diameter, eating motion(Asian J Occup Ther 18: 65−70, 2022)

Introduction
Many reports have described analysis of eating,which is important for independence of self-care [1, 2, 3,
4, 5]. Previous our report has described characteristicsof healthy participants’ visual axis and pupil diameterfound during unassisted eating and robot-assisted eating[6]. Results show that all participants have a criticalvisual point (CVP) during unassisted eating as the spoon
moves from the plate to the mouth. The CVP contributes
to eye-hand coordination during eating, facilitating
monitoring of smooth upper extremity motion andReceived: 31 July 2019, Accepted: 14 September 2021
Corresponding to: Hiromi Fujii, Yamagata Prefectural University of
Health Science, 260, Kamiyanagi, Yamagata-city, Yamagata, 9902212, JAPANe-mail: hfujii@yachts.ac.jp©2022 Japanese Association of Occupational Therapists

spoon manipulation. The CVP is the final point during
the eating motion [7]. However, the CVP disappeared in
all participants during robot-assisted eating. These findings suggested that the subjects followed the food with
their eyes until just before it entered their mouths during
robot-assisted eating. The Japanese geriatric healthservice facilities and at home needed caregiver-assisted
eating in the subjects. Characteristics of the visual axis
and pupil diameter during caregiver-assisted eating
remain unclear. In other words, from the characteristics
among unassisted eating, robot-assisted eating, andcaregiver-assisted eating, we can find a theoretical basis
for occupational therapists to provide caregivers withappropriate care guidance methods for their subjects.
Therefore, this study examined the kinetics of the visual
axis and pupil diameter during caregiver-assisted eating.

66

KINETICS OF VISUAL AXIS AND PUPIL DIAMETER DURING CAREGIVER-ASSISTED EATING

Methods

similarly to unassisted eating.

Participants
Twelve healthy volunteers (5 men, 7 women) participated in the study. The age range was 20-26 years(mean age, 22 ± two years). All participants had vision
sufficient to obtain a driver’s license, with no color
vision abnormality. They had affiliated psychic function
and did not have diseases or injuries that would impair
daily living activities. All participants provided informed consent to undergo the experimental procedures,
which were approved by the Ethics Review Board of
the Yamagata Prefectural University of Health Sciences(1210-09), Yamagata, Japan.

Data analysis

Instrumentation and data acquisition
Data were collected with a sampling frequencyof 30 Hz using an eye tracker (EMR-8B; NAC Image
Technology Inc., Tokyo, Japan), which detects infrared
reflections from the cornea, and a digital video camera(30 frames per second, NV-GS320; Panasonic Inc.,
Osaka, Japan). The digital video camera, located to theside of the participant, recorded motion of the spoon
bowl from the plate to the mouth. A digital motion picture waveform real-time synchronous recording system(the Teraview; Gigatex Co. Ltd., Osaki, Japan) was synchronized with a field image, a pupil image, and a video
camera image.

Procedures
Experimental conditions
Brightness in the test room was fixed at 652 lux.
The room temperature was set to about 24°C. Each participant sat on a chair (400-450 mm tall). The participant
held the eating assistant’s spoon before the trial began.
The distance between the mouth and the plate during
caregiver-assisted eating was fixed as 338-471 mm forall participants. The experimental food was a cereal with
15-mm-diameter toroidal pieces (Kokokun-no-chocowa;
Kellogg Co., Tokyo, Japan). The participant’s eyes werecovered with a visual mask to prevent prior visual information. The mask was removed at the start of the eatingtask. The trial ended when the food was in the participant’s mouth. The eating task was caregiver-assisted
eating (10 trials).
First, the participant was asked to eat food just as
in daily life. Therefore, we did not force the subjects
to look at the food or the spoon except to say, “Please
eat as usual”. A caregiver observed the motion speed,
spoon bowl trajectory, and eating motion accuracy. The
caregiver-assisted eating of participants was observed

1. Motion phases
Eating task motions were divided into three phases
using video data: phase 1 (P1), the motion of moving
the spoon to reach the food; phase 2 (P2), the motionof picking up the food; and phase 3 (P3), the motion ofmoving the spoon to the participant’s mouth. P3 wasalso defined as the “eating motion.”
2. Classification of eye movement
The visual axis position was ascertained from a
picture using a field camera, and was pursued during theeating task. Eye movements were classified as saccadic
eye movement (SEM), smooth pursuit eye movement(SPEM), fixation, and others. SEM was defined as eye
movement of angle speed greater than 50°/s. SPEM
was defined as eye movement of angle speed <50°/s.
Fixation was defined as eye movement inactivity that
continued longer than 0.10 s. Fixation was judged tohave occurred when the eye mark stopped at the same
position for more than three field camera images underthese conditions.
3. Visual axis position and spoon bowl motion
The visual axis position was divided into four
categories: The plate showed a block with the food.
The spoon showed the visual axis position on the spoon
bowl without the food. The food showed the visual axis
position on the food. Other positions showed blinking
or no placement of the plate, spoon bowl, or food. The
CVP was defined as the spoon bowl position at which
the visual axis was removed from the food in P3.
4. Pupil diameter
The pupil diameter was measured at 30 Hz using
eye mark data analysis software (EMR-dFactory; NAC
Image Technology Inc., Tokyo, Japan). The pupil diameter of each participant, which was measured before
and after the near-reflex test, was used as the reference
to assess differences between before and after the nearreflex test. Three patterns of pupil diameter change in
P3 were assessed: increase, decrease, or no change. All
trials included every pattern. The quantity of change ofthe pupil diameter was calculated based on the difference of the maximum and the minimum (min-to-max or
max-to-min) of P3.

Results
Figure 1 (participant A) presents changes in theAsian J Occup Ther 18: 65−70, 2022

Suzuki-Urayama A et al.

67

Fig. 1. Transition of visual axis and the pupil diameter during caregiver-assisted eating in the participant A
The figure shows digital video camera images (DVC), field camera images (FC), position of visual axis (VA) and pupil diameter(PD). Slash lines box of FC shows fixation of eyes. Dotted box of FC shows smooth pursuit eye movement. Black color box
shows saccadic eye movement. DVC and FC show start of task, end of Phase1, end of Phase2, and end of task sequentially fromthe left. Left dotted line shows task start. Dotted line of P1, P2 and P3 show end of each phases.

visual axis and pupil diameter that occurred during
caregiver-assisted eating. The spoon reached the foodwithin 1.3 s from the trial start (end of P1). The visual
axis of the participant was on the food. Furthermore, theparticipant picked up the food with the spoon in 1.9 s(end of P2). During P2, the visual axis position changed
from the food, to the spoon, to the food. Next, the participant moved the spoon to the mouth. It reached themouth in 3.9 s from the trial start (end of P3). During
P3, the visual axis position changed from the food tothe other 1.3 s after the trial start. The spoon at this time
was located 91 mm from the left eye of the participant.
No CVP was identified during P3.
Although the order of the visual axis position variedamong trials, the visual axis position and the eye movement pattern were similar from P1 to P3. Additionally,

all participants showed the same visual axis positions
and eye movement patterns as this participant.
In P1, the visual axis was fixed on the food 0.1 s
from the trial start. The eye movement pattern changed
from SEM (for 0.1 s), to fixation (for 0.2 s), to other patterns (for 0.2 s), to fixation (for 0.8 s). At that moment,
the pupil diameter increased by 0.6 mm, from 2.7 mm to
3.3 mm. During P2, the eye movement pattern changed
from fixation (for 0.2 s duration), to SPEM (for 0.1 s),
to fixation (for 0.3 s), to SEM (for 0.1 s). The pupil
diameter increased by 0.3 mm, from 3.3 mm to 3.6 mm.
During P3, the eye movement pattern changed fromfixation (for 0.2 s), to SPEM (for 1.0 s), to SEM (for 0.1s), to fixation (for 0.4 s), to other patterns (for 0.3 s).
The pupil diameter decreased by 0.4 mm, from 3.8 mm
to 3.4 mm. In the participant, the pupil diameter showed

68

KINETICS OF VISUAL AXIS AND PUPIL DIAMETER DURING CAREGIVER-ASSISTED EATING

Table 1. Pupil diameter of caregiver-assisted eating in phase 3
Subject

Pupil diameter (mm)Max (Min) to Min (Max)Near reflex (mm)

Type

Dif.

Counts

Max

Min

Dif.

A

–
3.7
–

–
3.4
–

Inc
Dec
No

–
0.3
–

0
10
0

3.8

2.7

1.1

B

–
4.5
–

–
3.3
–

Inc
Dec
No

–
1.2
–

0
10
0

4.5

2.6

1.9

C

5.4
5.4
5.3

5.8
5.2
5.3

Inc
Dec
No

0.4
0.2
0.0

1
7
2

4.9

3.4

1.5

D

4.0
4.2
4.0

4.1
3.9
4.0

Inc
Dec
No

0.1
0.3
0.0

7
2
1

4.8

2.7

2.1

E

–
3.8
–

–
3.3
–

Inc
Dec
No

–
0.5
–

0
10
0

3.4

2.3

1.1

F

–
4.3

–
3.8

Inc
Dec
No

–
0.5
–

0
10
0

5.1

3.3

1.8

G

–
4.3
–

–
3.9
–

Inc
Dec
No

–
0.4
–

0
10
0

4.5

3.2

1.3

H

–
5.4
–

–
5.0
–

Inc
Dec
No

–
0.4
–

0
10
0

5.0

3.3

1.7

I

–
5.1
–

–
4.4
–

Inc
Dec
No

–
0.7
–

0
10
0

4.3

3.4

0.9

J

–
3.9
–

–
3.3
–

Inc
Dec
No

–
0.6
–

0
10
0

3.5

2.4

1.1

K

5.0
4.9
5.4

5.3
4.8
5.4

Inc
Dec
No

0.3
0.1
0.0

6
2
2

4.4

3.2

1.2

L

3.4
3.6
–

3.6
3.4
–

Inc
Dec
No

0.2
0.2
–

2
8
0

3.2

2.7

0.5

similar changes to those of other trials. However, thisparticipant’s change in pupil diameter showed only adecrease in P3 (Table 1).
Among all participants, the CVP disappeared completely in all trials during P3.
The min-to-max and max-to-min pupil diameters,
differences, and changing counts for caregiver-assisted
eating in all participants during P3 are shown in Table 1.
For participant A, the max-to-min pupil diameters
decreased from 3.7 to 3.4 mm. The difference in pupil
diameter was 0.3 mm. The pupil diameter decreased

in all trials. Eight participants showed decreased pupil
diameter.
For participant K, the min-to-max and max-tomin pupil diameters increased (from 5.0 to 5.3 mm),decreased (from 4.9 to 4.8 mm), or showed no change(stable at 5.4 mm). The pupil diameter increased by
0.3 mm and decreased by 0.1 mm. The pupil diameter change counts respectively showed an increase,decrease, and no change in 6, 2, and 2 trials. The nearreflex value decreased by 1.2 mm, from 4.4 mm to 3.2
mm. Three participants showed an increase, a decrease,

Asian J Occup Ther 18: 65−70, 2022

and no change in pupil diameter.
In participant L, the min-to-max and max-to-min
pupil diameters respectively increased (from 3.4 to 3.6mm) and decreased (from 3.6 to 3.4 mm). The pupil
diameter increased by 0.2 mm and decreased by 0.2
mm. The pupil diameter change counts increased by 2
and decreased by 8 only in participant L. The near reflex
value decreased by 0.5 mm: from 3.2 mm to 2.7 mm.

Discussion
All participants had visual axis on a spoon or foodfrom P1 to P3 in caregiver-assisted eating. Moreover,
CVP disappeared completely in all trials during P3 of allparticipants. The result was similar to a previous report[8]. CVP contributed to the role of eye-hand coordination during eating, as shown by visual monitoring ofsmooth upper extremity motion and spoon manipulation[7]. CVP is the final spot [7, 9]. We speculated thatthe participant sub-consciously or consciously moves
without dropping food from the spoon at CVP during
unassisted eating [7]. Previous reports have describedthat no CVP exists for robot-assisted eating [6]. Therefore, caregiver-assisted eating is natural in non CVP. A
participant does not have somatosensory information
during eating motion in caregiver-assisted eating. The
positional information of a spoon is obtained only fromvisual information [6]. We speculated that participant
anxiety was stronger with caregiver-assisted eating thanwith unassisted eating. All participants feel anxious
when the spoon tip nears the participant.
Table 1 shows pupil diameter P3 of three patterns.
Most patterns showed only about 67% decrease of pupil
diameter. These findings were similar to results obtained
for robot-assisted eating [6]. The pupil diameter decrease occurs in the near reflex. These data suggest thatthe participant looked carefully at the food or the spoon
using an accommodation reflex and a convergence reflex[10]. The next pattern was a 25% increase, a decrease,and no change of pupil diameter. One other participant
showed an increase and a decrease of pupil diameter.
Participants C and L of different types of pupil diameterchange showed that the decrease ratio of pupil diameter was frequent. Participants D and K showed thatthe increased ratio of pupil diameter was frequent. As
described above, these findings suggest that a decreaseof pupil diameter occurs in the near reflex. In unassisted
eating, there was no obvious decrease in pupil diameter as in the near reflex, and the pupil diameter was
sometimes increased [6]. We speculated that the timing,
speed, and trajectory of eating motion in caregiver-assisted eating resembled those found for unassisted
eating. However, the causes of an increase and lack ofSuzuki-Urayama A et al.

69

change in pupil diameter remain unclear.
This study revealed that caregiver-assisted eating
resembled kinetics of visual axis and pupil diameter
during robot-assisted eating. Eating in natural timing,
natural speed, and natural trajectory improves the participant’s eating motivation. Therefore, a caregiver mustmatch the timing, speed, and trajectory of eating motion
with those of an individual participant. For further quality of life improvement, the occupational therapist (OTR)
must lead unassisted eating by the participant. The OTR,
who understands biological responses during eating
motion, must teach a caregiver assistance methods thatare suitable for a participant.

Study limitations
Caregiver-assisted eating elicited physiologicalresponses in healthy participants. However, challenged
persons were not assessed during caregiver-assisted
eating. Further studies are under consideration to investigate caregiver-assisted eating in challenged persons.

Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict ofinterest.

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Adults. Progress in Rehabilitation Medicine. 2017; 2.
[6] Suzuki A, Takahashi Y, Nito M, Suzuki K, & Fujii H.

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KINETICS OF VISUAL AXIS AND PUPIL DIAMETER DURING CAREGIVER-ASSISTED EATING

Visual Axis Analysis during Unassisted Eating andRobot-assisted Eating. Asian Journal of Occupational
Therapy. 2016; 11: 43-52.
[7] Suzuki Y, Fujii H, Sato T, Sasaki S, Fukuda E. Eye-handcoordination during eating among healthy people. Japanese Occupational Therapy Research. 2011; 30: 422-431.
(in Japanese with English abstract).
[8] Saitou H. The characteristics of view point during eating
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healthy human subjects - (in Japanese). 2007.

[9] Sasaki S, Suzuki Y, Nito M, Kawakatsu Y, Fujii H. Contribution to visual axis by upper extremity motion during
eating in the healthy humans: Survey of various amountsof juice of the spoon during eating (in Japanese withEnglish abstract). The Japanese Occupational Therapy
Research (sagyouryouhou). 2013; 32 (1): 64-74.
[10] Bando T. The neuronal mechanisms of eye movements
related to depth perception (in Japanese with English abstract). Advances in neurological sciences (Shinkei kenkyu
no shinpo). 1996; 40 (3): 419-428.

■ORIGINAL ARTICLE

Sensory Modulation and Behavior of Preschool-Aged
Children with Special Education Needs
Yuji Hirose1, Chieko Karashima2, Go Igarashi3
1

Nagoya City University East Medical Center
Department of Occupational Therapy Faculty of Rehabilitation, Biwako Professional University of Rehabilitation3
Occupational Therapy Sciences, Prevention & Rehabilitation Sciences Course, Division of Integrated Care Sciences Technology,
Department of Integrated Health Sciences, Graduate School of Medicine, Nagoya University
2

Abstract: Objective: The number of children with special education needs (SEN) is on the rise in Japan. However, thebehavior and sensory modulation functions of preschool-aged children with SEN have not been clarified. The purposeof this study was to examine the behavioral and sensory modulation characteristics of preschool-aged children with
SEN compared with those of children without SEN.
Methods: We conducted a cross-sectional survey using a questionnaire on children’s behavioral problems and sensory
modulation, which was reported by nursery teachers who cared for children with and without SEN. Forty-two nurseryteachers who were involved with the care of children with and without SEN were asked to complete the Japanese version of the Eyberg Child Behavior Inventory (ECBI) and the Japanese version of the Short Sensory Profile (SSP).
Results: The results showed that both ECBI and SSP scores were significantly higher in children with SEN than in children without SEN (p<0.01), and that the SSP domain scores for underresponsive/seeks sensation and auditory filteringin children with SEN were significantly correlated with ECBI scores (p<0.05).
Conclusion: Children with SEN had more sensory modulation bias and behavioral problems than children without
SEN, and there was an association between sensory modulation bias and behavioral problems in children with SEN.
Keywords: sensory modulation, behavior assessment, preschool, special education needs(Asian J Occup Ther 18: 71−78, 2022)

Introduction
In 1981, the Education Act of 1981 institutionalized
the concept of “special educational needs” (SEN) in
the United Kingdom. Children with SEN have learning
difficulties that require special educational support.
Even in preschool-aged children, SEN is present when
they have more difficulties in learning than their peers,or when they are likely to have difficulties in learning
without special educational support. Because SEN isa pedagogical concept, it includes children with andwithout a diagnosis of disability [1]. Children who neededucational support include those who need support for
Received: 15 November 2020, Accepted: 8 November 2021
Corresponding to: Chieko Karashima, Department of Occupational
Therapy Faculty of Rehabilitation, Biwako Professional University of
Rehabilitation, 967, Kitasakacho, Higashiomi-shi, Shiga, 527-0145,
Japan
e-mail: c-karashima@ot-si.aino.ac.jp©2022 Japanese Association of Occupational Therapists

learning, daily life, and other activities and who have
behavioral problems in group life such as “restlessness,”“inability to control emotions,” and “frequent problems
with other children,” and this is a broad concept distinguished from developmental disorders. Therefore, thisconcept depends on the subjective judgments of parents,preschool teachers, and experts who take into accountthe results of some developmental tests. It has beenreported that the number of children with SEN is on therise in Japan [2].
Support for children with SEN should not focus
solely on the type and degree of disability, but also provide guidance and support for individual issues, focusing
on the comprehensive educational needs that arise fromeach child’s relationship with his or her environment [3].
The main supporters are specialists who provide support
through treatment and education at local developmental
support centers and developmental support offices andvisit nursery schools and schools. In Japan, the special
needs education program that started in 2007 to support

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SENSORY MODULATION AND BEHAVIOR OF CHILDREN WITH SEN

children with SEN through visits to regular classrooms
is also encouraging as a way to strengthen collaborative
support for children with SEN. Most of the support andconsultations are centered on the aforementioned behavioral problems of children with SEN and challenges incarrying out activities of daily living.
Sensory modulation disorder is a possible reason
for the behavioral problems seen in children with SEN[4]. Conversely, autism spectrum disorder (ASD) is adisorder that primarily impairs behavior and sensory
modulation. The development of assessment batteries
for the sensory processing characteristics in children
with ASD (e.g., Sensory Profile) and studies have been
conducted systematically by Dunn et al. Occupational
therapists assess these sensory modulation disorders
and the influence of the living environment to identify
factors that inhibit appropriate behavior and adjust theliving environment at nursery schools, kindergartens,
and schools. Many studies have already been conductedon the relationships between sensory modulation andbehaviors of children with ASD. For example, Brown
et al. pointed out that there are both aspects of sensory
modulation in children with ASD that are universal andunaffected by the environment, and aspects that are
affected by situations and activities [5]. Tomchek et al.
reported that sensory modulation in children with ASD
is related to language skills, and that children in thegroup with less adaptive behaviors are more likely tohave tactile and movement sensitivity and sensory seeking [6]. Similarly, Lane et al. found that biases in tactile
sensitivity, taste/smell sensitivity, underresponsive
seeking sensation, auditory filtering, and visual/auditory
sensitivity were associated with maladaptive behavior[7]. O’Donnell et al. noted that sensory modulationbiases in children with ASD are associated with behaviors such as irritability, lethargy, stereotypic behavior,
hyperactivity, and inappropriate speech [8]. It has also
been pointed out that there is a sensory processing bias
in children with attention deficit hyperactivity disorderas well as in children with ASD [9, 10]. In contrast, a
study of school-aged children with SEN reported thatsimilar to children with ASD, the sensory modulation of
those with SEN is more biased and that their behavioral
problems are more severe than those of TD children[11]. However, the behavior and sensory modulation
functions of preschool-aged children with SEN have notbeen clarified.
This study aimed to determine the characteristicsof the behavioral and sensory modulation functions ofundiagnosed children with SEN whose nursery teachers
feel they need support, in comparison to children without SEN. This study will enable inference of sensory
modulation functions from the behavioral characteristics

of children with SEN. This will contribute to the development of occupational therapy that supports the activities of children with SEN and improves the sensory
environment around them.

Materials and Methods
DesignThis was a cross-sectional survey using a questionnaire on children’s behavioral problems and sensory
modulation, which was reported by nursery teachers
who cared for children with and without SEN.
Participants
Forty-two nursery teachers from 16 facilities in
City A and 9 facilities in City B were surveyed. The
inclusion criteria were those who had at least 3 years ofexperience in the field.
Questionnaire
The Japanese version of the Eyberg Child Behavior
Inventory (ECBI) was used as a questionnaire for children’s behavior. The ECBI is an assessment tool that canbe answered by parents or alternative caregivers (nurseryteachers, etc.). The ECBI has two subscales: an intensity
scale, which captures the quantitative nature of children’s problematic behavior, and a problem scale, which
captures caregivers’ perceptions of parenting difficulties.
In this study, only the intensity scale was calculated as
the intensity score, and the response column required forthe calculation of the problem score was not includedin the questionnaire. The participants answered thefrequency of the children’s behavior problem for eachof the 36 ECBI items on a seven-point ordinal scale (1= never to 7 = always) in response to the question “Howoften does your child currently have this problem?” The
ECBI was translated into Japanese by Kamo et al. andconfirmed its reliability and validity [12].
We used the Japanese version of the Short Sensory
Profile (SSP) as a questionnaire for children’s sensory
modulation. The SSP, like ECBI, is an assessment toolthat can be answered by parents and alternative caregivers. The SSP contains 38 items and is divided into
seven domains: tactile sensitivity, taste/smell sensitivity,
movement sensitivity, underresponsive/seeks sensation,
auditory filtering, low energy/weak, and auditory/visual
sensitivity. The respondents were asked to respond toeach item using a five-point scale from “1 = never” to“5 = always,” with higher scores indicating a stronger
bias in sensory modulation. The SSP was translated into
Japanese by Hagiwara et al. and confirmed its reliability
and validity [13].

Asian J Occup Ther 18: 71−78, 2022

ProceduresThis study was conducted with the cooperationof the Board of Education of City A and the Welfare
Division of City B, Department of Child Welfare. An
unmarked self-administered questionnaire was sent
between December 2018 and January 2019 to nurseryschools and kindergartens that had received permission
from the head of the facility to participate in the study.
The subjects’ participation in the study was considered
to be their consent to participate in the study when they
returned the questionnaire.
The ages of targeted children for SSP and ECBI
were set from 3 years and 0 months to 6 years and
11 months, respectively. We excluded children withsymptoms of motor and intellectual disabilities andchildren with a diagnosis of some kind of developmental
disorder or those with a suspicion of a developmental
disorder. Prior to the selection of children with SEN,
the researcher gave a written and oral explanation of theconcept of SEN to the participants. After that, children
who did not meet the exclusion criteria of the study, but
for whom the participant wanted to consult a specialist
or for whom the participant received consultation fromfamily members, were selected as children with SEN.
The participants were asked to answer the questionnaire
according to the following procedure: (1) Using theclass roster, mark children who the participants feel need
to be supported (child with SEN). If there is more than
one child with SEN in the same class, all children with
SEN are marked. (2) With the exception of the childwith SEN in (1), the participants mark a child without
SEN by randomly pointing their finger at the class roster
with their eyes closed. (3) Answer the questionnaire forthe children marked with (1) and (2).
This study was approved by the ethics committee of
Nagoya University, School of Health Sciences, based on
the Helsinki Declaration (18-602).
Analysis
In this study, the sub-items of the ECBI were categorized in order to gain a more concrete understandingof the relationship between behavioral problems andsensory modulation functions in SEN children. We
decided to classify the ECBI sub-items into three categories: oppositional defiant behavior toward adults,
inattentive behavior, and conduct problem behavior,following the results of a previous study by Burns et al.
that conducted a factor analysis of the ECBI [14].
IBM SPSS Statistics version 26 was used forstatistical analysis. The ECBI intensity scores and SSPscores between children with and without SEN werecompared using the Mann-Whitney U test. Correlations
between ECBI intensity scores and SSP scores, as well

Hirose Y et al.

73

as correlations between SSP domain scores, were examined using Spearman’s rank correlation coefficient. The
significance level was set at 5%. The effect size r was
calculated by Z/√n. The effect size r is defined as small
at 0.10 and above, moderate at 0.30 and above, and large
at 0.50 and above [15].

Results
Forty of the 42 participants responded to the questionnaire, and the response rate was 95.2%. Data for 84
children with SEN and 42 children without SEN werecollected from the questionnaire. An average of 2.1 (2to 4) children with SEN was mentioned per participant.
After removing the missing data, we finally obtained
valid data for 80 children with SEN and 40 children
without SEN.
The ECBI total intensity score of children with
SEN was significantly higher than that of children without SEN (p<0.01). The effect size was 0.41, indicating
a moderate size. In all three categories of ECBI that
we classified, the intensity scores of children with SEN
were significantly higher than those of children without
SEN (p<0.01). The effect size of the conduct problem
behavior was the smallest at 0.35, and the other items
were above large size. Similarly, the total SSP score forchildren with SEN was significantly higher than that forchildren without SEN (p<0.01), and the effect size waslarger at 0.79. The scores of children with SEN werealso significantly higher than those of children without
SEN in all seven domains of the SSP (p<0.01). Moderate effect sizes were found for taste/smell sensitivity andmovement sensitivity, and large effect sizes were foundfor other domains (Table 1).
The relationship between each ECBI intensity scoreand each SSP score for children with SEN is shown in
Table 2. The total score of SSP showed a significant positive correlation with all three ECBI category intensity
scores (p<0.01). The SSP tactile sensitivity score wassignificantly positively correlated with ECBI intensity
scores for oppositional defiant behavior toward adults(rs=0.36, p<0.01). The SSP underresponsive/seeks
sensation score showed a significant positive correlation
with all three ECBI category intensity scores (p<0.05),
in particular, conduct problem behavior showed thestrongest positive correlation (rs=0.39, p<0.01). The
SSP auditory filtering score also showed significant
positive correlations with the ECBI total intensity scoreand all three category intensity scores (p<0.05). Amongthem, inattentive behavior showed the strongest positive
correlation (rs=0.39, p<0.01). The SSP low energy/weakscore was significantly negatively correlated with the
ECBI total intensity score (p<0.05).

74

SENSORY MODULATION AND BEHAVIOR OF CHILDREN WITH SEN

Table 1. Comparison of ECBI and SSP scores between children with and without SEN
Median (interquartile range)
Children without
SEN (n=40)

Children with SEN(n=80)

Zp

Effect size (r)63 (46–82)

104.5 (77.5–128.5)

4.53

0.00**

0.41

13 (10–18)

27.5 (18.75–42.25)

6.17

0.00**

0.56

Inattentive behavior

5.5 (4–8)

20 (14–23.25)

7.61

0.00**

0.7

Conduct problem behavior

10 (8–13)

16.5 (9–22)

3.81

0.00**

0.35

41 (38–43.25)

81.5 (69.75–96)

8.66

0.00**

0.79

7 (7–8)11 (8–14.25)

6.03

0.00**

0.55

ECBI total intensity score
ECBI category intensity score
Oppositional defiant behavior
toward adults

SSP total score
SSP domain score
Tactile sensitivity
Taste/smell sensitivity

4 (4–5)5 (4–7.25)

3.23

0.00**

0.3

Movement sensitivity

3 (3–4)4 (3–6.25)

3.7

0.00**

0.34

Underresponsive/seeks sensation

7 (7–7)18 (12–22)

7.88

0.00**

0.72

Auditory filtering

7 (6–7.25)

17 (13–20)

8.09

0.00**

0.74

Low energy/weak

6 (6–6.25)

17.5 (10–23)

7.38

0.00**

0.67

Auditory/visual sensitivity

5 (5–5)8 (6–10)6.9

0.00**

0.63

ECBI, Eyberg Child Behavior Inventory; SSP, Short Sensory Profile; SEN, special educational needs; Mann-Whitney U test,* p<0.05, ** p<0.01

Table 2. Relationship between each SSP score and each ECBI score in children with SEN
ECBI
SSP

Total score

Oppositional defiant
behavior toward adults

Inattentive behavior

Conduct problem
behavior

Total score

0.09

0.32**

0.29**

0.29**

Tactile sensitivity

0.16

0.36**

0.02

0.15

Taste/smell sensitivity

–0.14

0.19

0.07

0.1

Movement sensitivity

–0.09

0.04

–0.12

–0.03

Underresponsive/seeks
sensation

0.16

0.28*

0.28*

0.39**

Auditory filtering

0.20*

0.25*

0.39**

0.25*

Low energy/weak–0.21*

0.05

0.19

0.08

Auditory/visual sensitivity

0.03

0.19

0.08

0.07

ECBI, Eyberg Child Behavior Inventory; SSP, Short Sensory Profile; SEN, special educational needs; Spearman’s rank correlation coefficient, * p<0.05, ** p<0.01

The relationship between the SSP domain scoresof children with SEN is shown in Table 3. Significant
positive correlations were found between several domains, with the highest correlation coefficients between
underresponsive/seeks sensation and auditory filtering(rs=0.59, p<0.01).

Discussions
Characteristics of sensory modulation and behavioral
problem in preschool-aged children with SEN
The scores of SSP and ECBI were significantly
higher among preschool-aged children with SEN
than among children without SEN, suggesting thatpreschool-aged children with SEN have a larger bias

Asian J Occup Ther 18: 71−78, 2022

Hirose Y et al.

75

Table 3. Relationships between SSP each domain score for children with SEN
Tactilesensitivity

Taste/
smell
sensitivity

Movement
sensitivity

Underresponsive/
seeks
sensation

Auditory
filtering

Low energy/weak

Auditory/
visualsensitivity

Tactile sensitivity

1

0.09

0.43**

0.31**

0.29**.16.51**

Taste/smell sensitivity

0.09

1

0.24*

-0.02

0.04

.23*

.12

Movement sensitivity

0.43**

0.24*

1

0.04

0.19*

.29**

.23*

Underresponsive/seeks sensation

0.31**

-0.02

0.04

1

0.59**

.20*

.36**

Auditory filtering

0.29**

0.04

0.19*

0.59**

1

.30**

.35**

Low energy/weak

0.16

0.23*

0.29**

0.20*

0.30**

1.24*

Auditory/visual sensitivity

0.51**

0.12

0.23*

0.36**

0.35**.24*

1

SSP domain

SSP, Short Sensory Profile; SEN, special educational needs; Spearman’s rank correlation coefficient, * p<0.05, ** p<0.01

in sensory modulation and behavioral problems thanchildren without SEN. The characteristics of sensory
modulation and behavioral problems in preschool-aged
children with SEN have not been previously reported,and the results of this study are a new finding. It has
already been reported that preschool-aged children with
ASD have a bias in sensory modulation and behavioral
problems compared with TD children [8, 16]. However,this study revealed that preschool-aged children with
SEN also have a bias in sensory modulation and behavioral problems.
Green et al. reported that 66% of school-aged
children with ASD and 32% of children with SEN hada strong sensory modulation bias on the SSP total score,and for children with SEN, a strong auditory filtering
bias was present in 49%, which was the highest percentage of all domains [11]. The results of the present
study showed that in preschool-aged children with SEN,
all SSP domains scored significantly higher than thosein children without SEN, with moderate effect sizes
for taste/smell sensitivity and movement sensitivity
domains and large effect sizes for the other domains. It
is noteworthy that the auditory filtering domain showed
the largest effect size (r=0.74), which is similar to thatreported by Green et al. [11]. In addition, a study conducted by Stephanie et al. also points out the problem
of audiovisual filtering in school-age children with SEN[17]. Preschool-aged children with SEN have a greater
auditory filtering bias than children without SEN, andthis bias is likely to continue into school years. In addition to auditory filtering, green et al. also reported a highpercentage of children with SEN who showed a strong
bias in underresponsive/seeks sensation and low energy/
weak (32% and 28%, respectively) [11]. In the present
study, underresponsive/seeks sensation and low energy/

weak were also the items that showed the second largest
effect size after auditory filtering. As with auditory
filtering, it is likely that the characteristics of these twoitems from preschool age will continue into school age.
In the present study, we found the strongest positive
correlation between underresponsive/seeks sensation
and auditory filtering in terms of the association between
SSP domains in SEN children (rs=0.59). However, inBaker et al.’s previous study of autistic children, no
significant correlation was found between these two domains. On the other hand, Baker et al. reported that thestrongest positive correlation was found between movement sensitivity and visual/auditory sensitivity [16].
In the present study, although a significant correlation
was found between these two domains, the correlation
coefficient was only rs=0.23. The difference between
the results of Baker et al. and the present study may be
due to differences in the characteristics of the subjects,
but the relationship between the domains of SSP needs
further investigation.
Similarly, for ECBI, children with SEN scored significantly higher than children without SEN in all three
categories. The effect size was moderate for conduct
problem behavior and large for oppositional defiant
behavior and inattentive behavior. Caregivers have particular difficulty with social, attentional, and emotionallyrelated behavioral problems, such as “disobedience,”“roughness,” “restlessness,” and “spoiling,” in their children [18]. The behavioral problems of preschool-aged
children with SEN suggested in the present study may
be one of the reasons why caregivers have difficulty
coping with their behavior and feel the need for support.

76

SENSORY MODULATION AND BEHAVIOR OF CHILDREN WITH SEN

Relationship between sensory modulation and behavior
in preschool-aged children with SEN
For preschool-aged children with ASD, several
studies have reported an increase in behavioral problems
with greater bias in movement sensitivity, underresponsive/seeks sensation, auditory filtering, and low energy/
weak domains of the SSP [16, 19, 20]. The results ofthe present study showed that the underresponsive/seeks
sensation score of preschool-aged children with SEN
was significantly positively correlated with all three
category intensity scores of ECBI. The characteristics
of preschool-aged children with SEN and ASD are
similar in that the stronger the bias of underresponsive/seeks sensation domain, the stronger the behavioral
problems. If the characteristics of underresponsive/seeks
sensation are strong, these children’s behavior may
appear unpredictable because they overreact at sometimes and show no response at all at other times [13].
These characteristics may be perceived as inappropriate
and disturbing to others. The auditory filtering score ofpreschool-aged children with SEN were significantly
positively correlated with the ECBI total intensity scoreand all three categorical intensity scores, suggesting thatpreschool-aged children with SEN have similar characteristics to children with ASD in this respect as well. It
has been suggested that children with auditory filtering
difficulties are hypersensitive to sound or have a slower
response to sound [13]. In this regard, a high percentage
of children with ASD have auditory hyperesthesia [21,22], and it has been pointed out that there is a need for
an approach to the sensory modulation function in response to auditory stimuli [23]. The approach to sensory
modulation is not only a direct approach to the child, butalso an integrated approach to the sensory environmentof the place, surroundings, and situation. In this study,
inattentive behavior showed the strongest positive
correlation with auditory filtering, suggesting that thesensory modulation approach to auditory stimuli may beparticularly effective for inattentive behavior in children
with SEN.
Thus, the children with SEN in this study showedsome characteristics similar to the previously reported
relationship between sensory modulation and behavior
in children with ASD. Although this study excluded
children who had been diagnosed with or were suspected of having some kind of disability, it should be notedthat we cannot completely deny the possibility that there
were children with ASD among the children with SEN
included in this study.
Low energy/weak scores in preschool-aged children
with SEN were significantly negatively correlated withtotal intensity score of ECBI. Since children who havestrong characteristics of low energy/weak are considered

to get tired easily [13], they may be less likely to engage
in behaviors that are perceived by caregivers as dangerous or disruptive to group activities. Conversely, Baker
et al. reported an increase in behavioral problems forpreschool-aged children with ASD as the characteristics
of low energy/weak increased. However, this previous
study found a strong positive correlation between low
energy/weak scores and underresponsive/seeks sensation domains in children with ASD (r=0.65) and, in
addition, reported that seeks sensation features werestrongly associated with the emergence of stereotyped
behavior, and stereotyped behavior was also associatedwith the emergence of behavioral problems [16]. In thepresent study of preschool-aged children with SEN, thecorrelation between the low energy/weak score and theunderresponsive/seeks sensation score was only weakly
positive with rs=0.20. Therefore, the relationship between the characteristics of low energy/weak and behavioral problems may be different from those of children
with ASD.
Behavioral problems increase with increased movement sensitivity in preschool-aged children with ASD[16]. Although, in this study, the movement sensitivity
score did not correlate with the ECBI for each category
score for the children with SEN, there was a significant
difference in the movement sensitivity scores between
children with and without SEN, but the effect size wassmaller than the other domains. This suggests that thebias of movement sensitivity was not as strong as in theother domains and was not associated with behavioral
problems for preschool-aged children with SEN.
Suggestions for occupational therapy for preschoolaged children with SEN
Since there is an association between sensory
modulation and behavioral problems in preschool-aged
children with SEN, an approach to sensory modulation
may be an evidence for occupational therapy practice topromote adaptive behavior in preschool-aged children
with SEN.
When occupational therapists visit nursery schools
and other facilities to provide support to children with
SEN, it may be possible to infer sensory modulation
functions from information obtained from caregivers
about behavioral problems in daily life, play, and communicative situations of children with SEN and suggest
a direction for support. These reasoning processes may
be useful when presenting a direction of support in alimited amount of time.
Occupational therapists who assess children with
SEN at developmental support centers and hospitals
need to practice occupational therapy that takes into
account the differences in sensory environments, such asAsian J Occup Ther 18: 71−78, 2022

local nursery schools.

Limitations and future directions
In this study, both ECBI and SSP were answered by
the nursery teachers, not the children’s parents. In otherwords, we need to be cautious about the fact that theanswers are based on the child’s behavior at the facility.
It is possible that the participants have answered aboutchildren with SEN based on the usual life and play situations of children without SEN. In this study, we did not
ask about the age and gender of the children to protect
their personal information. Therefore, the effects of age
and gender need to be examined in the future. The present study compared children with and without SEN, so
the similarities between children with SEN and ASD are
only hypotheses. To examine the hypotheses obtained
from the present study, it is necessary to conduct asurvey of preschool-aged children with SEN and ASD.

Conclusions
Preschool-aged children with SEN, except for thosewith a diagnosis, were shown to have more sensory
modulation bias and behavioral problems than children
without SEN. Preschool-aged children with SEN, except
for those with a diagnosis, were shown to have more
oppositional defiant behavior toward adults, inattentive
behavior and conduct problem behavior when they had
more biased sensory modulation of “underresponsive/seeks sensation” and “auditory filtering.”

Declaration of Interest
The authors report no conflict of interest.

Acknowledgements:
We would like to express our gratitude to the Boardof Education of Nakatsugawa city, the Welfare Divisionof Nissin city and all the participants.

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[9] Shimizu VT, Bueno OFA, Miranda MC: Sensory processing abilities of children with ADHD. Braz J Phys Ther.
2014; 18(4); 343-52.
[10] Miller LJ, Nielsen DM, Schoen SA: Attention deficit hyperactivity disorder and sensory modulation disorder: A
comparison of behavior and physiology. Res Dev Disabil.
2012; 33(3); 804-18.
[11] Green D, Chandler S, Charman T, Simonoff E, Baird G.
Brief Report: DSM-5 Sensory Behaviours in Children
With and Without an Autism Spectrum Disorder. J
Autism Dev Disord. 2016; 46(11): 3597–606.
[12] Kamo T. The Japanese version of the Eyberg Child Behavior Inventory (ECBI) (in Japanese). Tokyo: Chiba test
center; 2016.
[13] Hagiwara T, Iwanaga R, Ito H, Tani I. The Japanese Version of the Sensory Profile (in Japanese). Tokyo: Nihon
Bunka Kagakusya Co., Ltd.; 2015.
[14] Burns GL, Patterson DR. Factor structure of the Eyberg
Child Behavior Inventory: a parent rating scale of Oppositional Defiant Behavior Toward Adults, Inattentive
Behavior, and Conduct Problem Behavior. J Clin Child
Psychol. 2000; 29(4): 569-77.
[15] Mizumoto A, Takeuchi O. Basics and Considerations for
Reporting Effect Sizes in Research Papers (in Japanese).
Studies in English Language (eigokyouikukenkyu). 2008;
31: 57-66.
[16] Baker AEZ, Lane A, Angley MT, Young RL. The rela-

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tionship between sensory processing patterns and behavioral responsiveness in autistic disorder: A pilot study. J
Autism Dev Disord. 2008; 38(5): 867-75.
[17] Stephanie AG, Roderic IN: Problems in Audiovisual
Filtering for Children with Special Educational Needs.
Iperception. 2020; 11(4): 1-19.
[18] Whitney R: Effect of Sensory-Based Behaviors on Maternal Stress and the Mother–Child Relationship [online].
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2020 October 31]. Available from: https://ajot.aota.org/
article.aspx?articleid=2714939.
[19] Foss-Feig JH, Heacock JL, Cascio CJ. Tactile responsiveness patterns and their association with core featuresin autism spectrum disorders. Res Autism Spectr Disord.
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[20] Hamed-Daher S, Engel-Yeger B: The Relationships
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[21] Bromley J, Hare DJ, Davison K, Emerson E. Mothers
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[22] Gomes E, Pedroso FS, Wagner MB. Auditory hypersensitivity in the autistic spectrum disorder. Pro Fono. 2008;
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[23] Thompson-Hodgetts S, Magill-Evans J: Sensory-BasedApproaches in Intervention for Children With Autism
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2020 October 31]. Available from: https://ajot.aota.org/
article.aspx?articleid=2676228.

■ORIGINAL ARTICLE

Motor Learning of Handwriting Using theNon-dominant Hand
Mitsunobu Kono1, Kaoru Inoue2, Tomoko Kawaguchi1, Masashi Yoshitake1,
Syunji Sako3
1

Department of Occupational Therapy, Faculty of Health Sciences, Kinjo University, Ishikawa, Japan
Division of Occupational Therapy, Faculty of Health Sciences, Tokyo Metropolitan University, Tokyo, Japan3
Department of Physical Therapy, Gifu University of Health Science2

Abstract: To investigate the features associated with the mastery of neat and speedy handwriting, 23 healthy volunteers
practiced writing with their non-dominant hand. The participants were randomly divided into two groups. One group(n = 12) started writing simple symbols such as dashes, circles, and triangles (−, ○, and △) and then after 1 week,
advanced to writing individual characters. The other group (n = 11) started by copying entire sentences. The practiceperiod lasted 4 weeks (7 days/week). Results showed no major differences between the groups in terms of handwriting
learning effectiveness; however, there was a trade-off between the speed at which the participants wrote and the neatness of their writing. These findings suggest that the process of learning to master handwriting is consistent with theFitts’s law.
Keywords: non-dominant hand, handwriting, motor learning(Asian J Occup Ther 18: 87−93, 2022)

Introduction
In the field of occupational therapy, patients wholose functionality in their dominant hand due to diseaseor injury are often provided with guidance regarding thetransfer of hand-dominance. When the objective of sucha therapy is to regain the ability to write, for example incases where returning to work is expected or when writing is an essential method of communication, the motor
learning of handwriting is frequently part of the therapy
program.
Chinese characters (kanji) were imported to Japan
from China via the Korean peninsula during the 5th and6th centuries CE. Based on these characters, two types ofsyllabaries (hiragana and katakana) were developed inJapan around the 9th century CE. These three charactertypes are commonly used in Japan. Thus, Japanesepatients who need to learn handwriting have to master
Received: 18 March 2021, Accepted: 6 January 2022
Corresponding to: Mitsunobu Kono, 1200, Kasama-machi, Hakusan,
Ishikawa, 924-8511, Japane-mail: kohno_mi@kinjo.ac.jp©2022 Japanese Association of Occupational Therapists

these three character types.
Mastering handwriting requires both speed andneatness. Generally, practice progresses in the steps ofincreasing difficulty, beginning with simple outlined
shapes (such as −, |, /, ×, and ○), then advancing tokanji, which comprises straight lines ( 三 , 川, 日, 田,and 目), and finally to more complex kanji and the hiragana syllabary. [1-3] An alternative approach is “random
practice,” one aspect of R.A. Schmidt’s theory of motor
learning;[4,15] this entails the simultaneous practice oftasks at different levels of difficulty. Although progressis generally slower, this method is considered to be more
effective than the block practice method for the retentionof skills and the transfer of skills to practical problems. [4, 5]
Many occupational therapists utilize block practice,which involves initiating practice with simple tasks suchas coloring in outlines and then advancing to writing
characters, because they have more experience withthis method. [1-3] However, only a few studies have investigated effective methods for improving handwriting
speed and neatness through practice. In the present
study, we compared the motor learning efficacy using
the block and random practice methods for the development of handwriting proficiency among individuals

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MOTOR LEARNING OF HANDWRITING

undergoing hand-dominance transfer therapy. The aimof this investigation was to identify the factors which
influences the motor learning of handwriting.

Methods
Participants
The study enrolled 23 healthy volunteers who usedtheir right hand when performing common, everyday
activities such as holding a pencil when writing, holding
chopsticks when eating, or throwing a ball. None of theparticipants underwent hand-dominance transfer fromtheir left to their right hands during childhood. Threeparticipants were males and 20 were females. Theirmean age was 20.7 ± 0.5 years. The participants wererandomly assigned to two groups. The 23 participants
began by writing symbols such as −, ○, and △. Subsequently, 12 subjects advanced to kanji (consisting of
only three strokes), hiragana, and then sentence copying. As these tasks became increasingly difficult, these12 participants were placed in the block practice group.
Eleven participants were placed in the random practicegroup in which they were made to practice sentence
copying from the beginning. Participants were randomly
assigned to the groups.
This study was approved by the Institutional
Review Board of the Kinjo University (no. 27-16).
The participants were provided with the descriptions ofstudy contents and methods. Moreover, the participants
provided written informed consent before participation.
Procedures
Each day during the 4-week practice period, theparticipants wrote 200 characters in horizontal lines
using HB pencils. The paper was lined with a grid of 1
× 1 cm squares. Because the study aimed to investigate

the motor learning process when writing was practiced
to gain speed and neatness, the participants were notprovided with any instructions except for a descriptionof the characters that were required to be practiced.
For the block practice group, the specific type ofpractice was changed according to pre-determined steps:
during week 1, they practiced symbols (e.g., +, ×, and ○);during week 2, they practiced kanji involving strokes(e.g., 川, 三, and 口); during week 3, they practiced
hiragana; and during week 4, they copied sentences on
general topics (of a third grade elementary school level
as indicated by the Japanese Ministry of Education,
Culture, Sports, Science and Technology)6. In contrast,
the random practice group practiced copying entire sentences on general topics throughout the practice period.
For both the groups, the sentences on general topics
were of third grade elementary school level, as indicatedby the Japanese Ministry of Education, Culture, Sports,
Science and Technology, and included kanji with higher
numbers of strokes. The level of difficulty of each task
was determined by five occupational therapists and wasbased on the Japanese Ministry of Education, Culture,
Sports, Science and Technology’s Elementary School
Curriculum for the Japanese Language.[6]Outcome measures
The sentences on general topic of a sixth grade elementary school level, which included kanji with higher
numbers of strokes, were practiced on paper lined with a
1 × 1 cm grid using HB pencils.
Seven assessments were conducted: at the baseline(T0), at the end of each week during the practice period(T1, T2, T3, T4; total 4 h), a week after the end of thepractice period (T5), and 2 weeks after the end of thepractice period (T6) (Figure 1).
There were two outcome measures: the number of

Figure 1. Writing practice period and assessment points.
The assessment was carried out seven times; before practice (Time0: T0), the end of each week (T1, T2, T3, T4,
total four hours), a week after the end of the practice (T5), and two weeks after the end of the practice (T6).

Asian J Occup Ther 18: 87−93, 2022

Kono M et al.

89

Table 1. An example of character neatness scores

The baseline (T0) evaluation results of female (21 years old) in the random practice group are shown.
Each of these features were scored from 1 to 5 (5 = good), and the total scores were calculated. The
number of characters that this subject could write within the evaluation time was 30.

characters written and the neatness with which the characters were written.
The number of characters written was assessed bycounting the number of characters the participants wereable to copy within a time limit of 150 s. Character neatness was assessed using a method that was devised by
us and was based on the Elementary School Curriculum
for the Japanese Language of the Japanese Ministry of
Education, Culture, Sports, Science and Technology.
[6]
The characters were divided into the following fourgroups for assessment: hiragana, katakana, kanji comprising ≤7 strokes, and kanji comprising ≥8 strokes. The
assessments were based on the following features: theoverlapping of lines; wobbly lines; the correct usage of“stops” and “upward turns”; downward sloping characters; and the balance between kanji and other characters,
examining whether the kanji were more prominent thanothers. Each of these features were scored from 1 to 5
(5 = good), and the total scores were calculated. The
maximum total score was 100. Higher scores indicatedthat the characters were neatly and skillfully written.
Table 1 shows the example of scoring. This subject
was a 21 years old female in random practice group,copied 30 hand writing characters at baseline (T0) evaluation.
Two evaluators independently assessed character
neatness, and the final character neatness scores were themean scores of the two evaluators. The degree to which
the two evaluators’ scores matched was investigated by
calculating intraclass correlation coefficients for eachtime point.
Statistical analysis
The character neatness scores of the two groups

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MOTOR LEARNING OF HANDWRITING

at each time point were compared using the Mann–
Whitney U test. Chronological changes were examinedusing the Friedman and Wilcoxon rank sum tests. In
addition, the relationship between the number of characters written and character neatness was examined using
the Spearman rank correlation coefficient analysis. The
level of statistical significance was set at p < 0.05. The
analyses were performed using Microsoft Excel for Mac
2016 (Microsoft) and JMP 14.0 MAC (SAS InstituteInc.).

Results
There was good correlation between the scores of
the two evaluators for character neatness at each time
point, with intraclass correlation coefficients between
0.67 and 0.82 (Table 2). Also, there was not significant
difference between the scores of the two evaluators at

each time point.
Comparisons of the number of characters written
within 150 s and character neatness scores at eachtime point showed a significant difference between thetwo groups only in the number of characters at week
1 (Tables 3). No other significant differences wereobserved between the groups at any other time points(Tables 4).
In both groups, the number of characters written
in 150 s increased gradually from the baseline to thefinal retention assessment (p < 0.05; Table 3). Character
neatness scores in the block practice group showed asignificant difference only between the week 4 assessment and the final retention assessment (p < 0.05), withno significant differences observed between any othertime points (Table 4). In the random practice group,
there were significant differences in character neatness
scores between the week 1 and week 4 assessments andTable 2. ICC between two evaluators on the results of the neat of characters which the leaners wrote

Table 3. The change with time on the numbers of characters which the learners wrote about two practice groups

Asian J Occup Ther 18: 87−93, 2022

Kono M et al.

91

Table 4. The change with time on the neat of characters the learners wrote on two practices groups

between the week 4 assessment and the final retention
assessment (p < 0.05), but there were no significant
differences between any other assessments (Table 4).
The mean numbers of characters written in 150 s
and character neatness scores in the two groups weresubtracted from each case and the relationship between
the scores at each time point was investigated. Scatterplots of these individual values showed that many
individual scores at the baseline were in the vicinity ofthe mean scores and that the participants with a gradualincrease in the number of characters written in 150 s
showed a decrease in the rate of improvement in theircharacter neatness scores. On the contrary, participants
whose rate of increase in the number of characters
declined showed a tendency toward improvement intheir character neatness scores (Figure 2). There was nodifference between the groups in this trend.
The correlation analysis resulted in the following

a. T0(Before practice)b. T4(The last day of practices)c. T5(Retention assessment)

d. T6(Retention assessment)

Figure 2. The correlation between the numbers of characters and the neat of characters.

92

MOTOR LEARNING OF HANDWRITING

Spearman rank correlation coefficients: baseline, −0.33;
week 1, −0.57 (p < 0.01); week 2, −0.70 (p < 0.01);
week 3, −0.73 (p < 0.01); week 4, −0.74 (p < 0.01);
retention assessment 1, −0.84 (p < 0.01); and retention
assessment 2, −0.80 (p < 0.01) (Figure 2).

Discussion
For performing activities of daily living, it is important to be able to write at a standard speed and witha certain neatness so as to make the writing legible toothers.[7-9] Many studies have assessed the mastery of
handwriting by assessing the speed at which the individual writes, the pressure applied, and the accuracy(neatness) of the writing. Reportedly, computers havebeen used to assess accuracy by measuring one representative character.[10,11] Moreover, studies have reported
the use of computers with character-reading softwares,
using which the participants’ writing samples were
scanned and entered into the computer and the percentage of characters that the program could recognize wereassessed.[12,13] Many studies have assessed writing speed
using methods that are easy to implement in clinicalsettings. In contrast, although there many methods forassessing the accuracy (neatness) of characters, methods
that utilize computers may not be easy to use in clinicalsettings.
In the present study, we utilized assessment methods that do not require any kind of device and thus
are easy to implement in clinical settings. Using thesemethods, we counted the number of characters that
could be copied within a pre-determined time period (150s) to assess writing speed. Because there is no existing
method for objectively assessing character neatness,
we developed a quantitative method to assess the same.
An investigation of the reproducibility of our method
indicated good concordance in the scores that wereindependently determined by the two evaluators withintraclass correlation coefficients between 0.67 and 0.82,
indicating generally good reliability. To further improvereliability, we utilized the mean values of the scores determined by the two evaluators in the analyses. In addition, writing is a quiet activity, hence statue and muscle
strength do not impact significantly. In this research the
majority of our subjects were women, therefore we did
not compare male versus female.
Differences in the practice methods used to learn askill can have a major effect on the level of mastery ofthat skill.[4,5] In the present study, we compared the efficacy for learning handwriting using block and random
practice methods with a particular focus on the speed
and neatness with which the participants were able towrite characters. We did not observe any clear differenc-

es between the two groups in terms of learning efficacy.
However, the components that express handwriting performance are not limited to speed and neatness alone.
They also include the way the pencil is held, a fine control of pencil, the shape of the hand, the pressure withwhich the pencil is held and used, and various other elements.[8-13] The writer’s attitude and objectives also havean effect on learning efficacy.[2] For example, a writer
may have in mind a goal of writing quickly or neatly.
The elements that are required to learn handwriting may
not indicate the same degree of mastery. In addition,it has been reported that at least 60 min of practiceper day is required to master handwriting and that theacquisition of a serviceable speed requires 3 months
whereas acquiring the ability to write neatly requires 6months of practice.[2] Thus, mastering handwriting witha high degree of motor skill takes more than the 4-weekpractice period utilized in the present study, which
presumably is too short to acquire this mastery. Thismay be one reason why we did not observe a difference
between the two groups in terms of learning efficacy.
On the contrary, by contrasting the number ofcharacters and neatness, it was noted that participants
who had poor rates of improvement in the numberof characters written in the time limit tended to show
improved character neatness scores. The number ofcharacters and speed was negatively correlated, withincreasing significance as the practice process continued
on. This suggested a trade-off between writing speed
and character neatness. No difference was found by thedifferent practice methods used. The same relationshipwas maintained at the retention assessments conducted
after the end of the practice period. This suggests that it
was difficult for the subjects to learn writing speed andneatness simultaneously.
The number of characters written indicates ‘motor
speed’, while the neatness score indicates ‘motor precision’. According to Paul M. Fitts, “when required motor
precision is increased, it results in longer time for motor
action (he Fitts’s law,[4,15])”. Similarly, this research
result of trade-off relationship between the number ofcharacters and writing speed suggests that the handwriting speed and neatness undergo a learning process
consistent with the Fitts’s law, regardless of the learning
method used.
No objectives or other instructions regarding learning handwriting were provided to the participants. The
results of this study suggest that this may have had aneffect on whether they emphasized speed or neatness as
they learned. We intend to further study the characteristics of mastering handwriting with the non-dominant
hand over longer practice periods and by instructing theparticipants to emphasize either speed or neatness as anAsian J Occup Ther 18: 87−93, 2022

objective of learning.
Conclusion
To investigate the characteristics of mastering
handwriting, we compared learning effects in the termsof the number of characters that could be written withina time limit and character neatness over a 4-weekpractice period between the two groups: block practicegroup, in which practice began with simple symbols andthen gradually progressed to more difficult tasks, andrandom practice group, in which entire sentences were
copied from the beginning. The reason for focusing
on speed and neatness was that mastering handwriting
includes various components such as handwriting speed,
neatness, pencil pressure, and hand shape and thatsimultaneously learning all of these may not provide
results that represent the learning process. However, focusing these two characteristics may be one reason why
we did not observe any major differences between thegroups in terms of learning efficacy. It is also possiblethat the 4-week practice period utilized in this study was
insufficient for revealing any differences in the learning
efficacy between the two methods. Nevertheless, weobserved a trade-off between handwriting speed andneatness, which was consistent with the Fitts’s law.

Declaration of conflicting interests
The authors of this study have no conflicts of interest to declare.

References[1] Hara T, Suzuki A. Rehabilitation igaku zensho 10
Sagyoryoho kakuron. Ishiyaku Shuppan. 1988 ; 57-59, inTokyo.
[2] Sakai H. Syoji no kikite kokan kunren. JJOT. 1992 ; 26 :351-355.

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93[3] Tateishi N, Nakayama H. Rehabilitation - Hikikite syoji
ni kansuru kenkyu. JART. 2003 ; 50 : 183-188.
[4] Richard A.Schmidt, Craig A.Wrisberg. Motor Learing
and Performance 2nd ed, Human Kinetics.Human Kinetics. 2000 ; 147-253, in U.S.
[5] Saitoh E, Yoneda C, Fujino H, Nagae M, Kanada Y.
Rehabilitation ni okeru undou gakusyuu. Sogo Rehabilitation. 2004 ; 32 : 1157-1164.
[6] Monbukagaku-syo. Syougakko gakusyu shidoyoryou
kaisetsu (Kokugohen). 2008.
[7] Ikeda C, Nakashima S, Takisawa S, Nakamura Y, Sengoku Y. Syoji no Yomiyasusa ni kansuru hattatsuteki
keikou. JOTR. 2013 ; 32 : 14-22.
[8] Shimizu H, Yoshikawa H. Shojidosa no syujuku yosoku.
JOTR. 1989 ; 8 : 594-603.
[9] Endoh T, Sugiura T, Koyama H, Setoshita M, Nagata
A. Nokekkansyogai migikatamahi kanjya no syojidosabunseki-shoji no sagyotokusei to sagyotyu no kindenzu
oyobi kansetsu undo tono kankei. JOTR. 1999 ; 18 : 269278.
[10] Miyashiro N, Marutani T, Ota T, Koshiba T, Nishiguchi
H, Yokomizo K. Syogaikoreisya no syojidosa tokusei ni
tsuite. The Japanese Journal of Ergonomics. 1990 ; 26 :331-335.
[11] Okajima Y, Igusa Y, Kimura A, Kondo K, Chino N. Migisyoji to hidarisyoji no undo oyobi keitaikaiseki niyoru
hanbetsu. Jpn J Rehabil Med. 1996 ; 33 : 182-187.
[12] Akezaki Y, Kawakami Y, Hiraga Y, Nomura T, Satoh A.
Hikikite no syojiseikakusei no koujyo saseru rensyuhoho.
Rigakuryoho Kagaku. 2009 ; 24 : 689-692.
[13] Tsuji Y, Akezaki Y, Ideta M, Aramaki R. Hikikite niyoru
syojirensyuhoho no kentoh – Gurid sen wo mochiita mosyarensyuhoho no yukousei-. JJOMT. 2016 ; 64 : 84-87.
[14] Nakashima S, Sengoku Y, Nakamura M (2002). Senbikikadai ni okeru hikkiyogu no hajikeitai to sosasei no hattatsutekikankei ni kansuru yobitekikenkyu. JOTR. 2002 ;21 : 109-117.
[15] Paul M.Fitts. The information capacity of the humanmotor system in controlling the amplitude of movement.
Jounal of Experimental Psychology. 1954 ; 47 : 381-391.

■ORIGINAL ARTICLE

Factors Related to the Visual Information Processingof Children with Learning Disabilities Who Have
Difficulty Acquiring Kanji Writing: Features Revealedby the Rey–Osterrieth Complex Figure Test
Shoji Onishi1, 2, Hanae Kosuge3, Keiko Kumagai4
1

Yokohama North Area Habilitation Center for Children
Doctoral Program in Disability Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
3
Institute for Traffic Accident Research and Data Analysis, Tokyo, Japan
4
Faculty of Human Sciences University of Tsukuba, Ibaraki, Japan
2

Abstract: The Rey–Osterrieth complex figure test drawings of 68 children with learning disabilities who have difficultyacquiring kanji writing were evaluated using Osterrieth’s scoring system (accuracy scale) and the organizational scoring
system (drawing strategy scale) to understand the factors involved in their visual information processing. After 1 weekor more, a second evaluation was performed with a color-coded setting for the components in the figure. The scores ofeach scale were normalized into z-scores. Using the z-scores as the dependent variables, a two-factor analysis of variance was performed for the color-coding and evaluation scale factors. Children with learning disabilities who have difficulty learning kanji writing had a problem with perceiving the components of the figure as a unit, which suggests thatthey found it difficult to recall the figure. It is considered that the factor involved in the visual information processingof children with learning disabilities who have difficulty acquiring kanji writing is largely influenced by the disability
in using the composition strategy that promotes recall. A comparison of the evaluation results, based on the presence orabsence of attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), suggests that children
with ADHD and ASD tend to be more affected by the impaired use of composition strategies.
Keywords: Rey–Osterrieth complex figure, learning disabilities, kanji writing, visual information processing(Asian J Occup Ther 18: 79−85, 2022)

Introduction
There are three different characters in Japanese: hiragana and katakana, which are phonetic characters, andkanji, which are ideographic characters. In the former
two characters, there is a one-to-one correspondence between the letters and sounds. For example, the hiragana“あ” is pronounced only as “a,” and the katakana “ア”
is also pronounced only as “a.” On the other hand, mostkanji characters do not correspond to a specific sound.
For example, the kanji “男 (male)” is pronounced as
Received: 12 January 2021, Accepted: 20 December 2021
Corresponding to: Shoji Onishi, Yokohama North Area Habilitation
Center for Children, 16-3 Kuzugaya Tsuzuki-ku,Yokohama-shi,
Kanagawa-ken 224-0062, Japane-mail: remedios0024@gmail.com©2022 Japanese Association of Occupational Therapists“otoko” or “dan” depending on the context.
Compared to the other characters, kanji generally
have more strokes and are more complicated in form.
For example, the number of strokes of the kanji “鬱 (depression)” is as many as 29. Most kanji are divided into
two or more components: left and right or up and down.
For example, the kanji “男 (male)” is a combination of“田 (paddy)” and “力 (force).”
Japanese students are required to learn 1,026 kanji
in elementary school and 1,110 in junior high school.
However, Uno et al. [1] found that 6.1% of children
with learning disabilities (LD) had difficulty acquiringkanji writing, which was higher than for the acquisitionof hiragana (1.6%) and katakana (3.8%). Furthermore,learning kanji writing may be a major cause of learned
helplessness in children with LD [2].
Wakamiya (2017) [3] suggested that some brain
functions that are involved in visual information pro-

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VISUAL INFORMATION PROCESSING OF CHILDREN WITH LEARNING DISABILITIES

Fig. 1. Rey–Osterrieth complex figure

cessing may be related to writing and the perception ofquantity, and that deficits in these functions cause LD. In
particular, he focused on the large variety of charactersused in Japanese orthography and their morphologicalcomplexity and assumed that they place a heavy burden
on morphological perception and recognition.
The Rey–Osterrieth complex figure (ROCF) test
(Fig. 1) is often used as a test of visual information
processing in case studies of children with LD whohave difficulty acquiring kanji [4-10]. In the ROCF
test, Osterrieth’s (1944) [11] scoring system (hereinafterreferred to as “the accuracy scale”) is generally used,which evaluates the accuracy of the morphology andposition. Based on this accuracy scale, the factors thathinder the acquisition of kanji writing have been identified as impaired figure recall [4,7] and impaired visual
cognition and figure recall [5]. However, no impairmentsof visual cognition or figure recall were found when theaccuracy scale was used in another study [8,9].
On the other hand, Hashimoto et al. (2006) [6] used
the organizational scoring system (hereinafter referred
to as “the drawing strategy scale”) that was devised by
Chervinsky, et al. (1992) [12], which is a scale for evaluating the composition strategy in terms of how many
components of the figure are drawn together. This drawing strategy scale evaluates planning among executivefunctions [13]. By using this scale, they were able toidentify that it is difficult for a child with attention-deficit hyperactivity disorder (ADHD) and developmental
coordination disorder (DCD) to acquire kanji writing
because of the impaired use of composition strategies
that promote recall. Usually, kanji is acquired throughvisual copying that combines the overall picture andthe components of the character (e.g., the kanji “男” islearned as both the “田” and “力” components), but children with LD just copy the entire character as the figure.
Separately, Onishi and Kumagai (2019) [10] reported
that four children who had LD and difficulty acquiringkanji writing all showed impaired use of the composition strategy, which suggests the need for learning guidance that takes into account the composition strategy
for children who have LD and difficulty acquiring kanji
writing. Onishi and Kumagai (2019) [10] considered thecomposition strategy and reported the learning effect ofgiving guidance by color-coding each stroke of the kanji
so that the components can be easily recognized.
In fact, a unified view of the factors that hinder theacquisition of kanji writing has not been established,
and there are different interpretations depending on
the evaluation scale that is used. To consider effective
support for these children, it is necessary to understandwhat visual information processing factors affect theirlearning of kanji writing.
Therefore, the purpose of this study was to identify
the hindering factors in children with LD who havedifficulty acquiring kanji writing by evaluating their
ROCF using both the accuracy and drawing strategy
scales, which specifically focus on the aspects of visual
recognition/recall and composition strategy. This study
is the first to employ both scales when investigating thefactors that influence the acquisition of kanji writing inchildren with LD.
As per Onishi and Kumagai (2019) [10], who
considered the composition strategy and the learning
effect, we will confirm the effect of considering thecomposition strategy on the figure recall performance bycolor-coding the components of the Rey complex figure.
Many studies have reported executive dysfunction
in children with ADHD and autism spectrum disorder(ASD) [14-15]. Some of these studies used the Rey’s
complex figures [15-17]. Furthermore, McGee et al.
(1989) [18] reported that children with reading disabilities (RD) and attention deficit disorder (ADD) had lower
recall performance in the ROCF test than children withRD alone. Oka (2017) [19] stated that ASD and ADHD
are associated with cognitive dysfunctions including
executive dysfunction, and the cognitive traits become
more complicated in cases with LD. Therefore, we will
also examine the effect of the presence or absence of
ADHD or ASD on the accuracy scale and the drawing
strategy scale.

Methods
Participants
Sixty-eight elementary school children (boys = 54,
girls = 14; second grade (7 to 8 years of age) = 13, third
grade (8 to 9 years) = 22, fourth grade (9 to 10 years)= 15, fifth grade (10 to 11 years) = 12, sixth grade (11to 12 years) = 6) who met the test conditions (1) to (4)(see below) were retrospectively selected from medical

Asian J Occup Ther 18: 79−85, 2022

charts. The test conditions were as follows:(1) Children from second to sixth grade who were
native Japanese speakers and attend the X medical facility.
(2) Children with an intelligence quotient (IQ)
of 85 or higher on the Wechsler Intelligence Scale forChildren-Fourth Edition’s Full-Scale IQ, the second edition of the Kaufman Assessment Battery for Children’s
cognitive comprehension scale, or the Tanaka–BinetIntelligence Scale-V.
(3) Children whose writing grades in kanji were in
the 25th percentile or less in the Screening Test of Reading and Writing for Japanese Primary School Children[20].
(4) Children who had been diagnosed with LD by adoctor.
Procedure
The ROCF test was conducted face-to-face on thefirst day of occupational therapy in the occupational
therapy room. A therapist explained how to perform thetest, and the participant copied a sample figure on A4
size paper with a pencil. After the copying was completed, the therapist collected the sample figure and thecopy. After 3 minutes, the therapist handed another sheetof A4 paper to the participants and instructed them torecall (remember and draw) the copied figure.
After 1 week or more, the ROCF test was performed again in the same setting and using a similar
process (Fig. 2) although the components of thedrawing were coded in different colors. Regarding thecolor coding of each component of the figure, we tookcare not to intersect the lines of the same color, andconfirmed that even a person with color weakness canrecognize the components.
The participants were instructed not to rotate thepaper during the test. If a mistake was made, the useof an eraser was prohibited but drawing a double line

Fig. 2. Rey–Osterrieth complex figure (with color-coded
settings for each component)

Onishi S et al.

81

and redrawing was allowed. The therapist used an iPadto record a video only during the copying process. The
video was employed for the scoring when using thedrawing strategy scale.

Evaluation of the participants’ performancein the ROCF test
Accuracy scale
The copying and recall were evaluated using Osterrieth’s scoring system, which divides the ROCF into 18
units and evaluates the accuracy of their morphologies
and positions. For example, if a large rectangular unit isdrawn correctly in terms of morphology and position,
2 points will be given to the unit, but if either the morphology or position is wrong, 1 point will be given. If it
is wrong in terms of both morphology and position, 0.5
points will be given. In short, the score is determined
depending on how accurately the figure is drawn. The
maximum scale score is 36 points.
Drawing strategy scale
Only the task of copying is evaluated when using
Chervinsky’s organizational scoring system, which
divides the ROCF into six sections and evaluates how
many components of each section are drawn. For example, in the first section, if the participant draws a large
rectangle with diagonal, horizontal, and vertical lines
inside it, he/she will be awarded 15 points. If he/she
draws only a rectangle and moves on to another section,
he/she will be given only 5 points. In other words, thescore is determined by how many components of the
figure are included in the drawing. The scale score wascalculated using the scoring method of Hattori (2004)[21] with a maximum of 54 points.
Statistical analysis
The ROCF scale scores of the 68 participants werenormalized to standard z-scores in reference to Hattori(2004) [21]. To evaluate the factors related to the visual
information processing in the ROCF test of the children
with learning disabilities who have difficulty acquiringkanji writing, in terms of both the accuracy and drawing
strategy scales, a two-factor analysis of variance was
performed among the participants for the color-coding
factors (with or without color coding) and evaluation
scale factors (Table 1); that is, the copying-drawing
strategy, copying-accuracy, and recall-accuracy. The
Bonferroni test was used as the post-hoc test.
In addition, 68 study participants were grouped
according to their diagnosis of ADHD and ASD. The
test results and IQ were compared by one factor variance analysis. The Bonferroni test was used as the post-

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VISUAL INFORMATION PROCESSING OF CHILDREN WITH LEARNING DISABILITIES

Table 1. The combination of the task content andevaluation scale factors in the Rey–Osterriethcomplex figure test

hoc test. The R (version 3.5.1) free statistical analysis
software was used for the statistical analysis. The significance level was set to 5%.
Ethical considerations
This study was conducted with the approval of the
Research Ethics Committee of the institution to which
the first author belongs. The relevant tests were agreed
upon by the participants and their parents.

Results
Breakdown of the participants’ diagnoses
All 68 eligible children were diagnosed with LD.
Of these, 12 were diagnosed with LD alone, ,6 with at
ADHD, 22 with ASD, one with DCD and 27 with combined ADHD and ASD (Fig. 3).
Relationship between the figure’s color-coding factors
and evaluation scale factors
The basic statistics of the z-score for the figure’s
color-coding and evaluation scale factors were calculated (Table 2). To investigate the factors that are related
to the visual information processing of the children withlearning disabilities who have difficulty acquiring kanji
writing, a two-factor analysis of variance was performed
for the color-coding factors (with or without color
coding) and evaluation scale factors (copying-drawing
strategy, copying-accuracy, and recall-accuracy). A significant interaction was found (Fig. 4), which suggested
that the relationships between the factors were strong (F(2, 134) = 28.93, p < .01, ηp2 = .30).
In the test of the simple main effect of the col-Fig. 3. Breakdown of the diagnoses of the 68 participants. LD = learning disabilities alone; DCD = developmental
coordination disorder; ADHD = attention deficit hyperactivity disorder; ASD = autism spectrum disorder.

Table 2. Average value and standard deviation of the z-scores for each factor of the visual information processing and figure’s
color coding

M = mean; SD = standard deviation.

Asian J Occup Ther 18: 79−85, 2022

Onishi S et al.

83

Fig. 4. Average z-score for each of the color-coding factors and evaluation scale factors of the figuresor-coding factors, the copying-drawing strategy and recall-accuracy were significant at the 1% level (F (1, 67)= 63.83, ηp2 = .49; F (1, 67) = 98.20, ηp2 = .59). In thesimple main effect test of the evaluation scale factors,
both with and without color coding were significant at
the 1% level (F (2, 134) = 11.29, ηp2 = .14; F (2, 134) =12.03, ηp2 = .15).
The multiple comparison that involved the Bonferroni test indicated that the z-score of copying-accuracy
was significantly higher than that of the copying-drawing strategy and recall-accuracy at the 5% level in thecondition without color coding. In the color-coded
condition, the z-score of the copying-drawing strategy
was significantly higher at the 5% level than the copying-accuracy and recall-accuracy.
The effects of ADHD and ASD comorbidity
Of the 68 study participants, 67 excluding one

both with LD and DCD were analyzed. There were 12
children in the LD only group, 6 in the LD with ADHD
group, 22 in the LD with ASD group, and 27 in the LD
with ADHD and ASD group. The test results and IQ
were divided into the 4 groups and compared by one
factor variance analysis. (Table 3). A significant difference at 5% was found only for the copying-drawing
strategy under the condition without color coding (F(3,63) = 3.03, p<.05, η2= .13). Bonferroni’s multiple
comparison results showed no significant difference atthe 5% level, but there was a significant tendency at the
10% level. The LD with ADHD and ASD group tended
to have a lower z-score than the LD only group, and theLD with ASD group (Table 3).

Discussion
To clarify the factors that are related to the visual

Table 3. Differences in the evaluation results depending on the children’s diagnoses

LD, learning disabilities alone; ADHD, attention deficit hyperactivity disorder; ASD, autism spectrum disorder; IQ, intelligence quotient; M, mean; SD, standard deviation.
* p<.05. † p<.10.

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VISUAL INFORMATION PROCESSING OF CHILDREN WITH LEARNING DISABILITIES

information processing of children with learning disabilities who have difficulty acquiring kanji writing, their
ROCF were evaluated using both an accuracy scale anddrawing strategy scale. A two-factor analysis of varianceof the figure’s color-coding factors and evaluation scale
factors revealed that the interaction was significant witha large effect size (ηp2 = .30).
In the normal test method without color coding,the z-score for copying-accuracy was significantly
higher than for the copying-drawing strategy and recall-accuracy. This suggests that children with learning
disabilities who have difficulty acquiring kanji writing
are not unable to accurately copy (copying-accuracy)
the morphology and position of the figures but thatthey have difficulty copying all of the components ofthe figures (copying-drawing strategy), efficiently committing them to memory, and hence remembering them(recall-accuracy). This may correspond to “the impaired
use of composition strategies that promote recall” asdescribed by Hashimoto et al. (2006) [6]. The results
suggest that many of the 68 children could not perceive
the components of the figure as a unit and that theyfound it difficult to efficiently remember them because
they tended to copy by piecing together the details.
When writing kanji, such children do not copy the kanji“男” by perceiving the components of “田” and “力”;
they copy it as a simple figure instead. Since the copied
kanji cannot be efficiently memorized, it becomes moredifficult to remember as the number of character strokes
increases.
On the other hand, the test of the simple main effectfor the color-coding factors of the figure found no significant difference in the copying-accuracy, whereas the
copying-drawing strategy and recall-accuracy with color
coding were significantly higher. The multiple comparisons indicated that there was no significant difference
between copying-accuracy and recall-accuracy in thecolor-coding condition. This finding suggests that thecolor coding of the figure’s components makes it easierto perceive them and that it compensates for the disability in using the composition strategy that promotes therecall of the figure. Therefore, when learning kanji writing, it may also be easier to memorize the components
of a character by using color coding.
In this study, the children who visited the facility
to which the first author belongs first experienced
the without color-coding condition and then the color-coding condition, which means that the influence of
iterative learning on the effect of the color coding of
the figure cannot be denied, and that there is a limit to
the generalization of the results. However, the test of
the simple main effect of the color coding of the figure
found no significant difference in the copying-accuracy.

It is therefore considered that the influence of the color
coding of the figure is larger than the influence of iterative learning. Finally, the results also suggest that it isimportant to support the use of the composition strategy
when visually copying kanji during learning support forchildren with learning disabilities who have difficultyacquiring kanji writing.
Comparing by diagnoses, a significant difference
was found at the 5% level among the 4 groups. However, no significant difference was found at the 5% level inthe post-hoc test. Although, a significant tendency wasobserved at the 10% level. These findings suggested thatchildren with ADHD and ASD tended to have inferior
results when attempting the copying-drawing strategy.
Okamaki (2017) stated that ASD and ADHD are associated with cognitive dysfunctions including executive
dysfunction. Our results also suggested that children
with LD combined with ADHD and ASD had lower
performance on the drawing strategy scale without color-coding that required more executive function. It wassuggested that the performance of the drawing strategy
scale without color-coding may deteriorate. In contrast,
a significant difference was not found among the fourgroups in the drawing strategy scale with color coding.
The color coding of the components of the figure compensated for executive function deficits (impairments inthe use of the composition strategy to promote the recallof the figure). The children with LD combined with
ADHD and ASD may need special support for composition strategies.
Limitations of this research and future issues
In this study, all of the research participants experienced the first ROCF test in a non-color-coded conditionand completed the second ROCF test in a color-coded
condition. This order was used because it was difficult
to counterbalance the conditions due to the ethics of theclinical work. Therefore, there is a limit to the generalization of the results.
All the participants were children who attended
one medical facility. Many of the children had ADHD
or ASD, suggesting that characteristics other than LD
also affect their performance. Moreover, the number ofparticipants was limited because this study was limited
to children with LD who had difficulty acquiring kanji
writing. It is necessary to increase the number of participants in future studies to further investigate the effectsof learning disabilities alone and combined with otherdiagnoses.

Acknowledgments
We would like to thank the children and their par-

Asian J Occup Ther 18: 79−85, 2022

ents who participated in this study.

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kango daigaku kiyou). 2004; 10: 1-10.

■ORIGINAL ARTICLE

Types of Grasping Chopsticks and Their Functionality
in Typically Developing Preschool Children
Masashi Tsuzuku1, Chieko Karashima2, Go Igarashi3
1

SUTEKI variation Co.,Ltd
Department of Occupational Therapy Faculty of Rehabilitation, Biwako Professional University of Rehabilitation3
Occupational Therapy Sciences, Prevention & Rehabilitation Sciences Course, Division of Integrated Care Sciences Technology,
Department of Integrated Health Sciences, Graduate School of Medicine, Nagoya University
2

Abstract: Objective: In Asia, chopsticks are popular eating utensils, and the use of chopsticks is closely related to foodculture. Therefore, the type in which children grasp chopsticks and the functionality of these grasping patterns are important for occupational therapists. The purpose of this study was to investigate the various types of grasping chopsticks
in typically developing preschool children and compare the functionalities of these types.
Methods: We investigated various types of grasping chopsticks in 102 typically developing preschool children. There
were 72 preschool children who performed four types of chopstick operation tasks: two pick-up and carry tasks, ascoop-up and carry task, and a cut task. These task scores were compared between the traditional and untraditional
grasping types.
Results: Within the 102 participants, we found the traditional and four untraditional grasping types. There was no significant difference between the traditional and untraditional grasping types in the “pick-up and carry” and “scoop-up
and carry” task scores (p>0.05). For all grasping types, the “cut task” score was low.
Conclusion: There were no differences in functionality between traditional and untraditional grasping types. Furthermore, we found that functionality was affected by food shape. These results may provide insights on interventions
during meals, especially for children who are learning how to use chopsticks.
Keywords: typically developing children, preschool, chopsticks, meal, activity of daily living(Asian J Occup Ther 18: 95−102, 2022)

Introduction
In Asia, chopsticks are popular eating utensils, andthe use of chopsticks is closely related to food culture.
Therefore, using chopsticks is not only a skill but also
an important occupation throughout an individual’s
lifespan. The traditional type of grasping chopsticks
involves grasping one stick (movement stick) with the
thumb, index, and middle finger, while the other (static
stick) is grasped with the thumb and ring finger (Figure1). This is regarded as the proper method for using
chopsticks. Social meals lead to better communication
Received: 1 March 2021, Accepted: 6 January 2022
Corresponding to: Chieko Karashima, Department of Occupational
Therapy Faculty of Rehabilitation, Biwako Professional University of
Rehabilitation, 967, Kitasakacho, Higashiomi-shi, Shiga, 527-0145,
Japan
e-mail: c-karashima@ot-si.aino.ac.jp©2022 Japanese Association of Occupational Therapists

among peers; however, those with improper chopstickgrasps may feel uncomfortable around others [1].
Therefore, the traditional type of grasping chopsticks is
recommended for appearance and etiquette. However,with decreased opportunities to acquire table manners,
the types of grasping chopsticks have become diverse,
and the number of those who use the traditional graspingtype has gradually decreased [2, 3]. In addition, there
is an increasing number of adults who cannot grasp
chopsticks using the traditional type [4, 5], which may
be regarded as a loss of Japanese tradition [3].
The method by which chopsticks are grasped isconsidered to be a basic skill acquired during earlychildhood in Japan [2]. However, there are individual
differences in how chopsticks are grasped and handled,
and a few children acquire the traditional type of grasping chopsticks [6, 7]. Continuous practice is necessary
to acquire the traditional grasp type, and this type may
be introduced at home to children at approximately 2

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TYPES OF GRASPING CHOPSTICKS AND FUNCTIONALITY IN PRESCHOOL CHILDREN

years old when fine motor skills are developed enoughto grasp chopsticks [8]. Therefore, studies have focusedon various types of grasping chopsticks during earlychildhood; however, they were based on existing grasp
patterns [4, 7]. Furthermore, to our knowledge, no studies have assessed various types of grasping chopsticks
in early childhood.
Chopsticks have two functions: The first is a “basic
function” to pinch, support, and carry, and the second
is an “additional function” to cut, scoop, and flake [3].
Several studies have shown that the traditional grasp
type has better functionality than other types [1, 2, 9].
However, these studies did not assess grasping types
in early childhood, and only a few were examined forfunctionality. Additionally, no studies have examinedthe effects of food shape or dish position on chopstick
functionality.
Using chopsticks is an important occupation forchildren’s development in Japan and other Asian countries. Occupational therapists involved in nursery careand child rearing often intervene during meal times.
Therefore, it is necessary for occupational therapists tobe knowledgeable in the various types of grasping chopsticks and their functionality under various situations.
In this study, we clarified various types of graspingchopsticks during early childhood and examined thefunctionality of several grasping patterns by performing
tasks using different types of food and dish positions.
The purpose of this study was to investigate the various
types of grasping chopsticks in typically developingchildren, categorize these types by using video observation (Part I), and to compare their functionality under

several conditions (Part Ⅱ).

Materials and Methods
DesignTwo studies were conducted. Part I was observational. Types of grasping chopsticks were investigated intypically developing children and categorized according
to finger position. Part II was the experiment. Chopstick
operation tasks were performed to compare the functionality of the traditional and untraditional grasping types.
This study was approved by the ethics committeeof Nagoya University, School of Health Sciences, inaccordance with the Helsinki Declaration (15-610).

Part Ⅰ
Participants
A total of 102 healthy children between ages 5
and 6 participated in Part I of the study. There were 56
boys (54.9%) and 46 girls (45.1%). Participants wererecruited by convenience sampling from a preschoolthat received comprehensive community support fromour research group in Aichi Prefecture. We selected apreschool with an equal amount of indoor and outdoor
activities. We excluded children who were diagnosed
with developmental disorders and obvious impairments
in fine motor skills. The first author conveyed the natureof the study to all participants and their parents and provided written informed consent to the parents.

Figuretype
1. Traditional
type of grasping chopsticks
Figure 1. Traditionalof grasping chopsticks
The movement stick is grasped with the thumb, index, and middle fingers,

The movement stickis thegraspedwiththe thumb,index,
middlewhile
static stickis grasped
with thethumb andand ring
finger.fingers, while the static
stick is grasped with the thumb and ring finger.

Asian J Occup Ther 18: 95−102, 2022

Measures and Procedure
The participants were observed during lunch andinstructed to use chopsticks according to their usual
way. Since we focused on the usual way of using chopsticks, participants used their own chopsticks during the
research. For this reason, the shape, width, and length ofchopsticks varied. Motions of picking up and bringing
food to the mouth using chopsticks were recorded fivetimes per participant using two video cameras (NVGS300, Panasonic, Tokyo, Japan). The cameras were
set in front and near the non-dominant hand side of theparticipants to observe finger positions.
Date Analysis
First, we used the video recordings to create still
images of each participant picking-up food and bringing
food to the mouth and observed the various chopstickgrasping types. Based on a previous study [3], we defined the traditional grasping type (pincers-pinching) as
follows: the movement stick is grasped with the thumb,index, and middle fingers, while the static stick is
grasped with the thumb and ring finger. All other grasping types were regarded as untraditional. Untraditional
grasping types were categorized according to finger
position similarities.
Results
The majority of participants (98) were right-handed, and only four participants were left-handed. The
traditional grasping type was used by 17 participants,
whereas 85 used untraditional types. The untraditional
grasping types were divided into four categories (untraditional type I, n=37; type II, n=28; type III, n=3; typeIV, n=17; Figure 2).

Part Ⅱ
ParticipantsParticipants in Part Ⅱ of the research included 72
healthy children between ages 5 and 6 who usually
ate with chopsticks. There were 42 boys (58.3%) and30 girls (41.7%). Participants were recruited by convenience sampling from three preschools in the Aichi
and Gifu prefectures. As in Part I, we selected threepreschools where there were equal amounts of indoor
and outdoor activities. These preschools received comprehensive community support from our research group.
Children diagnosed with developmental disorders or
obvious fine motor skill impairments were excluded.
The first author conveyed the nature of the study toall participants and their parents and provided written
informed consent to the parents.

Tsuzuku M et al.

97

Procedure
All participants were asked to perform four experimental tasks. Four types of food were used in the tasks
and placed in a dish on a table. To investigate the effectof dish position on functionality, the dishes were placedin four positions: (a) near the dominant hand side andnear the body, (b) near the dominant hand side and far
from the body, (c) near the non-dominant hand side andnear the body, and (d) near the non-dominant hand sideand far from the body (Figure 3). A tall plastic container
was also placed as a food destination. We used thiscontainer based on the assumption that food would bedelivered to the mouth. For each type of food, the participants were asked to perform the tasks in the order of(a) to (d). Participants were instructed to perform eachtask for 30 seconds using their own chopstick-graspingtypes. The details of the four tasks are as follows.
1. Tofu pick up and carry task (tofu task): Tofu (2.5
by 2.5 by 2.5 centimeters) was picked up from a dishand placed in a container in front of the participant.
2. Soybean pick-up and carry task (soybean task):
Soybeans were picked up from a dish and placed in acontainer in front of the participant.
3. Rice scoop up and carry task (rice task): Rice
was scooped up from a dish and placed in a container infront of the participant.
4. Flour dough cut task (flour dough task): Elongated flour dough was placed on a dish and cut at 1 cm
intervals using chopsticks. Red lines were drawn on thedough to indicate 1 cm intervals.
Measures
During the tasks, the motions of the participants
were recorded using two video cameras (NV-GS300,
Panasonic, Tokyo, Japan). The cameras were set in front
and near the non-dominant hand side of the participant.
The number of “pick-up and carry,” “scoop-up andcarry,” and “cut” motions were counted, and each counted number was defined as the task score. Task scores
were measured by two researchers and determined basedon their agreement.
Data Analysis
From the video recordings, the chopstick graspingtypes were divided into traditional and four untraditional
types based on the Part I results, and the average task
scores were calculated for each grasping type. Dunnett’s
multiple comparison test was used to compare task
scores between the traditional and untraditional types.
The control and experimental groups used traditional
and untraditional grasping types, respectively. The task
scores of each grasping type were compared among thetofu, soybean, and rice tasks using multiple comparison

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TYPES OF GRASPING CHOPSTICKS AND FUNCTIONALITY IN PRESCHOOL CHILDREN

Type I: The fingers used for the movement and static sticks are the same used during the traditional type.
However, the finger position is different.

[A] The middle finger is above the movement stick.

[B] The middle finger is under the movement stick.

Type II: The fingers used for the movement stick are the same used during the traditional type.
However, the finger positions are different.

[C] The static stick is grasped with [D] The static stick is grasped with [E] The movement stick is grasped
the thumb, ring, and little finger.
the thumb.
with the pulp of the index finger.

[F] The movement stick is graspedby rolling the index finger.

Type III: The fingers used for the static stick are the same used in the traditional type.
However, the finger positions are different.

[G] The movement stick is grasped with the thumb and index finger.

[H] The index finger is extended.

Type IV: Different fingers are used to hold the movement and static sticks than those used in the traditional type.

[I] The movement stick is grasped with the thumb,index, middle, ring, and little fingers, and the static
stick is grasped with the thumb.

[J] The ring and little finger are flexed.

[K] The movement stick is grasped with the thumband index finger, and the static stick is held withthe thumb, middle, and ring fingers.

[L] The index finger is extended.

[M] The index finger is not extended.

[N] The ring and little finger are extended.

Figure 2. Categorized untraditional types of holding chopsticks
Figure 2. Categorized untraditional types of holding chopsticks

Asian J Occup Ther 18: 95−102, 2022

Tsuzuku M et al.

99

Figure 3.Figure
Experimental
setting for a right-handed
participant
3. Experimental
setting
for a right-handed participant
The dishes were placed in four positions: (a) dominant hand side and near the body, (b)far from the (a)body,(c) non-dominantandnearnear theThe dishes weredominant
placedhand
in sidefourandpositions:dominant
handhandsideside
andthebody,
body, (b)and (d) non-dominant hand side and far from the body. A container was placed in front of
dominant hand eachsideparticipant.
and far from the body, (c) non-dominant hand side and near the

body, and (d) non-dominant hand side and far from the body. A container was placed in
front of each participant.

Bonferroni-Dunn’s test. This analysis was performed
for each of the four positions of the dish: dominant handside; the mean of the results from positions (a) and (b),non-dominant hand side; the mean of the results frompositions (c) and (d), near the body; the mean of theresults from positions (a) and (c), far from the body;the mean of the results from positions (b) and (d). The
threshold for significance was set at p <0.05. All statistical analyses were conducted using the IBM SPSS
version 24.0.

Results
A total of 69 participants were right-handed, andthree participants were left-handed. The number of participants using each grasping type was as follows: traditional type, n=15; type I, n=24; type II, n=23; type III,n=2; type IV, n=8. In this study, only two participants
were classified as type III. Therefore, we decided to exclude type III participants from the subsequent statisticalanalysis.
For the tofu, soybean, and rice tasks, there were no
significant differences between the average task scoresof the traditional and four untraditional grasping types
at all dish positions (Table 1). However, for the flour
dough task, the average task score of the traditional typewas significantly higher than that of types II and IV atdish position (b) (p<0.05).
For the traditional type and type II, the average task
score was significantly higher in the tofu, soybean, andrice tasks, respectively, at all dish positions (p<0.05)(Table 2). For type I, except for the tofu and soybean
tasks at the non-dominant hand side dish position, theaverage task score was significantly higher in the tofu,
soybean, and rice tasks, respectively (p<0.05). For type
IV, the average task scores of both the tofu and soybean
tasks were significantly higher than those of the ricetask at all dish positions (p<0.01), although, there wereno significant differences in the average task score at all
dish positions between the tofu and soybean tasks.

Discussion
In a previous study by Mukai et al, they reported
that 55.6% of children aged 6 to 7 years old used the
traditional type of holding chopsticks [8]. This previous
study defined the traditional type of holding chopsticks
only in terms of the fingers used to holding the movement and static sticks and this is different from ourstudy. We defined the traditional type of holding chopsticks in terms of the fingers used to hold the sticks andthe finger position. In this study, the traditional type of

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TYPES OF GRASPING CHOPSTICKS AND FUNCTIONALITY IN PRESCHOOL CHILDREN

Table 1. Comparisons of average task scores between each grasping typeTofu pick-up and carry task

Traditional type (n=15)
Type Ⅰ (n=24)Type Ⅱ (n=23)
Type Ⅲ (n=2)
Type Ⅳ (n=8)

Soybean pick-up and carry task

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

13.8±3.4
14.8±3.4
12.7±3.5
12.0±1.4
11.8±2.912.5±3.3
13.0±3.2
11.5±3.2
12.0±0.0
11.0±1.814.5±3.3
14.3±3.3
12.7±3.3
17.0±0.0
11.1±2.2

12.3±3.0
12.9±3.0
11.2±2.712.5±2.1
11.6±2.0

10.4±3.2
11.5±3.7
10.7±2.812.5±0.7
10.3±2.8

10.1±2.6
11.2±3.4
9.0±2.3
9.5±0.7
9.1±2.8

11.7±2.912.7±3.8
10.7±2.911.0±0.0
11.9±2.3

10.5±3.0
11.6±4.0
9.3±2.5
11.0±1.4
11.0±3.5

Rice scoop-up and carry task

Traditional typeType Ⅰ
Type Ⅱ
Type Ⅲ
Type Ⅳ

Flour dough cut task

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

7.2±2.77.3±2.85.9±2.1
8.5±0.7
7.1±2.0

5.9±2.3
5.8±2.55.2±2.1
5.5±0.7
6.1±1.77.4±2.3
7.3±2.8
6.2±2.77.5±2.1
6.9±2.0

6.1±2.5
6.0±2.6
5.3±2.1
5.0±1.4
5.4±1.6

1.9±1.5
1.7±1.0
1.8±1.2
1.5±0.7
1.8±0.92.8±1.5
1.9±1.1
1.7±1.1*
2.0±1.4
1.1±1.0**

2.4±1.6
2.2±1.3
2.1±0.9
1.5±2.1
1.6±1.1

2.2±1.3
2.0±1.1
2.2±1.2
3.0±4.2
1.9±0.8(a)–(d) indicates dish positions: (a) dominant hand side and near the body, (b) dominant hand side and far from the body, (c) non-dominant handside and near the body, and (d) non-dominant hand side and far from the body. Dunnett’s multiple comparison was used. The control group included those who used the traditional grasping type, and the experimental groups included those who used grasping types I, Ⅱ and Ⅳ.
*: p<0.05, **: p<0.01

Table 2. Comparisons of average task scores among tofu, soybean, and rice tasks
Tofu

Soybean

Rice

PA

PB

PC

Traditional type(n=15)(a, b)(c, d)(a, c)(b, d)

13.1±3.4
13.4±3.3
14.1±3.3
12.4±3.1

10.2±2.911.1±3.0
11.0±3.1
10.3±2.8

6.6±2.6
6.7±2.4
7.3±2.5
6.0±2.4

.001
.010
.000
.015

.000
.000
.000
.000

.000
.000
.000
.000

Type Ⅰ(n=24)(a, b)(c, d)(a, c)(b, d)

13.9±3.4
13.6±3.2
14.5±3.3
12.9±3.1

11.3±3.512.1±3.912.1±3.7
11.4±3.7

6.5±2.7
6.6±2.87.3±2.85.9±2.5

.000
.101
.001
.048

.000
.000
.000
.000

.000
.000
.000
.000

Type Ⅱ(n=23)(a, b)(c, d)(a, c)(b, d)

12.1±3.4
12.0±3.1
12.7±3.4
11.3±2.99.8±2.7
10.0±2.7
10.7±2.8
9.2±2.4

5.5±2.1
5.8±2.5
6.0±2.4
5.2±2.1

.001
.004
.006
.000

.000
.000
.000
.000

.000
.000
.000
.000

Type Ⅲ(n=2)(a, b)(c, d)(a, c)(b, d)

12.0±0.8
14.8±2.914.5±3.0
12.3±1.3

11.0±1.8
11.0±0.8
11.8±1.0
10.3±1.3

7.0±1.8
6.3±2.1
8.0±1.4
5.3±1.0---

Type Ⅳ(n=8)(a, b)(c, d)(a, c)(b, d)

11.4±2.4
11.4±2.0
11.4±2.5
11.3±1.99.7±2.811.4±2.911.1±2.6
10.1±3.2

6.6±1.9
6.1±1.97.0±2.0
5.8±1.7

.150
1.000
1.000
.416

.000
.000
.000
.000

.002
.000
.000
.000

Tofu, tofu pick-up and carry task; soybean, soybean pick-up and carry task; rice, rice scoop-up and carry task. (a)–(d) indicate dish positions; (a,b) dominant hand side, (c, d) non-dominant hand side, (a, c) near the body, (b, d) far from the body. Task scores were compared among the tofu,
soybean, and rice tasks using the multiple comparison Bonferroni-Dunn’s test. A compared tofu and soybean task scores, B compared tofu andrice task scores, and C compared soybean and rice task scores.

Asian J Occup Ther 18: 95−102, 2022

holding chopsticks was observed in 17 out of 98 participants (17.3%) in Part Ⅰ and in 15 out of 69 participants(21.7%) in Part Ⅱ. However, if we include the subjects
who were classified as type I, which corresponds to the
traditional type of holding chopsticks according to thedefinition of the previous study [8], the number of participants becomes 54 out of 98 (55.1%) in Part Ⅰ and 39
out of 69 (56.5%), which is almost the same ratio as theprevious study.
There were no differences in the average task score
between each grasping type, except for dish position (b)of the flour dough task. Mukai stated that when carrying
soybean or tofu, individual dexterity and proficiency
in using chopsticks have a greater impact than differences in the type of holding chopsticks [10]. During
early childhood meals, children repeatedly carry foodby pinching using chopsticks [7]. Therefore, even if aparticipant may grasp chopsticks using an untraditional
type, its functionality may be developed through repeated practice during meals.
In contrast, cutting is not commonly performed
during early childhood [7]. The average task scores ofthe flour dough task for each grasping type were low
compared to those of the other tasks. Since there are
few learning opportunities during early childhood to use
the “cut” task, this functionality may be low regardlessof the grasping type. However, the dish position may
partially affect the functionality of the “cut” operation.
At dish position (b), participants manipulated the chopsticks by extending the elbow joint. When the movementof the extensor muscles at the elbow joint is dominant,it may be difficult to continuously open and close
chopsticks because the flexor muscle movements aresuppressed. On the other hand, the traditional graspingtype involves high muscle activity in the short thumb
abductor muscle, short thumb flexor, and dorsal interosseous muscle due to the continuous opening and closing
motion with the movement stick [11]. Furthermore, inthe traditional type, the finger positions on the chopsticks are stabilized during operation [10]. Therefore, thetraditional type may have higher functionality than types
Ⅱ and Ⅳ in the “cut” operation. However, there were no
significant differences in average task scores between
the traditional and untraditional types at dish position (d),despite the dish being positioned far from the body. We
were unable to determine the cause of this discrepancy.
In addition, since we did not provide detailed instruction
on the sitting posture and chair position of the participants when they performed the task, there may be individual variations in the effects of the elbow extension
movements described above. Therefore, we concluded
that the functionality of the “cut” operation is low for
the traditional and untraditional grasping types.

Tsuzuku M et al.

101

The average scores of the tofu and soybean tasks
were significantly higher than those of the rice task.
Rice must be scooped carefully because it easily falls
apart. In addition, the tofu and soybean tasks involvea one-unit operation in which opened chopsticks areclosed, while the rice task involves a two-unit operationin which a scooping motion is performed while closing
opened chopsticks. Therefore, complexity in food shapeand difficulty in chopstick operations may affect functionality.
For the traditional type, types I and II, the averagescores of the tofu task were significantly higher thanthose of the soybean task. Tofu has a larger contact
area with chopsticks than soybeans. Therefore, picking
up tofu may be easier than picking up soybeans. In
addition, types I and II have similar elements to the traditional type because the fingers used for grasping sticks
are the same. For type IV, it may be difficult to operate
both the movement and static sticks with stability because it has very little similarity to the traditional type.
Therefore, for type IV, the functionality of picking up
tofu is similar to that of picking up soybeans, despite theformer being easier to perform.
Although a child may use untraditional types forgrasping chopsticks, its functionality does not differ
from that of the traditional type. Since food shape may
affect the functionality of chopsticks, it is important to
prepare “easy-to-pinch” foods that facilitates eating,especially when the child is learning how to use chopsticks. In the future, a larger study using the motion
analysis method may be used to investigate the force
quality and quantity in different joint segments duringchopstick use.
Limitations
In this study, since only two participants were classified in type III, we were unable to draw any conclusions regarding its functionality. In addition, participants
were recruited from a limited area in Japan. In futurestudies, a larger sample size should be used.
Although we only used the type of grasping chopsticks to define the control and experimental groups inPart Ⅱ, the functionality of chopsticks might be influenced by the child’s age, sex, and frequency of chopstickuse. Furthermore, we did not indicate the seating postureand non-dominant hand position during the tasks, which
may have partly influenced the task results.

Conclusions
There was no difference in the functionality of the“pick-up and carry” and “scoop-up and carry” operations between the traditional and untraditional grasping

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TYPES OF GRASPING CHOPSTICKS AND FUNCTIONALITY IN PRESCHOOL CHILDREN

types. The “cut” operation had low functionality for traditional and untraditional grasping types. In traditional
and untraditional grasping types, the “pick-up and carry”
operation is more functional than the “scoop-up andcarry” operation. In the “pick-up and carry” tasks, types
I and II had similar functionality to the traditional typefor all food sizes used in this study. Since using chopsticks is an important occupation in Asia, occupational
therapists must knowledgeable in the various types ofgrasping chopsticks and their functionality under various
situations.

Declaration of Interest
The authors report no conflict of interest.

Acknowledgements:
We would like to express our gratitude to the preschool staff members and all the participants.

References[1] Uehara M, Ooba K, Katoh Z. Differences of developmental stages in Dexterity of Holding and Handling Chopsticks (in Japanese). The bulletin of the Seki Gakuen(sekigakuenkiyou). 2014; 8: 7-15.
[2] Tachiyashiki K, Yamagishi Y, Imaizumi K. Relationships
between the Handling Motion of Chopsticks and the
Writing Motion of a Pencil in Elementary and JuniorHigh School Students (in Japanese). Journal of cookery
science of Japan (nihonchourikagakukaishi). 2005; 38(4):355-61.
[3] Yamauchi T, Koide A, Yamamoto A, Oba K. Effect ofParental Training on Table Manners and the Way of
Holding Chopsticks (in Japanese). Journal of cookery
science of Japan (nihonchourikagakukaishi). 2010; 43(4):260-4.
[4] Murata Y. Research on the Actual Condition of How
Children (2~5 years) Use Chopsticks (in Japanese). The
bulletin of Musashino Junior College (musashinotankidaigakukenkyukiyou). 1992; 6: 5-15.
[5] Ooka T, Kuroishi S, Mukai Y. The Development of theManipulation of Chopsticks for Feeding and Pick up
Functions in Early Childhood (in Japanese). The Japanesejournal of pediatric dentistry (syounishikagakuzasshi).
2006; 44(5): 713-9.
[6] Iyoda H, Adachi M, Takahashi E. Development of Eating
Behavior with Utensils, and Food Intake in 1 to 5 YearOld Children (in Japanese). The journal of child health(shounihokenkenkyu). 1995; 54(6): 673-85.
[7] Iyoda H, Adachi M, Takahashi E. Developmental Changes of Grip Patterns and Using Ways of Utensils in 1 to
5 Year-Old Children Related to the Dishes in a Nursery
School Food Service (in Japanese). The journal of childhealth (shounihokenkenkyu). 1996; 55(3): 410-25.
[8] Mukai Y, Hashimoto K. A Study on the Ways of Holding
Chopsticks (Part 3) (in Japanese). Journal of home economics of Japan (kaseigakuzasshi). 1983; 34(5): 269-75.
[9] Sakata Y. The Decisive Factor in Using Chopsticks:
In the Case of Junior High school Boys and Girls (inJapanese). Kyoto Women’s University Journal of foodscience (kyotojoshidaigakusyokumotsugakkaishi). 1994;
49: 53-64.
[10] Mukai Y, Hashimoto K. A Study on the Ways of Holding
Chopsticks (in Japanese). Journal of home economics ofJapan (kaseigakuzasshi). 1978; 29(7): 467-73.
[11] Mukai Y, Hashimoto K. A Study on the Ways of Holding
Chopsticks (Part 2) (in Japanese). Journal of home economics of Japan (kaseigakuzasshi). 1981; 32(8): 622-7.

■ORIGINAL ARTICLE

Development of the Perfect O Sign Quantification Tool
Maki Ando1, Ryosuke Ikeguchi1, 2, Tomoki Aoyama3, Keisuke Irie3,
Masakatsu Takeda3, Kohei Mukaiyama3, Rie Yamawaki4, Akemi Maeda4,
Takashi Noguchi1, Manabu Nankaku4, Hiromu Ito1, Shuichi Matsuda1, 2
1

Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
Department of Rehabilitation Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
3
Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
4
Rehabilitation Unit, Kyoto University Hospital2

Abstract: Objective: The perfect O sign is often evaluated in carpal tunnel syndrome but there are no clear criteria.
The purpose of this study is to develop a tool for quantifying the perfect O sign and to investigate the values of the perfect O sign in healthy subjects using this method.
Methods: Participants are healthy 20- to 30-year-old volunteers (n = 13) without any clinical symptoms of carpal tunnel syndrome. Surface electromyogram was used to measure the amplitude of the abductor pollicis brevis (APB), firstdorsal interosseous muscle (FDI), flexor digitorum superficialis (FDS), and extensor digitorum communis (EDC) while
performing the perfect O sign in three different wrist positions: neutral, dorsiflexion, and palmar flexion. The roundnessof the perfect O sign in healthy subjects was measured by approximating a circle using 7 points in the photo captured
by a smartphone and imported to a personal computer.
Results: The FDI/APB ratio was significantly lower in the dorsiflexion position than that in the palmar flexion position,and the FDS/APB ratio had a significantly lower dorsiflexion position than that of the other two wrist positions. Basedon these results, a device was developed that holds the wrist in the dorsiflexion position. The mean roundness of theperfect O sign using the device in 13 healthy volunteers was 80.46 ± 9.47%.
Conclusions: Dorsiflexion of the wrist can minimize the effect of other muscles while performing the perfect O sign.
The perfect O sign can be quantified by calculating the roundness.
Keywords: carpal tunnel syndrome, perfect O, quantification, roundness(Asian J Occup Ther 18: 103−110, 2022)

Introduction
In patients with carpal tunnel syndrome, paralysisof the abductor pollicis brevis (APB) prevents thumb
opposition [1], which causes functional disabilities in tip
pinch in combination with sensory impairment [2-4].
When affected individuals attempt to make a circle
with their thumb and index finger, it becomes elliptical.
Bunnell reported this finding and called it the “round O,”
and other researchers have called it the “perfect O sign”
Received: 18 March 2021, Accepted: 6 January 2022
Corresponding to: Ryosuke Ikeguchi, Department of Rehabilitation
Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 603-8164, Japane-mail: ikeguchir@me.com©2022 Japanese Association of Occupational Therapists[5-8]. As this physical finding is simple and takes only
a few seconds to obtain, it is widely used to evaluate thefunction of thumb opposition in the clinical setting [9].
The perfect O sign is expressed as positive or negative
according to the examiner’s subjective decision as towhether it looks round or not—there are no clear criteria[9]. For precise evaluation of patient disability and clinical treatment, the perfect O sign must be quantified.
Some patients with carpal tunnel syndrome canmake the perfect O sign, even if there are atrophies of
the thenar muscles. Compensatory movements may
occur by muscles that are not impaired, such as intrinsic
muscles other than the median nerve–innervating, extrinsic flexor, or extensor muscles. Some patients may
use those muscles and adjust them with assistance fromthe wrist positions to perform the perfect O sign.
The purpose of this study is to develop a tool

104

PERFECT O SIGN QUANTIFICATION TOOL

to quantify the perfect O sign. The amplitude of theabductor pollicis brevis (APB; responsible for palmar
abduction of the thumb), first dorsal interosseous muscle(FDI; an intrinsic muscle innervated from the ulnar
nerve), flexor digitorum superficialis (FDS; an extrinsic
muscle belonging to the forearm flexor muscle group),and extensor digitorum communis (EDC; an extrinsic
muscle belonging to the forearm flexor muscle group)
was measured using a surface electromyogram while thepatient performed the perfect O sign in three different
wrist positions: neutral, dorsiflexion, and palmar flexion
to determine the optimal wrist position for evaluationof the perfect O sign that minimizes the effect ofcompensatory movement using muscles other than the
APB, including intrinsic and extrinsic muscles and wrist
positioning. The secondary purpose is to investigate thevalues of the roundness of the perfect O sign in healthy
subjects using this method.

Methods
Participants
Thirteen healthy subjects between 20 and 30 yearsof age participated. No participants had clinical symptoms of carpal tunnel syndrome or any APB muscle
atrophy, pain, contracture, morphological abnormalities,
or any history of traumas or surgeries of the wrist andfingers. This study was approved by the ethics committee of Kyoto University Hospital. All participants
provided written informed consent before study participation.

ProtocolHealthy participants were instructed to make theperfect O sign with the thumb and index finger in threedifferent wrist positions: 80° dorsiflexion position, 70°
palmar flexion position, and neutral position with immobilization by orthoses. The forearm rotation was neutral
and elbow flexion was 90°. The sensors of a surface
electromyograph (TeleMyo2400, Noraxon, USA) wereattached to the APB, FDI, FDS, and EDC. The average
amplitude of four muscles, including during the perfect
O sign, was recorded in each position for 3 s (Fig. 1).
The subjects were instructed to touch the tips of theirthumb and index finger together without any strength (asin the tip pinch) while making the perfect O sign. The
amplitude ratio of APB compared to the other muscles,
the FDI/APB ratio, FDS/APB ratio, and EDC/APB ratio
in three different wrist positions was calculated.
Creating a device to take digital pictures of the perfect
O signWe developed a device to take digital pictures of theperfect O sign. We achieved standardized pictures bymaking the position of each joint and the photographic
angle constant. In particular, the dorsal side of the upperarm was supported by an L-shaped plate attached to theproximal part of the testing platform, the elbow was held
in a 90° flexion position, and the forearm was immobilized in the neutral position with Velcro tape. The wrist
joint was held in the optimal position by two bars fromboth the dorsal and the palmar respectively at the distalof the forearm, and another bar that can push around theneck and head of the third metacarpal from either dorsal
or palmar side. Of the three different wrist positions, theFig. 1 Measurement of the amplitude of four muscles, APB, FDI, FDS, and EDC, using surface electromyogram in three different wrist
positions immobilized by orthoses.

Asian J Occup Ther 18: 103−110, 2022

Ando M et al.

105

optimal wrist position was determined from the resultsof the amplitude ratio of each muscle described above.
The bar that pushed the metacarpal was designed to be
short enough to not interfere with the points taken to
approximate the perfect O as a circle. The smartphone
holder was attached to the bar immediately above thetesting platform where subjects made the perfect O sign,
which was set horizontal to the table so that the photographic angle is constant.

to a personal computer were assigned as the vertexes ofa polygon and used to approximate the polygon into a
circle and obtain the roundness.
Analyzing the roundness of the perfect O sign in a
carpal tunnel syndrome patient
The roundness of the perfect O sign in a single
patient with carpal tunnel syndrome diagnosed by clinical symptoms and electromyograph was measured as
described above.

Analyzing the roundness of the perfect O sign
In the picture of the perfect O sign, seven points
were marked: 1) the palmar contact point between
the index finger and the thumb, 2) the interphalangeal
crease of the thumb, 3) the palmophalangeal crease of
the thumb, 4) the proximal palmar crease (PPC) on thefirst web, 5) the palmophalangeal crease of the index
finger, and 6) the proximal and 7) distal interphalangeal
crease of the index finger (Fig. 2). The roundness wascalculated using ImageJ software (National Institutes of
Health, USA). The seven points on the picture imported

Verifying the validity of the tool
To evaluate the reliability of the measurement of theroundness of the perfect O sign using this tool, we calculated the intra- and inter-rater reliability. For the former,
the roundness of the perfect O sign made by healthy
subjects in three pictures was measured five times byfour raters and the interclass correlation coefficient (ICC)(1, k) was calculated. For the latter, the roundness ofthe perfect O sign in six pictures was measured onceby four raters and the ICC (2, k) was calculated. ICC
values larger than 0.9 indicate that the reliability of theFig. 2 The seven points to approximate the shape of the perfect O sign to a circle.
A) Performing the perfect O signB) Dotting the seven points
1) The palmar contact area between the thumb and the index finger
2) The interphalangeal crease of the thumb3) The palmophalangeal crease of the thumb4) The proximal palmar crease on the first web5) The palmophalangeal crease of the index finger
6) The proximal interphalangeal crease of the index finger
7) The distal interphalangeal crease of the index finger

106

PERFECT O SIGN QUANTIFICATION TOOL

measurement is excellent; values between 0.75 and 0.9
are good, 0.5 to 0.75 are moderate, and less than 0.5 arepoor [10].
Statistical analysis
Data were compared using an analysis of variance(ANOVA). When a significant difference was detected,
the Bonferroni post hoc test was applied. Differenceswere considered statistically significant at p < 0.05.
All statistical analyses were performed with JMP pro
software version 15.10.0 (SAS Institute Inc., Cary, NC,
USA). Regarding the sample size, assuming a 40%
difference in the average and standard deviation amonggroups with a 95% confidence interval and statisticalpower of 90%, it was estimated that we would needat least 13 subjects according the results of Rainodi etal [11]. The sample size was calculated with JMP pro
software version 15.10.0 (SAS Institute Inc., Cary, NC,
USA).

Results
The amplitude of FDI and APB was almost constantcompared to those of FDS and EDC (Fig. 3).
The amplitude ratio of APB to the other muscles
revealed that the FDI/APB ratio was significantly lower(p = 0.0271) in the dorsiflexion position than that in thepalmar flexion position, and the FDS/APB ratio wassignificantly lowest (p = 0.0457) in the dorsiflexion
position among the three wrist positions (Fig. 3). The
EDC/APB ratio in the palmar flexion position was significantly lower (p < 0.001) than that in the neutral position, but there was no significant difference between thepalmar flexion and the dorsiflexion positions. Based onthese results, the dorsiflexion position was considered
to be the most optimal testing position for the perfect O
sign among the three different positions.
Based on the results of the amplitude ratio of APB,a device was developed to keep the wrist in the dorsiflexion position during evaluation of the perfect O sign
(Fig. 4).
The roundness of the perfect O sign in healthy
subjects measured with this tool was 82.08 ± 7.92% (Fig.
2). Using the same method, the roundness of the perfect
O sign in a single patient with carpal tunnel syndrome
diagnosed by clinical symptoms and electromyograph
was measured, and it was 40.20% (Fig. 5). The measurement reliability using this tool was demonstrated to
be excellent by ICC (1,1) and ICC (2,1) values of 0.951
and 0.971, respectively.

Discussion
The perfect O sign is constructed of two semicircles. One is formed by the palmar side of the flexed
distal interphalangeal (DIP), proximal interphalangeal

Fig. 3 The waveforms of the APB, FDI, FDS, and EDC, those amplitude and the amplitude ratio of the FDI, FDS, and EDC to the APB
in three different wrist positions. The lower values indicate the reduced influence of the muscle to the APB. The bucket in thegraph and † in the table indicate significant differences.

Asian J Occup Ther 18: 103−110, 2022

Ando M et al.

107

Fig. 4 The developed device.
A, B) The full image of the device when taking photos with a smartphone camera.
C) The view from directly above.
D) The method to immobilize the wrist in the dorsiflexion position. The two blocks attached to the bars hold the proximal of thewrist from the dorsal and the palmar side, and the other block pushes the third metacarpal from the distal to the proximal direction.
E) The image through a smartphone camera.

Fig. 5 Measurement of the roundness of the perfect O signin a patient with carpal tunnel syndrome.

(PIP), and metacarpophalangeal (MP) joint of the index
finger, and the other is formed by the palmar side of
the flexed interphalangeal (IP) and MP joints of thethumb. In addition, the thumb is flexed and the MP andcarpometacarpal (CM) joints are internally rotated whenobserved in the plane on the radial side of the index
finger [12]. Some patients with carpal tunnel syndrome
can make a perfect O sign despite the thenar muscle
atrophy. Some wrist positions can allow the patient tomake the perfect O sign using assistance from muscles
that are not impaired, such as intrinsic muscles otherthan the median nerve–innervating, extrinsic flexor,
or extensor muscles. When the APB is paralyzed, it ispossible to make a perfect O sign with compensatory
movements using extrinsic and other intrinsic muscles
with adjustments to the wrist joint. To minimize theinfluence of muscles other than the APB in the perfect
O sign, the wrist position was evaluated so as to reduce
compensatory movement. Compensatory movement was
initially evaluated using the results of surface electromyogram of muscles in different wrist positions to eliminate the effect of muscles other than the APB. Many
intrinsic and extrinsic muscles which are not innervatedby lower median nerve contribute to the compensatory
movement. In this experiment, the forearm flexor (FDS),
extensor (EDC), and ulnar nerve–innervating muscle(FDI) were selected to detect the wrist position that minimizes compensatory movements by muscles other thanthe APB as the optimal testing position because of using
surface electromyography. Force produced by muscles
depends on the muscle weight and average length ofmuscle fibers [13], [14]. The muscles analyzed in thisstudy included both the intrinsic and extrinsic muscles,
which have different muscle weights and muscle fiber
lengths, in addition to individual differences among
subjects. Therefore, we employed a comparison using

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PERFECT O SIGN QUANTIFICATION TOOL

the ratio not the amplitude itself. That is, we determined
the wrist position in which the APB was relatively lessaffected by other muscles that assist to make the perfect
O sign as optimal. In the dorsiflexion wrist position, the
FDI/APB ratio and FDS/APB ratio were significantly
lower although the EDC/APB ratio was not. There
was no significant difference in the EDC/APB ratio
between dorsiflexion and palmar flexion. These results
revealed that the dorsiflexion wrist position is where
the amplitude of these muscles other than the APB was
minimized during the perfect O sign. Therefore, theoptimal testing position of the wrist is the dorsiflexion
position. The dorsiflexion position is thus recommended
when evaluating the perfect O sign in clinical practice,even when not using the device developed herein. The
forearm rotation was set in the neutral position and theelbow joint was set at 90° flexion. Because the extrinsic
muscle length varies in forearm rotation and the pictureof the perfect O sign is taken in a constant direction, we
fixed the forearm and elbow position.
Li and Nimbarte reported that when the median
nerve is blocked at the wrist, compensatory increases
in the ranges of motion at the PIP and DIP of the index
finger and the MP joints of the thumb [15]. They described that the compensatory movement was createdby the extrinsic muscles of the thumb and index finger
as theses extrinsic muscles are located in the forearmand should not be impaired by the nerve block at thewrist, and the robust output was likely augmented by themuscle spindles and Golgi tendon organs of the extrinsic
muscles of the thumb and index finger [15]. In the dorsiflexed position of the wrist the FDS is stretched and theoutputs by the muscle spindles and Golgi tendon organs
easily produced, leading to decreasing the muscle amplitude. As Li and Nimbarte described, the flexor pollicis
longus (FPL) can contribute to the formation of the perfect O sign [15]. The flexor pollicis longus muscle exist
deeper than the FDS muscle and in the current study we
did not evaluate the FPL amplitude using surface electromyography.
As for the roundness, the number of points required
to approximate the shape of the perfect O sign to a circle
was considered. Seven points that are easy to identify on
the picture to approximate the shape of the perfect O toa circle were assigned. It is sometimes difficult to identify the palmar point on the palmophalangeal crease of thethumb and the proximal palmar crease in the first web.
Although these two points were changed, the roundness
was similar. The values of the healthy volunteers and thepatient with carpal tunnel syndrome were compared, anda difference was identified.
Previous researchers have investigated the thumb
opposition motion using different methods [16-22].

Kerkhof et al. used dynamic computed tomography (CT)to quantify thumb opposition kinematics [16]. Kuroiwa
et al. used a three-axis gyroscope to measure thumb pronation and the palmar abduction angle [17-19]. Other
researchers used a motion capture system to detect the
thumb opposition motion [10-22]. All of these methods
require special equipment, however, such as CT, sensors, or a motion capture system. In addition, they taketime and cannot be utilized in outpatient clinics.
With this tool, the perfect O sign can be used as an
objective finding based on a quantitative examinationthat does not take a great deal of time and is not acomplicated or invasive procedure. As a result of theseadvantages, it is possible to follow the natural course of
the APB weakness observed in carpal tunnel syndrome
without patient stress. The improvement in opposition
function was also evaluated by comparing before andafter carpal tunnel release surgery, and by comparing the
opposition function among various surgery techniques,
such as tendon transfers. In addition, this method was
employed to evaluate the disease severity of carpal
tunnel syndrome. If severity can be determined by thecutoff value of the roundness, this tool could be useddiagnostically as a non-invasive alternative to electromyogram.
There are several limitations in this study. First,
unlike needle electromyogram, surface electromyogram
does not indicate precise muscle amplitude. Not all of
the muscles that may be involved in thumb oppositionand compensatory movements while making the perfect
O sign were evaluated. The opponens pollicis (OP) is themuscle responsible for volar abduction and pronation of
the thumb and is innervated by the median nerve. Manyvariances of innervation in the thenar muscles, such as
Riche-Cannieu anastomosis (RCA), exist, and the highprevalence of the thenar muscles innervated by a motor
branch of the ulnar nerve or both the ulnar nerve andthe median nerve has been reported, especially in the
APB range (4.9–82.6%) and the OP range (16.4–60.8%)[23-26]. This may be one of the explanations for the
discordance between the findings of electromyogramthat show severe neuropathy and the absence of thenar
muscle atrophy or thumb opposition dysfunction. It isreasonable to evaluate both the OP and the APB when
determining the optimal wrist position for evaluation of
the perfect O sign. Surface electromyography could not
be used to evaluate the OP because it lies in a deeper
layer immediately dorsal to the APB. Nevertheless,the contribution of the APB is speculated to be greaterthan that of the OP in thumb opposition because it has alarger lever arm as a result of its origin and insertion.
Similarly, the muscle belly of the FDS exists closeenough to the surface to be palpable, and it can beAsian J Occup Ther 18: 103−110, 2022

evaluated by surface electromyography. The flexor digitorum profundus that belongs to the same group of forearm flexor muscles as the FDS exists in a deep layer, itcannot be evaluated by surface electromyography. It was
impossible to measure the amplitude of muscles such as
the lumbrical muscles and flexor pollicis brevis muscles
by surface electromyography. It was also impossible
to use needle electromyogram for healthy volunteers
because it is an invasive method that could potentiallyinvolve infection and pain.
Second, the number of subjects in this study was
small. Although some significant results were obtainedwith a small number of volunteers, it is recommended
that a larger number of subjects be used and that thevalidity of this tool be examined in future research.
The third limitation is the possibility that an orthosis hindered the excursion of the muscles when wemeasured the amplitude using surface electromyography
to determine the optimal wrist position for evaluationof the perfect O sign. To minimize this effect, a volar
support part of the orthosis was designed as its overhang
toward the thenar was small enough to not hinder the
excursion of the thenar muscles, including the APB, andthe band over the first web was designed to be as narrowas possible so as to not hinder the excursion of the FDI.
Despite this, there remains the possibility of an obstacle
to muscle excursion other than the thenar muscles and
FDI.
Lastly, the roundness of the perfect O sign was only
obtained in a single patient with carpal tunnel syndrome.
This was merely a reference value for the disease. Thereis some possibility that amplitude of each muscle whena healthy person forms the perfect O sign differ fromthose of a carpal tunnel syndrome patient. The effect oflimb and wrist position in cases of carpal tunnel syndrome may be different. A larger amount of data should
be collected in the future so as to enable verification of
the difference between subjects with and without carpal
tunnel syndrome.

Conclusion
The optimal wrist position for evaluating the perfect O sign was examined, and a quantification tool forthe perfect O sign was developed based on the results.
The optimal wrist position for the perfect O sign wasdetermined to be dorsiflexion. The roundness of theperfect O sign in healthy subjects obtained using thistool was 82.08 ± 7.92%. In the future, we will conduct
research with an increased number of subjects both withand without carpal tunnel syndrome, and demonstrate
the validity of this tool.

Ando M et al.

109

Acknowledgments
This research received no specific grant from any
funding agency in the public, commercial, or not-forprofit sectors.

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T, Okawa A. A new method of measuring the thumbpronation and palmar abduction angles during opposition
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■CASE REPORTS

Effect of Perceptive Exploration Activity on Spoon
Manipulation by Paralyzed Upper Extremity with
Sensory Disturbance in a Patient with Stroke
Hemiparesis: A Single-Subject Research Design
Masato Sato1, Yukio Mikami2, Fumihiro Tajima2
1
2

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

Abstract: Introduction: Functional use of a paralyzed upper extremity in patients with hemiparesis after stroke depends on the specificity of the task. Further, task specificity-dependent upper extremity use is an important factor in therecovery of upper extremity function. The purpose of this study was to investigate the usefulness of a perceptive exploration activity in consideration of the specificity of the task for Japanese male patient in his 70s and monitor its effecton spoon manipulation using the affected arm.
Methods: A single-subject research design was implemented in the ABAB trial. The facilitation of selective movementof the paralyzed upper extremity and self-care skill training were provided during baseline A and A’ as occupational
therapy (OT). In addition to the OT, 10 minutes of perceptive exploration activity was added during the interventions B
and B’. The required time (RT) and number of errors (NOE) in task performance were monitored as the outcome of thetherapeutic effect. Goal Attainment Scaling (GAS) and Fugl-Meyer Assessment (FMA) were also adopted to evaluate
individual goals and changes in upper extremity function.
Results: RT and NOE in task performance were decreased with interventions B and B’ compared to baselines A and A’.
GAS score improved in interventions B and B’, and FMA showed a gradual improvement within each phase.
Conclusion: Spoon manipulation using the paralyzed upper extremity with sensory disturbance was improved by perceptive exploration activity. Current therapy suggests that perceptive exploration activity may be effective in improving
movement skills in the manipulation of tools.
Keywords: hemiparesis, paralyzed upper extremity, spoon manipulation, perceptive exploration activity, ABAB trial(Asian J Occup Ther 18: 111−115, 2022)

Introduction
Restoration of functional use of the paralyzed upper
extremity is one of the goals of occupational therapy(OT) in patients with stroke hemiparesis because paralyzed upper extremities often cause difficulty in manipulating tools for everyday items by problems such as
sensory disturbance and motor control [1]. In addition,
approximately 50% of stroke patients experience sensoReceived: 4 October 2021, Accepted: 8 February 2022
Corresponding to: Masato Sato, Department of Rehabilitation,
Hashimoto Municipal Hospital, 2-8-1, Ominedai, Hashimoto, Wakayama, 648-0005, Japane-mail: sato.my1005@gmail.com©2022 Japanese Association of Occupational Therapists

ry disturbance, which negatively affects the functionaluse of the upper extremities [2].
The functional use of the upper extremities is
supported by the corticospinal system [3]. For upper
extremity function supported by the corticospinal
system depends on the specificity of the task, and the
exploration of perceptual information and motor control
are important factors for the recovery of upper extremity
function [4]. Therefore, the exploration of perceptual
information and motor control that depends on the specificity of the task is a hypothesis that improves the functional use of the paralyzed upper extremity. The purposeof this study was to monitor the effects of perceptive
exploration activity performed.

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EFFECT OF PERCEPTIVE EXPLORATION ACTIVITY ON SPOON MANIPULATION

MethodSubject
The patient, a male in his 70s, diagnosed with acerebral infarction in the left middle cerebral artery inferior trunk area participated in this study.
This study was initiated on day 127 of the illness.
Brunnstrom’s stages were right upper extremity IV,
finger V. The paralyzed upper extremity had had sensory
disturbance and therefore was not used in activities ofdaily living (ADLs).
ADLs were required the setting and watching of
the environment. The Functional Independence Measure
had 81 scores. Eating was performed by adjusting theenvironment of the dining table and manipulating thespoon of the non-paralyzed upper extremity. The spoon
manipulation of the paralyzed upper extremity was not
appropriate. He spilled most of the food because of thepoor fundamental movement of scooping.
Research Design
In this study, the ABAB trial was conducted
after obtaining informed consent from the patient. At
baselines A and A’, OT comprised facilitating selective
movement of the paralyzed upper extremity and selfcare skill training was provided for 40 minutes a day,five days a week. For interventions B and B’, a specificintervention for 10 min was added to OT.
Specific Intervention (Fig. 1a)Spoon manipulation using the paralyzed upper extremity was found to be difficult for scooping the food,so the task of stirring soybeans was selected. This task
is considered as a perceptive exploration activity that
scoops changes in the sense of resistance to soybeans
as an aggregate, and the movement to scoop is a fundamental movement skill of the hand [5].
In the therapy, the paralyzed upper extremity of thepatient was guided, and the hand shaping and soybean
movement were adjusted based on the change in thesense of resistance provided by the soybeans as an aggregate.
Outcome Measurements
1) Efficiency of spoon manipulation by the paralyzed
upper extremity (Fig. 1b, c)
Measurements of evaluation task were taken indaily sessions, measuring the required time (RT) and thenumber of errors (NOE) based on the beans spilled fromthe spoon.
2) Goal Attainment Scaling: GAS
GAS was measured at the end of each phase, andthe change in score was calculated [6].
3) Fugl-Meyer Assessment: FMA
The FMA was used to measure movement, sensation, range of motion, and pain in the upper extremity atthe end of each phase.
Data analysis
For the analysis, RT and NOE measured in eachperiod were compared by 2 standard deviation (2SD)
bands, Kruskal-Wallis H-test for analysis of variance,and Mann-Whitney U-test with Bonferroni correction
for multiple comparison and was considered statisticallyFig. 1. a) Reproduction of therapy scene by perceptive exploration activity.
b) Go stones. The surface is smooth, is 2.2 cm in diameter, and has a clear weight.
c) Evaluation task. Because there is no evaluation task for utensils manipulation so far, it was decided independently with reference to previous research in Japan. The setting on the table controlled the distance from the edge in front of the table to the Japanese bowl and the distance from the Japanese bowl to a different bowl to 15 cm. The Japanese bowl containing the Go stone is 13
cm in diameter and 6.8 cm in depth. A different bowl is 9 cm in diameter and 6.8 cm in depth. The evaluation task was to move
the Go stones placed in the Japanese bowl to a different bowl placed in front of the former as quickly as possible by manipulating
the spoon using the paralyzed upper extremity.

Asian J Occup Ther 18: 111−115, 2022

Sato M et al.

113

Fig. 2 Changes in required time and number of errors in task performance

significant at p < 0.05.
In addition, the correlation coefficient of RT, NOE
and FMA were calculated using the Spearman’s rankcorrelation coefficient.

Results
RT and NOE by 2SD bands showed a decrease
in interventions B and B’ (Fig. 2). Table 1 shows thechanges in outcomes during each phase. Intervention B’s

RT was reduced relative to baseline A (p = 0.013), but
NOE was not significantly different (p = 0.124). A comparison of intervention B and A’ showed an increase inboth RT and NOE (p = 0.026, p = 0.031). A comparisonof baseline A’ and intervention B’ showed a decreasein both RT and NOE (p = 0.013, p = 0.016). GAS
improved with interventions B and B’. In addition, thespoon manipulation at the B and B’ stages has smoothly
changed the process of scooping food and eating it to
the mouth. The FMA showed a gradual improvement in114

Effect of Perceptive Exploration Activity on Spoon Manipulation by Paralyzed Upper
Extremity with Sensory Disturbance in a Patient with Stroke Hemiparesis: A SingleEFFECT OF PERCEPTIVE EXPLORATION ACTIVITY ON SPOON MANIPULATION
Subject Research Design1
Table
Effectof interventions
on the measures
main outcome measures
Table
1. 1.
Effectof interventions
on the main outcome

The required time and number of errors in the task performance indicate the mean value ± standard deviation.
The required time and number of errors in the task performance indicate the mean value
GAS: Goal Attainment Scaling, FMA: Fugl-Meyer Assessment.

± standard deviation.
each phase.
that Assessment.
our intervention improved spoon manipulation and
GAS: Goal Attainment Scaling, FMA: Fugl-Meyer
The correlation coefficient between FMA and RT
GAS score.
was -0.6 and NOE was -0.3; hence, a negative correlaIn addition, from the result of negative correlation
tion was observed.
between spoon manipulation and FMA, the effect ofrecovery of the motor function of the upper extremity on
spoon manipulation cannot be ruled out. Therefore, it isDiscussion
a future task to verify the function that greatest effect on
The paralyzed upper extremity of the patient before
spoon manipulation.
the intervention had sensory disturbance, and therefore
spoon manipulation was not practical. One underlying
Conclusion
mechanism may be disorders of the central nervous
system affecting tool manipulation of upper extremity
It has been shown that perceptive exploration acfunction, which is associated with motor and sensory
tivity may be effective in improving movement skills infunction [7].
tool manipulation of the paralyzed upper extremity with
Therefore, perceptive exploration activity was
sensory disturbance.
performed in this study to facilitate the perceptive
exploration function of the paralyzed upper extremity.
Acknowledgments:
Our observation is consistent with previous studies
suggesting perceptive exploration of the hand is an
The authors thank the patient for participation.
active movement that brings consistency between hand
movements and sensations, and reactions based on soReferences
matosensory input are the basis for acquiring movement[1] Bleyenheuft Y, Gordon AM. Precision grip in congenital
skills [8, 9]. In terms of the corticospinal system in theand acquired hemiparesis: similarities in impairments andfunctional use of the hand, the recruitment of corticospiimplications for neurorehabilitation. Front Hum Neurosnal neurons is activated during hand movement based on
ci. 2014; 8: 459.
perceptive exploration and regulates fine control of the[2] Meyer S, Karttunen AH, Thijs V, Feys H, Verheyden G.
hand [10]. Therefore, it would be reasonable to assume

Asian J Occup Ther 18: 111−115, 2022

How do somatosensory deficits in the arm and hand relate
to upper limb impairment, activity, and participation
problems after stroke? A systematic review. Phys Ther.
2014; 94 (9): 1220-31.
[3] Kandel ER, Schwartz JH, Jessell TM. Principles of
Neural Science, 4th ed. New York: McGraw-Hill; 2000.
[4] Shumway-Cook A, Woollacott M. Motor Control: Translating Research into Clinical Practice, 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2007.
[5] James T. Sensorimotor Control and Learning: An
introduction to the behavioral neuroscience of action.
Basingstoke: Palgrave Macmillan; 2012[6] Gordon JE, Powell C, Rockwood K. Goal attainment
scaling as a measure of clinically important change in

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115

nursing-home patients. Age Ageing. 1999; 28: 275-81.
[7] Lee HS, Kim JU. The effect of self-directed exercise
using a task board on pain and function in the upper extremities of stroke patients. J Phys Ther Sci. 2013; 25 (8):963-7.
[8] Hartmann MJ. Active touch, exploratory movements, andsensory prediction. Integr Comp Biol. 2009; 49 (6): 68190.
[9] Ostry DJ, Gribble PL. Sensory plasticity in human motor
learning. Trends Neurosci. 2016; 39 (2): 114-23.
[10] Muir RB, Lemon RN. Corticospinal neurons with a
special role in precision grip. Brain Res. 1983; 261 (2):312-6.

■ORIGINAL ARTICLE

Relationship between Driving Risk, Attention Function,
and Driving Characteristics of Healthy Middle-aged
and Older Female Drivers in the Fukui Prefecture inJapan
Kaori Kawabata1, Yasutaka Kobayashi1, Yutaro Omokute2, Chiaki Takama3,
Takato Kawakami3, Yoko Watanabe3, Miho Yamaguchi3, Kazuki Fujita1
1

Graduate school of Health Science Fukui Health Science University
Department of Rehabilitation, Fukui General Clinic
3
Department of Rehabilitation, Fukui General Hospital2

Abstract: Problem Statement: There is a need to determine whether a brain-injured person can return to driving fromthe viewpoint of a healthy individual’s driving abilities and characteristics. Accordingly, this study investigated theattention function and driving characteristics of healthy middle-aged and older female drivers in a region with a highlevel of automobile dependence, and examined their relationship with traffic violations and accidents.
Methodology: Participants were 81 healthy female drivers, with a mean age of 64.4 ± 8.4 years, whose incidences oftraffic violations and accidents, attention function, and driving characteristics were examined. Attention function was
evaluated using Trail Making Test Part A, Trail Making Test Part B, and Symbol Digit Modalities Test. Participants
were divided into two groups according to whether they had been involved in traffic violations or accidents. Statisticalcomparisons were performed.
Results: Drivers who experienced violations and accidents exhibited reduced attention function in the Trail Making
Test Part A assessments. Trail Making Test Part B and Symbol Digit Modalities Test were unrelated to driving risk.
Driving characteristics showed differences between the two groups.
Conclusion: In addition to attention function, potential personality changes and awareness of disease after brain damage may affect the driving function of people with brain damage, in addition to their driving characteristics and personality traits from before the brain damage. In the future, we aim to conduct a survey of drivers with brain diseases to help
determine criteria for whether a person with a brain injury can return to driving.
Keywords: middle-aged and older, female driver, traffic violations and accidents, visual attention, driving characteristics(Asian J Occup Ther 18: 117−126, 2022)

Introduction
For many people, driving automobiles (hereinafter,
driving) is an essential part of daily life. Although adecline in cognitive function from higher brain dysfunction resulting from brain injuries significantly
affects driving [1, 2], it has been reported that 40–80%
Received: 8 June 2021, Accepted: 20 March 2022
Corresponding to: Kaori Kawabata, Graduate School of Health Science Fukui Health Science University, 55 Egami-cho 13-1, Fukui-City,
Fukui 910-3190, Japane-mail: kawabata-ot@fukui-hsu.ac.jp©2022 Japanese Association of Occupational Therapistsof people who suffer brain injuries ultimately return todriving [3-6]. Whether a driver can return to driving
after a brain injury greatly affects the maintenance oflife, especially in automobile-dependent areas; hence,
there is often conflict over the support that should begiven to patients to facilitate a return to driving. Thereis a need to assess whether someone who has suffered abrain injury is more likely to commit traffic violations(hereinafter referred to as violations) or cause traffic accidents (hereinafter referred to as accidents). However,there is no international consensus on a standardized
assessment of an individual’s capacity to drive after
suffering a brain injury [7]. While no clear safety standards, such as specific test parameters and values, have

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DRIVING CHARACTERISTICS OF HEALTHY WOMEN

been established in Japan either, common assessments
include cognitive function tests and road assessments.
It has been reported that 90% of the information usedin driving is visual information, and cognitive function
tests are essential to assess visual attention function.
While attention function tests are highly valuable indetermining an individual’s fitness to drive [8, 9], it is
not clear what level of attention function would allow aperson who has suffered brain injury to drive as safely
as a healthy person. There have been no studies comparing and verifying the attention functions of healthy
drivers. In addition to cognitive function, driver genderand personal driving characteristics affect cognitive anddecision-making processes in driving [10]. According to
the statistics on traffic violations and accidents in Japan[11, 12], the accident rate is higher for women than formen when standardized by distance traveled, with anincreasing trend observed especially in middle-aged andolder drivers. Several studies have focused on the influence of driver personality characteristics on behavior at
the wheel among healthy drivers of different ages [13,14]. Several studies on patients with brain disease haveinvestigated their driving skills from the perspective ofattention function and operating skills [8,15–17], but
few studies have considered gender or driving characteristics [18]. It is believed that comprehensive judgment
is necessary for brain-injured people to resume driving[19], but t but no specific criteria for comprehensive
judgment for driving have been established. To date, nostudies have examined attention functions and driving
characteristics based on female drivers’ violation or
accident experience.
This study aims to fill this research gap by investigating the attention function and driving characteristicsof healthy middle-aged and older female drivers in a
car-dependent area, to examine the relationship between
these two variables and traffic violations and accidents,
and to compare the driving functions of healthy drivers
and drivers with brain diseases in the future.
The study protocol was approved by the Nittazuka
Medical Welfare Center Ethics Review Committee (NE:2019-35).

Material and Subject
Participants and Basic Attributes
Of the healthy individuals who participated in the“Health Checkup Project” held at commercial facilities
in Fukui, which comes under the Fukui Prefecture in
Japan, we recruited individuals who were: between 50
and 80 years, in possession of a regular automobile
license, and driving on a daily basis. This prefecture has
the highest automobile ownership rate in Japan and is atypical automobile-dependent region [20]. Those with ahistory of brain disease or brain trauma were excluded
from the investigation. As women accounted for approximately 80% of the 115 participants, we decided that
only data from female participants would be analyzed in
the study.
Participant age, gender, and driving records were
investigated based on a self-administered questionnaire.
Presence or Absence of Violations or Accidents
A self-administered questionnaire was used toinvestigate whether the participants were involved intraffic violations or accidents in the past three years. In
terms of violations, which included those cited by thepolice, participants were asked to choose all applicableinstances from a list that included the following options(1) stop sign violation, (2) over speeding, (3) ignoring
traffic light, (4) use of mobile phone, (5) not wearing
seatbelt, and (6) other. If (6) was selected, the participants were asked to describe the violation in detail.
Accidents were limited to those caused by negligence,
and we investigated the circumstances surrounding theaccident and whether there was property damage. Similarly, we investigated the incidence of personal injuries
suffered and the specific matter of the accident.
Attention Function
The Trail Making Test Part A (TMT-A) (A4 verticalversion), the Trail Making Test Part B (TMT-B) (A4vertical version), and the Symbol Digit Modalities Test
(SDMT) were performed to determine the time taken for
TMT-A and TMT-B and calculate the SDMT achievement rate. All of these tests require the visual attentionfunction. While TMT-A primarily requires the selection
function, TMT-B primarily requires the conversion
function, and SDMT requires the distribution function.
These tests are often used to judge driving aptitude.
In the present study, the cutoff values were set to 54 s
for TMT-A [21], 150 s for TMT-B [21], and 37.3% for
SDMT [22]. In addition, to evaluate as many participants as possible while the “Health Checkup Project”
was being held, the time limits for TMT-A and TMT-B
were set to 90 s and 180 s respectively, and the evaluation was aborted if it was not completed within the time
limit. If the evaluation was not completed within thetime limit, the time taken for evaluation was regarded as
90 s for TMT-A and 180 s for TMT-B. The evaluations
were performed without informing the participants about
the time limit.
Driving Characteristics
A self-administered questionnaire based on afour-point Likert scale was used to investigate howAsian J Occup Ther 18: 117−126, 2022

Kawabata K et al.

119

Table 1. Questionnaire about Driving Characteristics
Please answer about your driving. How applicable are the following statements to you usually?
Choose the one that best applies to you and mark the number to the right of each sentence with a circle.
Please answer honestly. Please answer with intuition without thinking too deeply.
1: Not applicable at all, 2: Not very applicable, 3: Quite applicable, 4: Very applicable1) I struggle to switch lanes in a traffic jam ＊

1

2

3

4

2) I prefer buses and trains over cars when there is not much difference in the amount of time it takes to arrive at
the destination

1

2

3

4

3) I keep a good distance between cars without worrying about being interrupted ＊

1

2

3

4

4) I make sure to slow down and stop appropriately

1

2

3

4

5) I look at the signal ahead and slow down or speed up in advance

1

2

3

4

6) Cars are a means of transportation, so I think it’s only necessary to move ＊

1

2

3

4

7) I cannot be focused on driving when I have worries and problems

1

2

3

4

8) I’m always worried about running over pedestrians

1

2

3

4

9) I avoid parking in no-park areas, even for a short time

1

2

3

4

10) I am confident in the width of the car

1

2

3

4

11) When traveling by car, I prefer a wide, well-maintained road with as much traffic light as possible, rather thana back road

1

2

3

4

12) I want to be as close to the front as possible even after a lane switch

1

2

3

4

13) I carefully check safety when switching lanes and at intersections

1

2

3

4

14) I adjust the speed so that I will not get caught in the previous signal

1

2

3

4

15) I think that the car is a status symbol (a cool car)

1

2

3

4

16) I drive fast or neglect to drive according to my mood

1

2

3

4

17) I am worried about causing a car accident

1

2

3

4

18) I always keep the speed limit

1

2

3

4

19) I overtake the car when overtaken

1

2

3

4

20) I overtake a lower grade car

1

2

3

4

21) I sounds the horn when the preceding car is late to start, such as when the traffic light turns green.

1

2

3

4

22) I switch lanes when given the slightest space

1

2

3

4

*: Reverse queitions

participants drove and used their cars (Table 1). The
questionnaire consisted of 18 questions from the Driving
Style Questionnaire (DSQ) [23] and four moral factor
questions concerning driving characteristics [24]. The
Driving Behavior Questionnaire (DBQ), developed by
Reason [25], is often used internationally as a questionnaire for driving behavior. However, since there is noJapanese version of the DBQ, the DSQ was used in thisstudy. Emotional factors, including anger and aggression
while driving, affect driving behavior (moral) [26], so
a moral factor was added. The DSQ consists of eight
principal components [23]: I. Confidence in driving
skills (Questions 1 and 10), II. Passivity for driving(Questions 2 and 11), III. Hasty driving (Questions 3
and 12), IV. Meticulous driving (Questions 4 and 13), V.
Prepared for traffic signals (Questions 5 and 14), VI. Car
that is a status symbol (Questions 6 and 15), VII. Unstable driving (Questions 7 and 16), and VIII. Worried
driving (Questions 8 and 17). Questions 9 and 18 wereadded as false discovery scales to check if they wereTable 2. Category of the Driving Characteristics
Category

Question number

Ⅰ

Confidence in driving skills

1,10

Ⅱ

Passivity for driving

2,11

Ⅲ

Hasty driving

3,12

Ⅳ

Meticulous driving

4,13

Ⅴ

Prepared for traffic signals

5,14

Ⅵ

Car that is a status symbol

6,15

Ⅶ

Unstable driving

7,16

Ⅷ

Worried driving

8,17

Ⅸ

Moral problems

19,20,21,22

False discovery scales

9,18

The driving characteristics were classified into categories Ⅰ to Ⅸ.
False discovery scales were not included in the categories.

answered from the perspective of social desirability [23].
Driving characteristics were ultimately classified intonine categories with the addition of IX. Moral problems(Questions 19, 20, 21, and 22) (Table 2).

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DRIVING CHARACTERISTICS OF HEALTHY WOMEN

For all questions, we calculated the number ofpeople who responded, “very applicable to quite applicable” and the number of people who responded, “notapplicable at all to not very applicable.” However, as
Questions 1, 3, and 6 were reverse questions, their response values were also reversed.

MethodWe provided participants with written explanations
about the purpose of the research and the methodology
through which personal information would be handled
before obtaining their oral consent to participate.
Analysis based on the Presence or Absence of Traffic
Violations or Accidents
The participants were divided into the No Violation/
Accident Group (hereinafter, NVA Group) or Violation/
Accident Group (hereinafter, VA Group) according towhether they had been involved in traffic violations
or accidents. Basic attributes, attention functions, anddriving characteristics were compared between the twogroups.
Analysis based on the Attention Function Results
Participants were divided into two groups according to the mean and standard deviation (SD) values of
TMT-A and TMT-B: good attentional function group(hereinafter, Good Group) and poor attentional functiongroup (hereinafter, Poor Group). The former comprised
participants whose scores for both TMT-A and TMT-B
were less than the mean + SD, and the latter included

those whose scores for one or both the tests were higher
than the mean + SD. Basic attributes and driving characteristics between the two groups were compared.
Statistical Analysis
Subsequently, the two groups were compared using
a t-test, a test of difference in population ratio, and aχ2-test. SPSS statistics 25 and Bell Curve for Excel
software (Social Survey Research Information Co, Ltd,Tokyo, Japan) were used as the statistics software; thesignificance level was set to 5%.

Results
Analysis based on the Presence or Absence of Traffic
Violations or Accidents
1）Basic Attributes
Table 3 shows the basic attributes of the participants. There were 81 participants, with a mean age of
64.4 ± 8.4 years and a mean driving experience of 36.7
± 8.6 years. The number of participants (proportion),mean age, and mean number of years of driving experience according to NVA/VA Groups were 63 participants(77.8%)/18 participants (22.2%), 64.4 ± 8.5 years/64.4± 8.3 years, and 36.8 ± 9.0 years/36.2 ± 7.5 years, respectively. Comparison of mean age and mean numberof years of driving experience between the two groups
showed no significant differences. The VA Group included 10 participants with experience of violations, sevenparticipants with experience of property damage accidents, and one participant with experience of violationand property damage accident. No participant reported

Table 3. Profile of the Participants
All participants(n=81)
Mean (SD)

NVA group(n=63)
Mean (SD)VA group(n=18)
Mean (SD)p

Age64.4 (8.4)

64.4 (8.5)

64.4 (8.3)

n.s.

Driving experience (years)

36.7 (8.6)

36.8 (9.0)

36.2 (7.5)

n.s.

Traffic violations(n=10)

Stop sign violation
Overspeeding
Not wearing seatbelt
Trespassing violation
Ignoring traffic signals
Use of mobile phone

5*
2
2
2
1
0

Property damage accidents(n=7)

Collisions
Scratches

5*3Traffic violations andProperty damage accidents(n=1)(Stop sign violation and Collision)

Personal injury accidents(n=0)
Statistics: T-Test was performed. n.s.: not significant*: One of them is experiences both stop sign violation and collision.

Asian J Occup Ther 18: 117−126, 2022

Kawabata K et al.

121

Table 4. Attention Function Examination
Cut-off

All participants(n=81)
Mean (SD)

NVA group(n=63)
Mean (SD)VA group(n=18)
Mean (SD)TMT-A (seconds)
Below the cut-off values (%)*Time limit over (%)

54

36.0 (11.3)

35.1 (10.4)
3.2
0

38.6 (13.9)
11.1
5.5

n.s
<.05

TMT-B (seconds)
Below the cut-off values (%)*Time limit over (%)

150

89.3 (31.7)

88.1 (31.9)
4.8
3.1

93.3 (31.3)
11.1
0

n.s.
n.s.

SDMT (%)
Below the cut-off values (%)

37.3

46.9 (8.8)

47.0 (8.9)
19

46.4 (8.4)
22.2

n.s.
n.s.

p

TMT-A: Trail Making Test part A, TMT-B: Trail Making Test part B, SDMT: Symbol Digit Modalities Test
*Time limit: TMT-A 90 seconds, TMT-B180 seconds
Statistics: T-Test and Hypothesis Testing for the Difference in the Population Proportions were performed.
n.s.: not significant
Table 5. Driving Characteristics

Statistics: χ2 Test was performed. n.s.: not significant

any personal injury accidents. The survey revealed thatfive participants had stop sign violations and two had
speeding violations. In addition, two participants werecaught not wearing a seatbelt, two had trespassing violations, and one was reprimanded for ignoring traffic signals. None of the participants had a traffic violation forusing a mobile phone while driving. Property accidents
comprised five participants with collisions and threewith minor damage on their vehicle.

2）Participants’ Attention Function
Table 4 shows the time taken for TMT-A andTMT-B, as well as the SDMT achievement rate ofeach group. The ratio of participants below the cutoff
values in the NVA/VA Groups was 3.2%/11.1% for
TMT-A, 4.8%/11.1% for TMT-B, and 19.0%/22.2%
for SDMT. The percentages of participants who wereunable to complete the assessments within the time limit
were 0%/5.5% for TMT-A and 3.1%/0% for TMT-B.
Although the VA Group did not differ significantly fromthe NVA Group in the TMT-A time, the VA Group had

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DRIVING CHARACTERISTICS OF HEALTHY WOMEN

a significantly higher percentage of participants below
the cutoff value (p<0.05). There were no significant differences between the two groups in terms of TMT-B andSDMT.
3）Driving Characteristics
Table 5 shows the proportion of responses to questions related to driving characteristics.
A significantly greater proportion of participants
responded “very applicable to quite applicable” forCategory IV (“I carefully check safety when switchinglanes and at intersections” [84%] and “I make sure toslow down and stop appropriately” [74.1%]), followed
equally by Category II (“When driving, I prefer wide,
well-maintained roads with as many traffic signals as
possible, rather than back roads” [61.7%]) and Category III (“I keep a good distance between cars withoutworrying about being interrupted” [61.7%]). The least
frequent response was recorded for Category IX (“Moralconcerns”), with less than 5% for all four questions.
The analysis of traffic violations/accidents and driving characteristics showed that the five questions thatelicited significant differences in responses between thetwo groups were: “I struggle to switch lanes in a traffic
Table 6. Attention Functions and Driving Characteristics

Statistics: χ2 Test was performed. n.s.: not significant

jam” (p<0.05) in Category I; “I cannot be focused on
driving when I have worries and problems” (p<0.05) in
Category VII; “I am always worried about running overpedestrians” (p<0.05) and “I am worried about causing
a car accident” (p<0.01) in Category VIII; and “I switch
lanes when given the slightest space” (p<0.01) in Category IX. The VA Group had a significantly greater proportion of participants who responded “very applicableto quite applicable.” There were no differences between
the two groups in terms of questions from Categories II,
III, IV, V, and VI. Furthermore, there were no significant
differences between the two groups in terms of responses
to the two questions added as false discovery scales.
Analysis based on the Attention Function Results
Table 6 shows the results of the analysis of attentionfunction results and driving characteristics.
The time required for TMT-A/TMT-B for all participants was 36.0 ± 11.3/89.3 ± 31.7 s. The Good Groupconsisted of 58 participants aged 62.7 ± 8.4 years andrequired 30.6 ± 7.1 s to complete the tests. The Poor
Group consisted of 23 participants aged 68.6 ± 6.8 years
and required 49.6 ± 8.2 s to complete the tests. The
Good Group was significantly younger than the Poor

Asian J Occup Ther 18: 117−126, 2022

Group. An analysis of driving characteristics by attention function showed that the two questions that elicited
significant differences in response between the twogroups were: Category I: “I am confident in the width ofthe car” (p<0.01) and Category Ⅱ: “When traveling bycar, I prefer a wide, well-maintained road with as muchtraffic light as possible, rather than a back road” (p<0.05).
The Poor Group had a significantly greater proportionof participants who responded “very applicable to quite
applicable.” There were no differences between the twogroups regarding questions from Categories III to Ⅸ andfalse discovery scales.

Discussion
Attention Function and Driving Risk
As the percentage of participants below the cutoff
value in TMT-A showed differences between the twogroups, we inferred that reduced selective attention
increased driving risk. However, TMT-B and SDMT
were found to be unrelated to driving risk. All accidents
experienced by study participants were collision andscratch accidents; there were no serious accidents that
resulted in personal injuries. In a study of elderly drivers
over 65 years old, Horikawa et al. [27] reported that
TMT-A results were related to mild collision and scratch
accidents, and that TMT-B results were unrelated toaccidents, which is consistent with our results. As such,
TMT-A can be regarded as an indicator that predicts therisk of violations or minor accidents. In contrast, a report
by Kobayashi et al. [22] that showed the importanceof SDMT, cited the results of Track Tests, which weredifferent from those discussed in the present study thatexamined violations and accidents. At present, there areno methods or clear criteria for objectively evaluating
driving risk from the perspective of attention function[27], and further studies are needed.
Driving Characteristics and Driving Risk
Driving characteristics, which recognized differences based on the presence or absence of violations or
accidents, were addressed by questions contained in four
categories (I, VII, VIII, and IX). As participants in the
VA Group agreed that they frequently struggled to switch
lanes during traffic jams and worried about causing a
car accident and hitting a pedestrian, it was evident thatthey were more anxious about driving than participantsin the NVA Group. Many participants in the VA Groupalso mentioned that they cannot concentrate on driving
when they have anxiety or worries, which suggests how
psychologically vulnerable they may be. Pêcher et al.
[28] reported that negative emotions, such as anxiety anddepression, enhance driving safety. Although negative

Kawabata K et al.

123

emotions can be a compensatory measure to enhancesafety, they may have acted as a factor impeding driving
concentration among individuals in the VA Group in ourstudy. In addition, many participants in the VA Groupmentioned that they switch lanes when given the slightest space, suggesting hasty driving. As it has been reported that hasty drivers struggle with emotional control,
such as managing their irritation and impatience, and areprone to make situational judgments [29], we conceived
that participants in the VA Group were more easily affected by other drivers and the surrounding environment
and tended to lose their cool while driving.
Previous studies on the driving aptitude of persons
with brain injury [18, 30] have suggested that incidences of traffic violations and accidents are affectedby the driving characteristics and personality of thedriver, regardless of brain injury. The present study also
showed that driving characteristics are related to traffic
violations and accidents, implying that in the future, it
may be important to consider a driver’s pre-brain injury
driving characteristics and personality when determining
whether the individual can resume driving. Furthermore,
Anstey et al. [31] clearly distinguished “driving ability” from “driving behavior,” mentioning that “driving
ability” is determined by an individual’s cognitiveand physical functioning, whereas “driving behavior”
is determined by an individual’s driving abilities andself-monitoring abilities. In other words, it is possiblethat the ability to accurately monitor one’s own driving
abilities affects driving risk. We feel that it is necessary
to evaluate the personality changes and disease awareness of an individual after experiencing a brain injury,
while remembering that brain injuries not only reduce
cognitive functioning, but also cause personality changes
and reduce disease awareness.
Importantly, in our study, the two groups showed nodifferences in terms of responses to all questions from
Categories II, III, IV, V, and VI.
In particular, most participants agreed with thequestions included in Categories II, III, and IV. In otherwords, the driving characteristics of the female drivers inthis study included meticulous and safe driving, passivity
for driving, and worried driving. According to a surveyof female drivers in their 20s to 50s [3], they are highly
anxious, lack confidence and leeway in their driving, andhave a strong perception that their driving is safe. This isconsistent with the characteristics of the female drivers
in this study. However, female drivers tend to drive ina self-centered manner without realizing that they are
causing inconvenience to other vehicles [3], and it ispossible that they generally perform safety checks suchas improper deceleration and stopping.
We believe that the fact that only a few participants

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DRIVING CHARACTERISTICS OF HEALTHY WOMEN

agreed with “I think that the car is a status symbol (acool car)” supports the results of a previous study [32]that suggested female drivers had less interest in automobiles themselves and were less likely to engage inrisky driving compared to male drivers. Moreover, giventhat only a few participants agreed with “I prefer buses
and trains over cars when there is not much difference inthe amount of time it takes to arrive at the destination,”
it is evident that there was relatively little use of public
transportation among the participants. We believe this isdue to the low convenience level of public transportationand overdependence on automobiles due to the participants living in an automobile-dependent zone.
Attention Function and Driving Characteristics
The group with poor attention function was older
than the Good Group, more confident in their sense ofvehicle width, and less likely to use narrow roads. Older
people tend to rate their own driving ability highly [33,34], which may lead to their confidence in their senseof vehicle width. In general, female drivers also tend tohave more accidents at narrow intersections [12], anddrivers with impaired attention functions and older drivers may be more reluctant to drive on narrower roads.
No significant differences were found for the other questions, suggesting that there are few differences in driving
characteristics by attention function.
Limitations of the StudyIn the present study, since TMT-A and TMT-B
assessments were made with a time limit given the circumstances of the testing environment, we were unable
to accurately measure the time taken by participants who
could not complete the assessment within the time limit.
As there was one participant from the VA Group who
could not complete TMT-A in time and two participantsfrom the NVA Group who could not complete TMT-B intime, it is necessary to be careful when interpreting theresults of attention function. Furthermore, it is unclear
whether driving characteristics are factors that cause violations or accidents or whether they are characteristics
resulting from experiences of driving violations or accidents. For this reason, there is a limitation to discussing
the relationship between driving characteristics anddriving risk. Moreover, previous studies have suggested
that cognitive functioning, driving characteristics, andaccident trends vary depending on gender [32,35,36].
Hence, it would be necessary to also verify the genderdifferences when examining the criteria for persons withbrain injury to resume driving.

Conclusion
This study unfolded in three main moves: 1) weinvestigated the attention function and driving characteristics of healthy middle-aged and elderly female drivers
in a region with a high level of automobile dependence,2) we examined the relationship between these twovariables and traffic violations and traffic accidents, and3) we conducted basic research to compare the driving
functions of healthy drivers and drivers with brain diseases. The results showed that subjects in the VA Group
more frequently demonstrated driving characteristics,
such as reduced attention function in the TMT-A assessments, reduced confidence in driving skills, unstable
driving, worries about driving, and moral problems, thansubjects in the NVA Group. Furthermore, analysis of attention functions and driving characteristics showed that
there was little possibility of differences in driving characteristics depending on attention functions. In addition
to attention function, potential personality changes andawareness of disease after brain damage may have affected the driving function of people with brain damage,in conjunction with their driving characteristics andpersonality from before the brain damage. In the future,
it will be necessary to investigate potential personalitychanges and pathology after brain injury, in addition
to driving characteristics and personality before brain
injury, as a driving function of drivers after brain injury,
and to clarify their relationship with traffic violations andaccidents.

Acknowledgments
The corresponding author’s institution was invited
to participate in the “Health Examination Project,” andsubsequently, we were able to participate in the project.
We would like to thank the project manager for understanding the purpose of the study and agreeing to collectthe data.

Declaration of interest
There are no conflicts of interest regarding the publication of this paper.

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■CASE REPORTS

Effect of Home-Visiting Support Combining theCanadian Occupational Performance Measure with a
Behavioral Reinforcement-based Checklist to EnableOccupation in a Client with Schizophrenia: A CaseStudy
Takayuki Kawaguchi1, 2, Noriyuki Okumura2, Kiyomi Takahashi2,
Megumi Shinozaki2, Aki Watanabe3
1

 epartment of Community Mental Health and Law, National Institute of Mental Health, D
National Center of Neurology and Psychiatry2Home-visit Nursing Station Minna-no-Tsubasa, Yokohama Comprehensive Care Continuum3
Department of Rehabilitation, Kitasato University School of Allied Health Sciences

Abstract: Introduction: Few reports describe the occupational therapy practice of reinforcing the daily life behaviors
hoped for by clients with schizophrenia in community mental health services. We outline a therapeutic process to enablebathing hoped for by a client with schizophrenia through the combined use of the Canadian Occupational Performance
Measure (COPM) and a checklist as a cognitive aid.
Methods: The study was divided into a baseline phase and intervention phase based on the single-system design. Theinterventions were focused on occupation based on the COPM and positive feedback by using the checklist. Assisted
bathing, advice, suggestions and prompting of voluntary activities were conducted in the baseline phase.
Results: The frequency of bathing per week increased significantly in the intervention phase compared to baseline
phase by binomial test (p = 0.03). Although bathing performance score and satisfaction score in the COPM assessment
decreased from 10 and 9 (20th week) to 6 and 4 (34th week), respectively, the assessment was influenced by the client’s
further positive inquiries into ways of bathing.
Conclusion: Bathing hoped for by a client with schizophrenia was enhanced, and further positive inquiries into activities of daily life in a personal context were initiated. The findings suggest that in community-dwelling clients withschizophrenia, a client-centered approach combining COPM and a checklist as a behavioral reinforcement-based cognitive aid is sufficiently appropriate for promoting client participation in activities.
Keywords: enabling occupation, COPM, behavioral reinforcement, schizophrenia, single-system design(Asian J Occup Ther 18: 127−131, 2022)

Introduction
Effective approaches focused on the personal
context are important to address the diversity of psychosocial difficulties of schizophrenia [1]. Behavioral
Received: 29 November 2020, Accepted: 16 March 2022
Corresponding to: Takayuki Kawaguchi, National Center of Neurology and Psychiatry, National Institute of Mental Health, 4-1-1 Ogawa
Higashi-cho, Kodaira-shi, Tokyo 187-8553, Japane-mail: kawagu-t@ncnp.go.jp©2022 Japanese Association of Occupational Therapists

reinforcement typified by the token economy has been
described as one of the evidence-based psychosocial
treatments in schizophrenia since being effective toimprove adaptive behavior such as personal hygiene andsocial interactions by using tokens based on material
rewards or social rewards (e.g., praise and encouragement) [2]. However, previous research had a bias toward
inpatients and institutionalized users, and few practicalstudies and specific methodologies in daily life withless restrictive for community-dwelling consumers havebeen reported [3]. We addressed this issue through thisstudy of home-visiting support combining behavioral

128

EFFECT OF COMBINING COPM WITH CHECKLIST

reinforcement and the Canadian Occupational Performance Measure (COPM) for a community-dwellingclient with schizophrenia. The COPM is useful for
focusing on a client’s occupation and has been shown
significant effects on clients’ self-perceived level of performance and satisfaction with the performance in theprevious study [4, 5].
The purpose of this study was to outline the behavioral reinforcement approach process combined with
the COPM for a client with schizophrenia. Approvalby the institution’s research ethics committee (approval
number: 2020-002B) and signed informed consent fromthe client were obtained in this study.

Case
The client was a man in his 50s with schizophrenia.
He was living at home with family and clinic follow-up
despite residual psychiatric symptoms. After bereaving
his parents’ deaths, he could not keep himself clean by
not bathing due to his obsession with a deviant lifestylein the absence of supporters although he continued tolive alone by eating out or eating prepared food. Worsening mental condition and poor hygiene had alienatedhim from his workshop community.
Our home-visiting support team had the requestof his clinic. The immediate goals shared with him in
home-visiting support were to keep clean by himself andparticipate again in his workshop activities.

MethodTherapy Process
The home-visiting support period was divided into
two phases (Table 1).
Baseline phase: 1st to 20th week
During this phase, the nursing staff provided assisted bathing to improve his poor hygiene and prompt
his attendance at the workshop to overcome alienationfrom his community based on observational assessment,
and his voluntary participation in these activities was
expected.
Intervention phase: 21st to 34th week
Due to behavioral reinforcement, the “Checklist of
Activity of Daily Living” (checklist; Figure 1) basedon behavioral activation was created with him andintroduced to record his daily activities [6]. The staff
provided positive feedback on his actions and records onthe checklist. Before beginning this phase, the COPM
approach was conducted to determine only the occupation “Bathing” by him to collaborate with staff among
all personal and meaningful occupations (looking at afavorite picture, taking a trendy vitamin or nutritional
supplement, etc.). Sharing the meaning of bathing
through the COPM was carried out by the occupational
therapist with recording its performance and satisfaction
scores. Attending the workshop was not assessed by
COPM as he had not voluntarily mentioned it.
Procedure
A single-system design with the advantage to ex-

Table 1. Experimental Procedure and Changes in Outcomes in Each Phase.
Baseline phase (1st to 20th week)

Intervention phase (21st to 34th week)

Interventions

・Assisted bathing・Advising on methods of keeping theclient clean
・Suggesting and prompting voluntarybathing and attending the workshop

・Sharing personal context and meaning ofbathing based on COPM assessment
・Recording on the checklist
・Positive feedback based on the checklist records

Frequency per week of attending (times)

0.8 (SD = 0.4, range: 0–1)

1.4 (SD = 0.5, range: 1–2)

Range of working time per week (minutes)
COPM assessment about bathing
Importance score (range: 1–10)
Performance score (range: 1–10)
Satisfaction score (range: 1–10)
Meaning and context (remarks)

10–60

60–1806 (20th week)
10 (20th week)
9 (20th week)“Bathing, for me, is meant to keep me
clean.”“It was nice to have the home-visiting
supporting staff come in and help me stayclean and show me all sorts of ingenious
ways to keep me clean.”

8 (34th week)
6 (34th week)
4 (34th week)“I’ve come to believe that bathing is not justabout keeping myself clean.”“When I was a student, I used to take a longsoak in the bath every day.”“The original meaning of bathing for me wasto warm up, so I want to soak more properly inthe bath.”

COPM: The Canadian Occupational Performance Measure; the checklist: The Checklist of Activity of Daily Living; SD: standard deviation. Values are mean, n, or score.

Asian J Occup Ther 18: 127−131, 2022

Kawaguchi T et al.

Fig. 1.	The Checklist of Activity of Daily Living. This checklist was created with the client and introduced to him. One checklist sheet
was used per week and was modified to fit the client’s needs. As shown in the figure, the client drew a circle to indicate that a task
was done or wrote a description of what he did in the appropriate column.

Fig. 2.	Frequency per week of bathing. Baseline phase: 1st to 20th week; Intervention phase: 21st to 34th week. Bathing behaviors
included bed-bath, some body washing, full-body showering and bathing. The solid gray line indicates the celeration line in thebaseline phase. Assisted bathing in the baseline phase was conducted mainly by the staff. In intervention phase, however, theclient conducted voluntary bathing by himself. The increase in bathing frequency per week in the intervention phase compared tothe baseline phase was statistically significant (p = 0.03).

129

130

EFFECT OF COMBINING COPM WITH CHECKLIST

amine causality between the intervention and changes
in the target behavior was selected as an outcome to test
effectiveness in the combined approach using the COPM
and checklist (Table 1). Bathing and attending the workshop were as target behaviors, and the implementations
per week of their activities were recorded by the clienton the checklist. Bathing behaviors included bed-bath,washing parts of the body, showering, and bathing,whether passively or voluntarily. Reliability of counting
the target behaviors was ensured when observing his implementation in daily life through the multidisciplinary
collaboration of our team staff, home helpers and workshop staff.
Data Analysis
The split-middle method and the binomial test wereadopted to compare bathing behavior per week in eachphase [7]. The outcomes of attending the workshop were
calculated only by averages and ranges of values as thenumber of attendance behaviors could not be increased
at his discretion due to acceptance by the workshop andholidays. A p-value <0.05 was considered to indicate
statistical significance.

Results
The client’s frequency of bathing per week increased significantly in the intervention phase comparedwith the baseline phase (p = 0.03, Figure 2). The numberof attendances per week and working time in the workshop also increased due to participation in cleaning or
cooking assistance (Table 1).
His meaning of bathing was shared in the COPM
assessment (Table 1). The performance and satisfaction
scores for bathing decreased in the intervention phase(34th week) compared to those before introducing thechecklist (20th week) (Table 1). We shared with him
that, based on his remarks, these decreasing scores were
influenced by his further positive inquiries into ways ofbathing (Table 1).

Discussion
Engaging in daily occupations is an important
aspect of the mental health and quality of life of people
with schizophrenia [8]. The results in the baseline phaseindicate that the behaviors of the client with schizophrenia were difficult to change by only suggesting andprompting voluntary behaviors. Although COPM scores
decreased due to the exploration of more personallycontextualized bathing, the client’s remarks and theimprovement of performance demonstrated the effect of
the COPM approach with promoting a positive aware-ness of the desire to enable personal and meaningful
occupation.
Focusing on involvement in activities of an individual with mental illness is important to achieve independence in the community, and aids may be helpful [9].
Visualization with the checklist as a cognitive aid basedon behavioral reinforcement techniques helped the client
to realize his execution status. Preferable behaviors
based on the client’s exploration of meaningful occupations (bathing in this case) may be self-reinforcers andlead to maintenance or alteration without intervention[10].
To validate the effectiveness of this therapeutic
approach in a future study, more sophisticated evidence
design (e.g., washout of interventions based on theconsent of the individual and well-considered ethics),
modeling and formulation of the interventions, and anincrease in the number of subjects are desirable.

Conclusions
The current home-visiting support combining
the COPM approach and the behavioral reinforcement-based checklist as a cognitive aid was sufficiently
appropriate for promoting engagement to activities by acommunity-dwelling client with schizophrenia.

Acknowledgements
We thank the client for his participation and thehome-visiting support team staff, the home helpers andthe workshop staff for their cooperation in this study.

References[1] Świtaj P, Anczewska M, Chrostek A, Sabariego C, Cieza
A, Bickenbach J, et al. Disability and schizophrenia: asystematic review of experienced psychosocial difficulties. BMC psychiatry. 2012; 12(1): 193.
[2] Dixon LB, Dickerson F, Bellack AS, Bennett M, Dickinson D, Goldberg RW, et al. The 2009 schizophrenia
PORT psychosocial treatment recommendations andsummary statements. Schizophrenia bulletin. 2010; 36(1):48-70.
[3] McMonagle T, Sultana A. Token economy for schizophrenia. Cochrane Database of Systematic Reviews.
2000; 3.
[4] Law MC, Baptiste S, Carswell A, McColl MA, Polatajko
H, Pollock N. The Canadian Occupational Performance
Measure (ed 3). Ottawa, ON: CAOT Publications; 1998.
[5] Cresswell MK, Rugg SA. The Canadian Occupational
Performance Measure: its use with clients with schizophrenia. British Journal of Therapy and Rehabilitation.
2003; 10(12): 544-53.

Asian J Occup Ther 18: 127−131, 2022

[6] Barlow DH, editor. Clinical handbook of psychologicaldisorders: A step-by-step treatment manual (5th ed.). New
York: Guilford Publications; 2014.
[7] Portney LG, Watkins MP. Foundations of clinical research: applications to practice (3rd ed.). Upper Saddle
River, NJ: Pearson/Prentice Hall; 2015.
[8] Bejerholm U, Eklund M. Occupational engagement inpersons with schizophrenia: Relationships to self-related

Kawaguchi T et al.

131variables, psychopathology, and quality of life. American
Journal of Occupational Therapy. 2017; 61(1): 21-32.
[9] Seberg M, Eriksson BG. Reablement in Mental HealthCare and the Role of the Occupational Therapist: A Qualitative Study. SAGE Open. 2018; 8(2).
[10] Kanfer FH, Karoly P. Self-control: A behavioristic excursion into the lion’s den. Behavior therapy. 1972; 3(3):398-416.

■ORIGINAL ARTICLE

Oculomotor Rehabilitation Program for a Patient with
Brain Injury in an Acute Care Hospital: A Single-Case
Experimental Design
Takayuki Watabe1, 2, Hisayoshi Suzuki2, Kunio Kabe1, 2, Shunya Hamabe1,
Mitsumasa Yoda3
1

Showa University Northern Yokohama Hospital, Rehabilitation Division
Showa University, School of Nursing and Rehabilitation Sciences, Department of Occupational Therapy
3
Showa University School of Medicine, Department of Rehabilitation Medicine
2

Abstract: Statement of the problem: We conducted a systematic review on oculomotor rehabilitation for patients withbrain injuries; however, an appropriate study design was not used and was inadequate for the evaluation of effect. Thus,in this study, we aimed to verify the benefits of our previously developed oculomotor rehabilitation program for patientswith brain injury hospitalized in an acute care hospital.
Methods: This report presents the case of a 50-year-old female patient hospitalized in an acute care hospital for disturbed consciousness and limb dysfunction due to subarachnoid hemorrhage and cerebral stroke. The patient showed
abducens nerve palsy of the right eye and right-sided gaze palsy. She received our oculomotor rehabilitation program.
An ABAB design was used: Phase A involved basic rehabilitation only, and Phase B involved basic rehabilitation plus
the oculomotor rehabilitation program. The program comprised training to promote pursuit, fixation, saccade, and vergence. Starting from day 40 of admission, the patient completed five 20-min sessions per week for 4 weeks forming
Phases A1, B1, A2, and B2. The oculomotor range of the right eye was measured during each phase.
Results: The patient did not exhibit fluctuation of vital signs or any adverse events following the oculomotor rehabilitation program. The mean expanded mobility ranges were 1.49 mm in Phase A and 4.91 mm in Phase B (p < 0.05).
Conclusion: Implementation of the oculomotor rehabilitation program promoted shortening of the extraocular muscles,
resulting in improvement of the oculomotor mobility range.
Keywords: oculomotor, rehabilitation, stroke, acute period(Asian J Occup Ther 18: 133−140, 2022)

Introduction
Oculomotor disorder is a serious disorder that
reduces the quality of life, as it causes double vision,
inhibition of gait and independent daily living, andcosmetic issues for patients [1]. Approximately 37%
of patients with oculomotor disorder experience someforms of ocular deviation as a result of brain injury [2];therefore, acute-phase hospitals encounter many stroke
Received: 14 May 2021, Accepted: 8 February 2022
Corresponding to: Takayuki Watabe, Showa University Northern
Yokohama Hospital, Rehabilitation Division, 35-1 Chigasaki-chuo,
Tshzuki-ku Yokohama-shi, Kanagawa, 224-8503 Japane-mail: taka1021@cmed.showa-u.ac.jp©2022 Japanese Association of Occupational Therapists

patients with oculomotor disorder. Although surgery has
been shown to be an effective treatment for oculomotor
disorder [3], it is highly invasive and many patients withthis disorder who are admitted to acute care hospitals
require monitoring, as one eye must be covered with apatch to block light. Covering the eye may help reduce
discomfort; however, a paralyzed eye may be overlooked [4], and disuse of the extraocular muscle may
affect the prognosis.
Recently, we conducted a systematic review on
oculomotor rehabilitation for patients with brain injuries[5], and based on the findings of the review and after
discussing with four experts (a neurologist, a rehabilitation specialist, a physiotherapist, and an occupational
therapist [mean duration of clinical experience, 30.5 ±0.5 years]), we developed a program that can be imple-

134

OCULOMOTOR REHABILITATION PROGRAM FOR STROKE

mented in rehabilitation hospitals for stroke patients [6].
In that report, we showed the efficacy of the programin a patient with left thalamic hemorrhage. The patient
did not undergo surgery, had stable status, and wasadmitted to the rehabilitation hospital. We assessed theeffect of the oculomotor rehabilitation program. However, an appropriate study design was not used and wasinadequate for the evaluation of effect. In addition, we
showed the efficacy of the program in subacute patients,
including those with subarachnoid hemorrhage [7]. In
that study, as for the subjects, time passes after the onset
or underwent surgery, therefore the state is stable. The
oculomotor rehabilitation program is not very invasive,
but it may be effective for a patient who admitted to anacute care hospital and underwent surgery. By using anappropriate study design, assessment of the effect of
the oculomotor rehabilitation program in brain injury
inpatients in an acute care hospital who had undergone
surgery seems to be significant. This single-case study
aimed to test the benefits of this oculomotor rehabilitation program for brain injury inpatients in an acute care
hospital using an ABAB design.

Methods
Participant
The participant was a 50-year-old, right-handed
female patient. She had a history of vertebral artery
dissection and is currently living with her husband andtwo daughters. She performed all housework. On presentation, she chiefly complained of double vision andwas urgently transported to our hospital due to a sudden-onset headache. Plain head computed tomography(CT) was performed on the day of onset, which showed
subarachnoid hemorrhage, and a diagnosis of subarachnoid hemorrhage due to rupture of vertebral artery
dissection was made. The patient remained oriented andcapable of communicating during transportation, but
her consciousness gradually declined (World Federationof Neurological Surgeons classification Grade V). Although no clear signs of limb paralysis were noticeable,
abducens nerve palsy of the right eye was observed. On
the day of admission, coil embolization was performed,
and the patient was placed on an artificial ventilator. On
day 2 of admission, she underwent ventricular drainage.
Head magnetic resonance imaging on day 3 revealed
elevated signals in the middle cerebellum, left cerebellar
hemisphere, and left side of the outer medullar oblongata (Figure 1a, b), indicating profound brain edema;
therefore, external decompression was performed on
the same day. From day 8, the patient initiated physiotherapy, occupational therapy, and speech and hearing
therapy. She was extubated on day 15 of admission andtransferred from the intensive care unit to the general
hospital ward. Normal-pressure hydrocephalus was
identified by plain head CT examination performedon day 30 of admission, and ventriculoperitoneal (VP)
shunt placement was performed on day 36. By this time,

Fig. 1. Radiography results that led to the diagnosis. (a) Plain head computed tomography scans taken on the day of
onset showing subarachnoid hemorrhage. (b) Diffusion-weighted head magnetic resonance image taken on
day 3 of admission showing elevated signals in the middle cerebellum and left cerebellar
hemisphere and on
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the left side of the outer medulla oblongata.

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the patient’s consciousness level had improved, and she
was capable of communicating. The oculomotor rehabilitation program was initiated on day 40 of admission.
Informed consent for inclusion in this case report was
obtained from the patient in writing.
Rehabilitation assessment
Neurological and neurophysiological findings
On day 8 of admission, when rehabilitation started,
the patient’s consciousness was extensively disturbed,
with a Glasgow Coma Scale (GCS) rating of eyes (E)of 1 point, verbal (V) intubated, and motor (M) scoreof 1 point, and she did not respond to stimulation. By
day 15 of admission, artificial ventilation was no longer
required, and the GCS rating had improved to E3, V2,
and M4 and to E4, V4, and M6 after VP shunt placement. Although her respiratory condition was stable, she
had remarkable sputum production requiring frequent
aspiration. She could maintain a bed-up seated position
for approximately 30 min without any changes to vital
signs, but experienced dizziness upon changing her head
position. The attending physician had instructed not tocompress the external decompression site of the left
occipital region and had prohibited extensive flexion of
the neck because of vertebral artery dissection.
On day 40 of admission, the patient was capable ofundergoing detailed neurological and neurophysiologicalassessment. Although the volume of her voice was low
and she appeared confused, she was capable of making
ordinary conversation. Her limbs were hypotonic andshowed strong proximal paralysis, with Brunnstrom
recovery stages of III–V–III for the right side and II–V–
II level for the left. Ataxia was noted in the left upperand lower limbs, as well as in the trunk. The presence ofsensory disorder was difficult to examine, and thermal
hypoalgesia of the right upper and lower limbs was
suspected. The patient exhibited profoundly impairedorientation; her Mini-Mental State Examination score
was 20 points. Routine activities required full assistance.
The bed-up sitting position could be maintained usingcushions, but both sitting and standing required fullassistance. The patient required tube feeding for meals,
had a balloon placed for urination, and used diapers fordefecation. All other self-care duties required full assistance.
Ocular motility disorder
Assessments were performed on day 40 of admission. When viewed from the front, the right eye showedstrabismus. There was no vertical deviation. Covering
one eye and evaluating the horizontal ocular motility
revealed remarkable restriction of the abduction of theright eye. With binocular vision, we identified conjugate

Watabe T et al.

135

deviation to the left and gaze palsy toward the right. The
possible duration of gaze toward the right was approximately 1 s, and nystagmus was evident. Pursuit was
relatively smooth, with no overshoot or undershoot, andthe convergence reflex was maintained. Diplopia wasobserved in all directions, and the patient complained ofstrong discomfort.
Oculomotor rehabilitation program
In our previous systematic review [5], we highlighted the utility of pursuit, fixation, saccade, andvergence exercises performed for 20-60 min per day,
2-6 times per week, for 3-10 weeks. The rehabilitation
program that was developed from these findings can be
performed at bedside, without the need to establish a
special environment [6]. During training, the patient wasplaced in the supine or bed-up sitting position, and theillumination of the room was bright. A therapist presented a target object 30 cm in front of the patient and asked
the patient to follow these steps: 1) Perform three sets of
pursuit motions by following the object in all eight directions with the eyes at a speed at which the patient can(pursuit); 2) perform three sets of fixing the gaze for 10
s at the limit of the mobility range of the eye in all eight
directions (fixation); 3) perform three sets of holding thetarget object that serves as a marker outside the patient’s
field of view and, then, rapidly bring it to above her
face into her field of view to attract the gaze as it moves
in eight directions randomly (saccade); and 4) perform
three sets of following the object as it is moved slowly
toward the patient 10 times to induce convergence(vergence). The tasks were performed with the right eye
closed, left eye closed, and with binocular vision, so as
to prevent symptoms that tend to appear, which would
mask the paralyzed eye. Each session lasted 20 min, andpatients attended six sessions per week for a total of 8
weeks. They were allowed to rest if fatigue or dizziness
was experienced during training and to massage thearea around the eyes if needed. For the present case, we
modified the program and used five 20-min sessions for
1 week to evaluate the utility of the program for patients
hospitalized in acute care hospitals (Figure 2).
Study design
Our participant was in the acute phase; therefore,
oculomotor spontaneous recovery was more likely to becaused. We used an ABAB design to inspect the effectof this program. Phase A involved basic rehabilitation
only, and Phase B involved the oculomotor rehabilitation program in addition to basic rehabilitation. Basicrehabilitation comprised lower-limb function training
and sitting/standing training, which were performed
during physiotherapy. Upper-limb function training and136

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ting position, and the therapist presented the target object to promote pursuit, fixation, saccade, and vergence of theeyes. Each session lasted 20 min. The patient was allowed to massage around the eyes as needed and to rest during
SURPRWHSXUVXLWIL[DWLRQVDFFDGHDQGYHUJHQFHRIWKHH\HV(DFKVHVVLRQODVWHGPLQ7KH
training whenever dizziness or eye fatigue was experienced. This figure was adapted from Watabe et al. [6]SDWLHQW ZDV DOORZHG WR PDVVDJH DURXQG WKH H\HV DV QHHGHG DQG WR UHVW GXULQJ WUDLQLQJZKHQHYHUGL]]LQHVVRUH\HIDWLJXHZDVH[SHULHQFHG7KLVILJXUHZDVDGDSWHGIURP:DWDEHHW
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Fig. 3. Measurement of the abduction range of the eye. The abduction range

was definedas theWKH
distance
fromH\HOLG
the innerWReyelidthe insidemargin RI WKH SXSLO GXULQJ PD[LPXP
DV WKH GLVWDQFH
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of the pupil during maximum abduction of the eye. Footage recorded

DEGXFWLRQRIWKHH\H)RRWDJHUHFRUGHGXVLQJDYLGHRFDPHUDZDVDQDO\]HGXVLQJWKH+$6
using a video camera was analyzed using the HAS-XViewer software(DITECT Co., Ltd.) to calculate the abduction range.

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Asian J Occup Ther 18: 133−140, 2022

daily-life movement training were performed during
occupational therapy. Communication and swallowing
training were performed during speech and hearing
therapy. Each therapy was performed for 20 min per
day for five times per week. The exercises presented in
Figure 2 were performed during oculomotor rehabilitation training for 20 min per day with breaks in between
for five times a week. Each phase lasted 1 week, and theprogram continued for a total of 4 weeks from day 41 ofadmission, through A1, B1, A2, and B2. Ocular motility
and range of right-eye motility were evaluated during
each intervention.
The ocular motility analysis software HAS-XViewer (DITECT Co., Ltd., Tokyo, Japan) was used tomeasure the range of ocular motility. In this study, we
analyzed the abduction range of the right eye, whichshowed the greatest level of impairment, by filming theright eye during maximum abduction movement using a
30-fps video camera (Sony Corp., Tokyo, Japan). Filming was conducted as follows: 1) placing a video camera
50 cm in front of the patient’s face; 2) placing a pillow
under the patient’s head in a bed-up position, 70° sitting
position; 3) fixing the patient’s head and neck; and 4)

Watabe T et al.

137

slowly moving the target object left and right in frontof the patient and instructing her to follow the object
with her eyes. The steps were repeated to take threemeasurements. Recorded footage was analyzed using
the HAS-XViewer software, and the mean result of thethree measurements was used for the analysis. The abduction range was defined as the distance from the inner
eyelid to the inside margin of the pupil during maximum
abduction (Figure 3).
The abduction range of the right eye was measured
before and immediately after the first intervention. In
addition, we determined the celeration lines of Phases
A1 and A2 using central partitioning and, then, extended
them to Phases B1 and B2, respectively. In Phases B1
and B2, the upper numbers of the extended celerationlines were examined by binomial distribution. The significance level was set at p <0.05.

Results
The patient did not exhibit fluctuation of vital signs
or any adverse events, such as exacerbation of dizzinessfollowing the oculomotor rehabilitation program. All

Fig. )LJXUH$EGXFWLRQUDQJHLQUHODWLRQWRWKHSKDVHRIWKHSURJUDP7KHDEGXFWLRQUDQJHVRI
4. Abduction range in relation to the phase of the program. The abduction ranges of the right eye were 11.76 mm before Phase
A1, 12.53 mm before Phase B1, 17.16 mm before Phase A2, 19.37 mm before Phase B2, and 24.55 mm immediately after
WKHULJKWH\HZHUHPPEHIRUH3KDVH$PPEHIRUH3KDVH%PPEHIRUH
Phase B2. The mean expansions of the abduction range were 1.49 mm in Phase A and 4.91 mm in Phase B. Comparison
with the extended celeration line and examination by binomial distribution reveals that the ocular motility range expanded
3KDVH$PPEHIRUH3KDVH%DQGPPLPPHGLDWHO\DIWHU3KDVH%7KHPHDQ
more when the patient engaged in the oculomotor rehabilitation program than when she did not (p < 0.05).

H[SDQVLRQV RI WKH DEGXFWLRQ UDQJH ZHUH  PP LQ 3KDVH $ DQG  PP LQ 3KDVH %

&RPSDULVRQ ZLWK WKH H[WHQGHG FHOHUDWLRQ OLQH DQG H[DPLQDWLRQ E\ ELQRPLDO GLVWULEXWLRQUHYHDOV WKDW WKH RFXODU PRWLOLW\ UDQJH H[SDQGHG PRUH ZKHQ WKH SDWLHQW HQJDJHG LQ WKH138

OCULOMOTOR REHABILITATION PROGRAM FOR STROKE

scheduled sessions were completed. The abduction
ranges of the right eye were 11.76 mm before Phase
A1, 12.53 mm before Phase B1 (PreB1), 15.74 mm
immediately after the first oculomotor rehabilitation
session, 17.16 mm before Phase A2, 19.37 mm before
Phase B2, and 24.55 mm after Phase B2. The abduction
range increased by 3.21 mm after the first oculomotor
rehabilitation session in PreB1. The mean expansionsof the abduction range in Phases A and B were 1.49 and4.91 mm, respectively. The upper numbers of Phase B
were compared using the extended celeration line withbinomial distribution and revealed that the ocular motility range expanded more in Phases B1 and B2 (i.e., when
the oculomotor rehabilitation program was included)
than in Phases A1 and A2 (i.e., when only basic rehabilitation was completed) (p <0.05) (Figure 4). With respect
to the ocular motility at the end of Phase B2, whenobserved from the front, the strabismus and abduction
range of the right eye improved. During joint movementof both eyes (binocular vision), we observed that thegaze palsy toward the right had improved and the patientwas capable of maintaining the gaze toward the right for
10 s. Diplopia disappeared in the frontal view, with only
slight diplopia remaining during rightward gaze (Figure5). The patient reported that the double vision had disappeared and there was less discomfort.

Discussion
Mechanism underlying the oculomotor disorder
In addition to the subarachnoid hemorrhage causedby the rupture of the vertebral artery, this patient had
infarct lesions from the middle cerebellum to the left
hemisphere and in the left side of the outer medulla
oblongata. Subarachnoid hemorrhage in the vertebral
artery region has been reported to be associated with
abducens nerve palsy [8,9]. As this patient had exhibited
abducens nerve palsy toward the right even before theonset of cerebral infarction, we believe that the abducens nerve had been compressed by a hematoma in thevertebral artery region. Conjugate deviation to the left
was not consistent with the patient’s lesion (which wason the left side). Horizontal gaze paralysis is caused byinjury to the paramedian pontine reticular formation(PPRF), which is located at the back of the pons [10].
We hypothesized that the patient had experienced temporary circulatory disturbance to the back of the ponsdue to compression caused by the hematoma from thesubarachnoid hemorrhage, brain edema, compression of
the back of the pons by normal-pressure hydrocephalus,
or a combination of these, which led to the horizontal
gaze paralysis. No other symptoms, such as smooth
pursuit disorder caused by injuries to the cerebellar
hemisphere, skew deviation, or ocular lateropulsion due
to damage of the medullar oblongata, were observed.
Based on the aforementioned, we predicted that the oculomotor disorder would improve with aspiration of thehematoma and consequent improvement of the impaired
circulation.
We considered that one-eye masking and compensatory approaches could promote the shortening anddisuse of the extraocular muscle and inhibit the recoveryFig. 5. Improvement in abduction due to the pro- gram. Prior to the intervention, we observed remarkable)LJXUH ,PSURYHPHQWLQ DEGXFWLRQWKHSURJUDPWRweWKHLQWHUYHQWLRQ
restrictionof abductionof the right GXHeye. WR
Whenbinocular
vision 3ULRU
was used,
identified
conjugate ZH

deviation to the left and gaze palsy toward the right. Diplopia was observed in all directions. After the
REVHUYHGUHPDUNDEOHUHVWULFWLRQRIDEGXFWLRQRIWKHULJKWH\H:KHQELQRFXODUYLVLRQZDVXVHG
program, the strabismus and abduction range of the right eye improved when observed from the front.

During joint movement of both eyes (binocular vision), the gaze palsy toward the right has improved and
ZHLGHQWLILHGFRQMXJDWHGHYLDWLRQWRWKHOHIWDQGJD]HSDOV\WRZDUGWKHULJKW'LSORSLDZDV
the patient is capable of maintaining the gaze toward the right for 10 s. Diplopia has disappeared in the

REVHUYHGLQDOOGLUHFWLRQV$IWHUWKHSURJUDPWKHVWUDELVPXVDQGDEGXFWLRQUDQJHRIWKHULJKW
frontal view, with only slight diplopia remain- ing during rightward gaze. Pre A1, before Phase A1; Post

B2, after Phase B2.
H\HLPSURYHGZKHQREVHUYHGIURPWKHIURQW'XULQJMRLQWPRYHPHQWRIERWKH\HVELQRFXODUYLVLRQ WKHJD]HSDOV\WRZDUGWKHULJKWKDVLPSURYHGDQGWKHSDWLHQWLVFDSDEOHRIPDLQWDLQLQJWKH JD]HWRZDUGWKH ULJKW IRU V 'LSORSLDKDV GLVDSSHDUHG LQWKH IURQWDOYLHZZLWK RQO\VOLJKW GLSORSLD UHPDLQLQJ GXULQJ ULJKWZDUG JD]H 3UH $ EHIRUH 3KDVH $ 3RVW % DIWHU

Asian J Occup Ther 18: 133−140, 2022

process. Therefore, we planned proactive treatment of
the oculomotor disorder to prevent secondary irreversible changes due to disuse and improve the patient’s
symptoms. Oculomotor disorder improved after 4 weeks
of intervention, confirming our hypothesis and the appropriateness of the treatment.
Characteristics of the oculomotor rehabilitation program
Our previous review [5] identified nine reports on
the benefits of the oculomotor rehabilitation programin multiple patients; however, only three randomized
controlled trials have described the effects of interventions involving computer programs. Despite the large
number of patients who experience oculomotor disorder,
research performed to date has been insufficient to develop rehabilitation programs for this condition.
The oculomotor rehabilitation program that wedeveloped is novel and does not require special tools or
skills. Similar to general mobility range training for thelimbs, the program primarily involves pursuit and fixation work, which are expected to prevent muscle atrophyin the direction of movement and prevent shortening of
the antagonistic muscle, as well as saccade to cope withsudden changes in the line of sight and vergence, which
trains the reflexes. This is the same for one-eye-masked
training, not just binocular vision. Once a patient has
adapted to a certain level to oculomotor disorder,
symptoms tend to appear, which mask the paralyzed eye[4]. Therefore, it is necessary to prevent disuse of theparalyzed eye by carrying out training while the healthy
eye is covered, rather than training with binocular visionalone.
As the intervention described in this report is conducted with the patient in the supine or bed-up sitting
position for 20 min, this program can be applied toacute-phase patients with low tolerability. While adverse
events of eye fatigue and dizziness are possible, ourpatient could complete the program without presenting such symptoms. This finding provides significant
evidence concerning the efficacy of the performed
eye-movement rehabilitation program.
In cases with direct injury to oculomotor centers,such as the horizontal oculomotor center of the PPRF
and medial longitudinal fasciculus [10], or vertical oculomotor centers, such as the rostral interstitial nucleusof the medial longitudinal fasciculus in the midbrain
reticular formation [11], a robust treatment to promote
nerve reorganization is needed. Nevertheless, the20-min intervention of the current program may not be
sufficient to achieve clinical improvement in such cases.
Our rehabilitation program was applied to a single patient. This was a limitation of the present study. Futurestudies examining the applicability of this oculomotor

Watabe T et al.

139

rehabilitation program should include a larger numberof patients in an acute phase.
To our knowledge, no study has yet reported on theuse of this oculomotor rehabilitation program for brain
injury patients hospitalized in an acute care hospitalwhere they had just undergone surgery and had low endurance. Thus, we believe that this program is safe andeasy to implement in clinical practice and applicable toother patients. Examination of the lesion led us to expectthat the present patient would achieve full recovery, andpreventing disuse of the extraocular muscle—which
would have led to its shortening or atrophy—produced
favorable results.

Acknowledgments
This study was conducted with the aid of the Showa
University Research Grant for Young Researchers.

Ethics approval
This study was conducted with the approval of the
Ethics Committee of the School of Nursing and Rehabilitation Sciences, Showa University (Approval No.
477). Furthermore, the patient and her family members
provided consent to the study and reporting the case.

Conflict of interest
The authors have no conflicts of interest directly
relevant to the content of this article.

References[1] Wagener SG, Kreiger R. Participation and quality of life
for persons with oculomotor impairments after acquired
brain injury (ABI). Br J Occup Ther. 2019; 82(8): 47584.
[2] Fowler MS, Wade DT, Richardson AJ, Stein JF. Squints
and diplopia seen after brain damage. J Neurol. 1996;
243(1): 86-90.
[3] Beauchamp GR, Black BC, Coats DK, Enzenauer RW,
Hutchinson AK, Saunders RA, et al. The managementof strabismus in adults—I. Clinical characteristics andtreatment. J AAPOS. 2003; 7(4): 233-40.
[4] Jampolsky A. Characteristics of suppression in strabismus. AMA Arch Ophthalmol. 1955; 54(5): 683-96.
[5] Watabe T, Suzuki H, Abe M, Sasaki S, Nagashima J,
Kawate N. Systematic review of visual rehabilitation interventions for oculomotor deficits in patients with brain
injury. Brain Inj. 2019; 33(13-14): 1592-6.
[6] Watabe T, Suzuki H, Sasaki S, Sako R, Ozasa Y, Nagashima J, et al. Efficacy of a new oculomotor rehabilitation
program in a brain injury patient. J Rehabil Neurosc.

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OCULOMOTOR REHABILITATION PROGRAM FOR STROKE

2020; 20(1): 7-12.
[7] Watabe T, Suzuki H, Sako R, Abe M, Aoki K, Yoda
M. Effect of an oculomotor rehabilitation program for
subacute brain injury patients with ophthalmoplegia: A
case-control study. Disabil Rehabil. 2021; 1-7, in press.
[8] Furtado SV, Mohan D, Hegde AS. Ophthalmic segment
aneurysmal subarachnoid hemorrhage presenting with
contralateral abducens nerve palsy: a false localizing
sign. Optometry. 2010; 81(9): 450-3.
[9] Munakata A, Ohkuma H, Nakano T, Shimamura N.
Abducens nerve pareses associated with aneurysmal sub-arachnoid hemorrhage. Incidence and clinical features.
Cerebrovasc Dis. 2007; 24(6): 516-9.
[10] Leigh RJ, Zee DS. Diagnosis of Central Disorders ofOcular Mobility. In: Leigh RJ, Zee DS, editors. The Neurology of Eye Movement, 5th ed. Philadelphia: FA Davis
Company; 1982; 219-25.
[11] Büttner-Ennever JA, Büttner U, Cohen B, Baumgartner G.
Vertical gaze paralysis and the rostral interstitial nucleusof the medial longitudinal fasciculus. Brain. 1982; 105(Pt
1): 125-49.

■RAPID COMMUNICATIONSPracticality of Using a Ladle for Sock Folding in
Hemiplegic Patients
Natsumi Atomura1, Teppei Sasaki2, Makiko Izumi3, Naoto Horikirigawa3,
Takaki Kafuku3
1

Ota Hospital
Yokohama Tsurumi Rehabilitation Hospital
3
Tohoku Medical School
2

Abstract: Purpose: Folding socks can be difficult for patients who rely on only one hand. We hypothesized thatthrough the following procedure, patients could easily fold their socks even with just one hand. First, place the roundedpart of a ladle between the leg and the chair. Then, stack the pair of socks on top of each other. Put your finger throughthe opening of the upper sock and hold up the lower sock. Finally, place the sock on the tip of the handle, and pull yourfingers down. The aim of this study was to compare how hemiplegic patients fold socks using the flip and tuck method
through the folding motion with and without a ladle, to demonstrate the effectiveness of this technique in folding socks.
Method: Forty hemiplegic patients participated in this study. After being instructed on how to fold a sock with andwithout a ladle, participants performed the folding motion using the flip and tuck method with one hand. After the experiment, it was determined whether the participants had successfully folded the socks, and the ease of folding was subjectively evaluated. Moreover, the folding time was measured using the captured video footage.
Results: When the ladle was used, all participants succeeded in folding the socks. The motion was easier and the folding time was significantly shorter when using a ladle than when not using a ladle.
Discussion: Using a ladle to fold socks is a practical method for hemiplegic patients.
Keywords: sock folding, hemiplegia, ladle(Asian J Occup Ther 18: 141−145, 2022)

1. Introduction
There are several ways of folding socks, including
the square, single-fold, roll, military, fold and tuck, andflip and tuck methods [1]. Among these, the flip andtuck method, which folds back only the elastic grip
part of the cuff, is considered a quick and easy way to
combine a pair of socks [2]. The flip and tuck method
is performed as follows. First, lay both socks on a flat
surface with one sock on top of the other. Then, holdone cuff and flip it inside out while tucking both socks
approximately halfway into the cuff [1]. The flip andtuck method is a two-handed maneuver, which can affectthe daily lives of patients, such as those diagnosed with
Received: 19 July 2021, Accepted: 8 February 2022
Corresponding to: Natsumi Atomura, Ohta Hospital, 4-4-14 Omorihigashi, Ota-ku, Tokyo, 143-0012, Japane-mail: takakafu@rinken.ac.jp©2022 Japanese Association of Occupational Therapists

orthopedic diseases or hemiplegia, who have to relyon using just one of their upper extremities. Althoughfolding socks with one hand is possible, learning thetechnique requires repeated practice. Furthermore, as
we have shown, some patients are unable to learn thetechnique even with practice. Hence, we considered how
everyday objects could be used to make folding socks
easier. We hypothesized that with the following novel
method, patients would easily be able to fold their socks
even with just one hand. First, place the rounded part ofa ladle, [3], between the thigh and surface of the seat.
Then, stack the pair of socks on top of each other. Put
your finger through the opening of the upper sock andhold up the lower sock. Finally, place the sock on the tipof the handle, and pull your fingers down.
The aim of this study was to compare the sockfolding motions (folding motions) of hemiplegic patients using the flip and tuck method, both with (folding
motion with a ladle) and without (folding motion without a ladle) a ladle, to demonstrate the effectiveness of142

UTILITY OF LADLE IN FOLDING SOCKS

utilizing this method for folding socks.

2. Methods
Participants
Forty patients with hemiplegia due to cerebral infarction or cerebral hemorrhage (20 men and 20 women,
including 10 men paralyzed on their left side, 10 men
paralyzed on their right side, 10 women paralyzed on
their left side, and 10 women paralyzed on their rightside) participated in this study. The mean age was
73 ± 11 (range, 48–91) years. Intelligence was tested
using the Revised Hasegawa’s Dementia Scale [4].
The median score of the participants was 26/30 (range,
16–30 points). All participants were in the chronic phaseof their illness, regularly used daycare facilities, and had
no experience of folding socks following the onset of
their medical condition.
This study was approved by the Ethics Committeeof Tohoku Medical School (approval number 373; approval date, February 18, 2021) in accordance with the
Declaration of Helsinki. Written consent was obtained
from all the participants after providing a detailed explanation of the study.
Equipment
The experiment was performed in a seated position, and the seat surface was set at a height where theparticipant’s hip and knee joints bent at 90°. A regular,commercially available ladle was used (Fig. 1) andplaced on the seat surface on the non-paralyzed sideof the patients. Ankle-length socks were placed on the
non-paralyzed thigh.
The folding motion was captured using myoVIDEO(NORAXON USA Inc., Scottsdale, Arizona, USA) at 30
frames per second with a webcam (c920r, Logitech Co.
Ltd., Lausanne, Switzerland) from two directions (fromFig. 1. Ladle used

the non-paralyzed side and the front) and was simultaneously recorded. The video footage was analyzed.
Folding instructions provided to participants
The procedure using the ladle is shown in Fig. 2(a). Hold the ladle that is placed on the seat surface andposition the rounded part between the thigh and seat (1)(2). Put your fingers in the opening of the sock (3). Holdthe sock at the bottom (4). Cover the tip of the handle ofthe ladle with the center part of the sock you are holding(5). Finally, lower your fingers and turn the rubber part
inside out (6)–(8).
The procedure without the use of a ladle is shownin Fig. 2 (b). Put your finger in the opening of the sock (1)(2). Hold the sock at the bottom (3). Turn it inside out
and press it against the thigh (4). Finally, while pressing
against the thigh, turn the rubber part inside out gradually (5)–(8).
Procedure
After the participants were taught how to foldsocks both with and without a ladle, they were allowed
to practice until they were satisfied. Subsequently, they
were instructed to perform the folding movements using
the flip and tuck method using only their non-paralyzed
hand.
After the experiment, it was determined whether theparticipants successfully folded the socks, and the easeof folding was subjectively evaluated. The folding time
was then measured using the captured video footage.
Analysis
Success or failure of folding socks
The finished state after folding with and without aladle was compared. Cases where the folded socks wereplaced on a desk and one of the sock toes could be lifted
without separating the left or right of the pair of socks

Asian J Occup Ther 18: 141−145, 2022

Atomura N et al.

143

Fig. 2. Folding procedure
The figure shows the folding procedure using the right hand. The upper row (a) shows folding with a ladle, and thelower row (b) shows folding without a ladle. When using one’s left hand, place the ladle on the outside of the left thigh,and follow the same procedure as that for the right hand. The numbers in the figure correspond to those in the text.

were deemed a success, whereas cases where the left
and right socks were separated were regarded as a failure. The success rate was analyzed using the chi-squared
test with a significance level of 5% or less.
Subjective evaluation of ease of folding
Participants evaluated the ease of folding on threescales: whether it was easier to fold the socks with aladle, whether it was the same as without, and whether it
was more difficult. Participants were also asked whether
they experienced pain or discomfort when using theladle.
Comparison of folding time
When a ladle was used, the time from when theparticipants touched the ladle to when they turned thesocks inside out was measured. Accordingly, when aladle was not used, the time from when the participants
touched the socks to when they turned them inside out
was measured. The recorded times were then compared.
A Wilcoxon signed-rank test was used for statistical processing, and the significance level was set to less than
5%. Participants who failed to fold socks were excluded
from the comparison.

3. Results
Success or failure of folding socks
Table 1 shows the participants’ success or failure

in folding the socks. All participants succeeded whena ladle was used. Fifteen participants (eight with leftside hemiplegia and seven with right-side hemiplegia)
failed when a ladle was not used. Of the 15 unsuccessful
individuals, 6 had the dominant hand on the paralyzed
side and 9 had the nondominant hand on the paralyzed
side. The success rate was significantly higher whenparticipants used the ladle than when they did not (p <.01).
Subjective evaluation of ease of folding
Thirty-five participants stated that using a ladle
was easier when folding the socks, three participants
expressed that it was the same with or without a ladle,
and two participants said that it was more difficult touse a ladle. Hence, 87.5% of the participants stated thatfolding with a ladle was easier than folding without aladle. No participant complained of pain or discomfort
due to using the ladle.
Comparison of folding time
Data from 25 participants were used for thecomparison. Table 1 shows the median folding times(interquartile ranges). The median times when using andwhen not using a ladle were 11.1 (9.3–14.2) and 18.1
(13.6–22.9) seconds, respectively. Using a ladle resulted
in significantly faster folding times than without using aladle (p < .01).
Moreover, the median times when using and not

144

UTILITY OF LADLE IN FOLDING SOCKS

Table 1. Success or failure of folding socks and folding time
With a ladle

Without a ladle

p value

Success

40

25

<.01

Failure0

15

Folding time (seconds)

11.1 (9.3-14.2)

18.1 (13.6-22.9)

Success or failure of folding socks<.01

Folding time is expressed in terms of median (interquartile range)

using a ladle for participants who failed to fold socks
were 13.5 (12.9–16.4) and 27.3 (19.1‐35.4) seconds,
respectively.

4. Discussion
In this study, folding socks with and without a ladleusing one hand was compared. Participants were able
to successfully fold the socks with a ladle, the task waseasier, and took significantly less time when using aladle than when not using a ladle. These results suggestthat folding socks using a ladle is more practical forhemiplegic patients.
To turn the elastic part of the socks inside out
without using a ladle, the elastic part must be graduallyturned over while pressing the socks against the thigh(Fig. 2b). In contrast, when a ladle is used, the elastic
part of the socks is turned over all at once by placing thesock on the handle of the ladle and then pulling it downwith the fingers (Fig. 2a). Thus, to fully turn over theelastic part of the socks, it is necessary to repeatedly turnover the section incrementally while pressing against thethigh when a ladle is not used, whereas when a ladle isused, one’s fingers are used to pull down the elastic partall at once. Thus, no repeated action is needed. It is presumed that when a ladle was used, the time required tocomplete the task was shortened because there were no
repeated actions. In addition, an extended time suggests
an increased difficulty in an action [5]. Hence, the factthat using a ladle resulted in a shorter folding time thanwhen it was not used suggests that folding with a ladleis less difficult. Therefore, as the difficulty level whena ladle was used was low, there were no failures, andthis resulted in the subjective evaluation that the method
made folding the socks easier.
To fold socks with the flip and tuck method using
both hands, the following procedure can be performed.
First, both the left and right socks are stacked on top ofeach other. Then, both thumbs are placed in one of thesock openings. Then, using one’s index, middle, and ring
fingers as support, the elastic part is turned inside out
by turning one’s thumbs outward [6]. In this way, whenfolding socks with the flip and tuck method, the folding
motion becomes easier when a form of physical support
is used. When the socks were folded with a ladle, the tipof the handle acted as this support, suggesting that thismethod made it easier for participants to turn the socks
inside out because of the support. Furthermore, because
the ladle is inserted in a fixed position between the thighand seat surface, the support provided by the ladle does
not move. Therefore, it is presumed that the openings ofthe socks could be turned inside out all at once when aladle was used.
Limitations and Future Directions
The participants in this study were limited topatients with chronic hemiplegia who were eligible toattend daycare facilities. In addition, hemiplegic patientswith severe brain dysfunction were excluded. Therefore,
it is unclear whether this method has a similar efficacy
in patients in the acute phase or with severe higher brain
dysfunction. Using this method of folding may also
be effective for patients who have to rely on only one
side of their upper body because of orthopedic disease.
The ladle used in this study was metal. Whether the
results would likely be similar with a plastic, silicone,or wooden ladle, has not yet been verified. In the future,
it will be necessary to test this method on patients withother conditions, such as acute hemiplegia, higher brain
dysfunction, or orthopedic disease, and ladles made ofdifferent materials.
In this study, a part of the sock washing process
was studied. However, as an activity during daily life, it
is crucial to focus on the entire sock washing process inthe future.

5. Summary and Conclusions
Hemiplegic patients were instructed to fold socks
both with and without a ladle. Subsequently, whether
the participants successfully folded the socks wasdetermined, and the ease of folding was subjectively
evaluated. Furthermore, the time required to complete
the task when the ladle was and was not used was com-Asian J Occup Ther 18: 141−145, 2022

pared. When a ladle was used to fold the socks, all theparticipants were successful, the task was easier, and thetime required was greatly reduced. In this way, these experimental results show the practicality of folding socks
using a ladle.

Conflict of Interest
There are no conflicts of interest to declare.

Acknowledgments
I would like to sincerely thank all the participantsin this study.

References[1] 6 Ways to Fold Socks [online]. Goldia Socks [cited 2021
March 7]. Available from: https://goldiesocks.com/blogs/

Atomura N et al.

145

news/6-ways-to-fold-socks[2] How to Fold Socks [online]. Organized 31 [cited 2021
March 7]. Available from: https://organized31.com/foldsocks/[3] Ladle [online]. RecipeTips [cited 2021 March 12]. Available from: https://www.recipetips.com/glossary-term/t-38236/ladle.asp[4] Imai Y, Hasegawa K. The Revised Hasegawa’s Dementia
Scale (HDS-R) evaluation of its usefulness as a screening test for dementia. J Hong Kong Coll Psychiatry.
1994;4:20-4.
[5] Sakamoto Y, Taniguchi T, Nagao T, Higashi T. Operation
time by handedness and non-handedness in works with
degree of difficulty differences. Ability of non-handedness and handedness (in Japanese). Bulletin of the Schoolof Allied Medical Science, Nagasaki University. 1994; 8:
93-5.
[6] How To Bundle Socks The Fast Way [online]. YouTube[cited 2021 June 22]. Available from: https://www.youtube.com/watch?v=nOwXrcd-z2E

■ORIGINAL ARTICLE

Influences of the Coronavirus Disease (COVID-19)
Pandemic on Occupational Therapy:
A Content Analysis of Long-Term Care Insurance
Service Facilities in Hokkaido
Kazuki Yokoyama, Hidekazu Saito, Takafumi Morimoto,Hisaaki Ota, Nozomu Ikeda
Department of Occupational Therapy, School of Health Sciences, Sapporo Medical University

Abstract: Objective: This study aimed to clarify the influence of the coronavirus disease (COVID-19) pandemic on
occupational therapy (OT), including changes in assessment and treatment, along with other restrictions and measuresin long-term care insurance service facilities.
Methods: We conducted a questionnaire survey from representatives of OT departments in long-term care insurance
service facilities in Hokkaido and obtained responses from 89 participants.
Results: More than half of the facilities remained unchanged in their assessments and treatments following the firstemergency declaration, after which their responses gradually decreased. As for the content of assessment, there wereincreased needs, such as body temperature, health condition, and physical/cognitive changes due to disuse syndrome,
while reduced opportunities were available to assess in areas, such as home environment, mobility outdoors, and instrumental activities of daily living outdoors. As for the content of treatment, while outings and group training had been
discontinued, prevention of disuse syndrome had been added. The treatment also incorporated changes in methods, suchas fixing the location and time. Restrictions related to OT were reported, including client participation, OT operations,and discontinuation of services. On the other hand, measures related to OT, such as thorough standard precautions,management of health conditions of the clients and housemates, and infection control measures by occupational therapists, were also mentioned.
Conclusions: Despite various restrictions, OT was provided by thoroughly implementing standard precautions, managing the physical conditions of the clients and housemates, providing new means of participant support and infection
control for the influences of the COVID-19 pandemic.
Keywords: COVID-19, occupational therapy, combating infectious diseases, content analysis, long-term care insurance service(Asian J Occup Ther 18: 147−155, 2022)

1. Introduction
Coronavirus disease (COVID-19) is caused bysevere acute respiratory syndrome coronavirus 2(SARS-CoV-2), and it was first reported by the World
Health Organization (WHO) in December 2019 following a report of a cluster of “viral pneumonia” cases in
Wuhan, China [1]. Thereafter, the number of infected
persons and related deaths increased worldwide. The

Received: 31 May 2021, Accepted: 8 February 2022
Corresponding to: Kazuki Yokoyama, South-1, West-17, Chuo-ku
Sapporo, Hokkaido, Japane-mail: k.yokoyama@sapmed.ac.jp©2022 Japanese Association of Occupational Therapists

WHO stated that COVID-19 could be characterized asa pandemic because of being deeply concerned both by
the alarming levels of spread/severity and inaction [2].
In Japan, the first case of COVID-19 was confirmed on
January 16, 2020. By December 27, 2020, Polymerase
Chain Reaction testing had confirmed positive viralserology for 217,312 people and 3,213 deaths had beenreported [3]. In particular, Hokkaido, the largest andnorthernmost prefecture, has seen a widespread increase
in COVID-19 incidence since the early stages of the disease due to transmissions among immigrating tourists,
mass infections at events, and problems with the urban
structure, such as people from various regions gatheringin large cities and dispersing to different regions [4][5]. Hokkaido’s first local emergency declaration ended

148

INFLUENCES OF COVID-19 PANDEMIC ON OT IN LONG-TERM CARE INSURANCE SERVICES

on March 19, 2020, and this was followed by a temporary decrease in the number of infected people [6][7].
However, on April 16, 2020, the Tokyo metropolitan,
Osaka, and surrounding areas were found to be infection
hotspots. There was a subsequent rapid increase in
the number of infected people nationwide; therefore,
the government declared a state of emergency, which
continued until May 25, 2020 in Hokkaido [6][7]. The
pandemic is still ongoing, and the situation remains
unpredictable.
The COVID-19 pandemic has had a profoundinfluence on rehabilitation, including occupational
therapy (OT). The Japanese Association of Occupational
Therapists has published an article titled “COVID-19
Infection Control/Occupational Therapy Work” [8].
According to this, practicing hand hygiene, use of protective equipment, and others are categorized as “Basics
of infection control in OT,” and places at risk of being
closed, densely populated, and compact, such as staff
rooms, OT visiting areas, and spaces for group activities(recreation, exercise, and calisthenics) are enlisted. It
has provided with tailored preventive strategies provided under “Specific measures in COVID-19 infection
control.”
Previous studies have shown that older adults areat a higher risk of poor prognosis and fatality fromCOVID-19 [9][10]. Older adults living in long-termcare facilities comprise 79% of the COVID-19 death tollin Canada [11]. Predictive factors of mortality amongolder adults with COVID-19 were premorbid activities
of daily living (ADL) impairment, comorbidity, and increased C-reactive protein levels [12]. Therefore, clients
being rehabilitated in long-term care insurance facilities
are at risk of severe outcomes of COVID-19. Furthermore, therapists must pay close attention to the client’s
condition and ensure infection control.
There are no specific protocols for infection control
in OT practice in long-term care insurance service facilities. In addition, few studies have comprehensively
examined what restrictions and measures were taken in
actual settings where OT was provided. It is necessary
to accumulate information provided by various sites
regarding OT and to consider the measures according
to the changing situation of COVID-19. In Hokkaido,
a state of emergency was declared twice, (February
28 to March 19, 2020; April 12 to May 25, 2020), andmeasures against infectious diseases were undertaken tocombat the evolving situation from an early stage. The
purpose of this study was to clarify the influences of
COVID-19 on OT in long-term care insurance facilities
in Hokkaido, focusing on changes in the contents of assessment and treatment, as well as other restrictions andmeasures.

2. Materials and Subjects
2.1. Research design
This was a cross-sectional study conducted using a
postal questionnaire survey method.
2.2. Participants
The participants were representatives of OT departments from 725 facilities in Hokkaido belonging tomembers of the Japanese Association of Occupational
Therapists in the fields of medical care, long-term care,and welfare for the disabled.
A list of facilities with occupational therapists wascreated using the list of facilities of the Japanese Association of Occupational Therapists, with permission foruse.
2.3. Data collection
The questionnaire was mailed to the representativesof the OT department of the target facilities, and responses to the questionnaire were requested. All authors
reviewed the items and responses in the questionnaire
to ensure that the content was valid and aligned withthe research questions and objectives. The questionnaires and consent forms were collected by mail using
enclosed return envelopes. The survey period was from
June 30 to August 14, 2020. The questionnaire survey
items are shown below.
2.3.1. Characteristics of facility and OT
We asked about the target category (medical care,long-term care, welfare, and others), presence or absence of COVID-19-infected patients, the number of clients per occupational therapist, and the locations of OT
before the first declaration of emergency in Hokkaido
due to COVID-19 (before February 27, 2020; hereafter,“pre-declaration”).
All applicable OT locations were selected fromthe following: 1) “facility room/residence”: the client’s
room or home, 2) “in OT department”: OT rooms
under the jurisdiction of the OT department, 3) “in thefacility”: day room or hall in the target facilities, and 4)“outside the facility”: outdoor or external facilities. In
addition, we extracted information on the type of service(facility service, commuting service, home-visit service,and others) using the Japanese Association of Occupational Therapists’ list of facilities and categorized thefacilities accordingly.
2.3.2. Influences of COVID-19 on OT in each period
To evaluate the influences of COVID-19 on OT,
participants were asked about the number of clients per

Asian J Occup Ther 18: 147−155, 2022

occupational therapist and location of OT across threetime periods: during Hokkaido’s first declaration of astate of emergency (February 28 to March 19, 2020;
hereafter, Period I), during the period in which thedeclaration was temporarily lifted (March 20 to April
11, 2020; hereafter, Period II), and during the national
declaration of a state of emergency (April 12 to May 25,
2020; hereafter, Period III). Then, they were requested
to complete open-ended responses on changes in thecontent of assessment and treatment from pre-declaration and COVID-19–related restrictions and measures to
OT across the three periods indicated above.

Yokoyama K et al.

149

lapped in terms of changes in the content of assessment
and treatment of OT. The analysis process was sharedwith the second and third authors, and the contents wererepeatedly reviewed and revised. Categories and codes
are represented by [ ] and < >, respectively.
2.5. Ethical considerations
This study was approved by the Sapporo Medical
University Ethical Review Board (approval number
2-1-2). The participants provided written informed consent for all procedures.

3. Results

2.4. Data analysis
Of the returned questionnaires, those in the “long3.1. Facility characteristics
term care insurance facilities” were selected for analysis
In total, 334 questionnaires were returned. Of thosein this study. First, the facility characteristics to whichquestionnaires, 89 (26.7%) were classified as longthe subjects belonged were tabulated. Next, trends in theterm care insurance facilities, with valid responses. The
number of clients per occupational therapist and location
long-term care services included facility service in 54
of OT from pre-declaration to Period III were identified.
facilities (60.7%), commuting service in 60 (67.4%),
Regarding the number of clients per occupational therahome-visit service in 26 (29.2%), and other services inthree (3.4%). One facility (1.1%) confirmed the presence
pist, the proportion of clients from Period I to Period III
of COVID-19 cases among the staff.
was calculated, with that of the pre-declaration period
being 100%. For the location of OT, the number and3.2. Number of clients in OT (Figure 1)
percentage of facilities at each location were deterThe mean values±standard deviations on themined, and the transition from pre-declaration to Period
proportion of clients during the pre-declaration period
III was clarified.
and in Periods I, Ⅱ, and Ⅲ were 100%, 90.3±16.6%,
Finally, changes in the content of OT assessments,
92.3±17.4%, and 90.5±19.8%, respectively. Comparing
treatments, restrictions on OT, and measures on OT
were coded with the procedures of content analysis [13].
In content analysis, qualitative data can be describedobjectively, systematically, and quantitatively. The procedures for the analysis were as follows:
1) The responses in the questionnaire were divided into
contextual sentences, and the sentences were divided
into record units to ensure that the meaning of the content could be understood. In addition, data which were
not adequately answered the question, were excluded.
2) Record units with similar semantic content weregrouped as the same record unit; then, they were coded.
At the same time, record units that did not correspond tothe options in the questionnaire were excluded from theanalysis.
3) Several codes were examined for commonalities andcategorized abstractly as a category. In addition, thecodes that had no commonality with other codes wereclassified into a category by a single code.
4) The number of occurrences of record units in theFig. 1. Number of clients in OT
codes and categories were counted, and the percentage
OT: Occupational Therapyof the total was calculated. Restrictions and measuresNote.
re-The trends in the number of clients per occupational therapist from pre-declaration to Period III were
OT: Occupational Therapy
lated to OT were analyzed as “Restrictions and measures
shown.
	Note. The trends in the number of clients per occupaother than the content of assessment and treatment”
tional therapist from pre-declaration to Period III were
because it was assumed that some recording units overshown.

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INFLUENCES OF COVID-19 PANDEMIC ON OT IN LONG-TERM CARE INSURANCE SERVICES

the number of clients during the pre-declaration period
and in Period III, 39 facilities (43.8%) showed a reduction and six (6.7%) showed an increase, while thenumber remained the same in 44 (49.4%).

Outside the facility
In the facility
In OT department

200

Cumulative number of facilities implementing (Facilities)

180

Facility room / residence
27

160

15

17

19

68

68

67

29

31

31

3.3. Location of the implementation of OT (Figure 2)
In the pre-declaration period, 54 facilities (60.7%)
provided OT in the facility room/residence, 36 (40.4%)
in OT department, 72 (80.9%) in the facility, and 27(30.3%) outside the facility. The OT locations in Period
I were 52 facilities (58.4%) in the facility room/home,
29 (32.6%) in the OT department, 68 (76.4%) in thefacility, and 15 (16.9%) outside the facility. No change
was reported in more than three facilities in any of thelocations in Periods II and III compared with that in
Period I.

140
120

72

100
80

36

60
40

3.4. Changes in the content of assessment in OT due to
COVID-19 (Table 1)
Variables that had an [increased need for assess0
ment] were <measurement of body temperature before
Pre-declaration
Period I
Period II
Period III
OT>, <checking health condition before OT>, <changes
Figure 2. The location of OT in the long-term care insurance
Fig. 2.	The location of the implementation of OT in the longin physical and cognitive functions due to disuse synOT: Occupational Therapy
term care insurance
drome>, and <stress responses>. There was an increase
Note. The number of facilities in each location of OT from pre-declaration to Period III were shown.
in the number of record units as time went on. A small
OT: Occupational Therapy
number of record units reported in <status of outdoor
	Note. The number of facilities in each location of OT
activities>, <opportunities for communication>, <awarefrom pre-declaration to Period III were shown.
ness of infection control>, <checking the physical con20

54

52

52

55

Table 1 Changes in the content of assessment in OT from pre-declaration
Category
Increased need for assessment

Reduced opportunities for assessment

The changed assessment methods

Code
Measurement of body temperature before OT
Checking health condition before OT
Changes in physical and cognitive functions due to disuse syndrome
Stress responses
Status of outdoor activities
Opportunities for communication
Awareness of infection control
Checking the physical condition of housemate or roommate
Contact with visitors from infection hotspots
Subtotal
Home environment
Mobility outdoors
IADL outdoors
Living conditions at home
Subtotal
Changes in the location and time as appropriate
Using telephone for absent clients
Subtotal

No change from the pre-declaration period
Total

Number of record units
Period I
Period II
Period III(n=78)(n=77)(n=78)
8 (8.9%) 7 (7.5%) 7 (7.2%)
7 (7.8%) 7 (7.5%) 7 (7.2%)
3 (3.3%) 7 (7.5%) 9 (9.3%)
2 (2.2%) 8 (8.6%) 9 (9.3%)
1 (1.1%) 1 (1.1%) 3 (3.1%)
1 (1.1%) 1 (1.1%) 1 (1.0%)
1 (1.1%) 0 (0.0%) 2 (2.1%)
0 (0.0%) 2 (2.2%) 2 (2.1%)
0 (0.0%) 0 (0.0%) 1 (1.0%)
23 (25.6%) 33 (35.5%) 41 (42.3%)
4 (4.4%) 4 (4.3%) 5 (5.2%)
4 (4.4%) 3 (3.2%) 2 (2.1%)
2 (2.2%) 2 (2.2%) 2 (2.1%)
2 (2.2%) 2 (2.2%) 2 (2.1%)
12 (13.3%) 11 (11.8%) 11 (11.3%)
3 (3.3%) 4 (4.3%) 3 (3.1%)
1 (1.1%) 1 (1.1%) 1 (1.0%)
4 (4.4%) 5 (5.4%) 4 (4.1%)
51 (56.7%) 44 (47.3%) 41 (42.3%)
90 (100.0%) 93 (100.0%) 97 (100.0%)

OT: Occupational Therapy, IADL: Instrumental Activities of Daily Living
Note. The Changes in the content of assessment in OT from pre-declaration were grouped into four categories. The number of record units for eachcategory and code were shown.

Asian J Occup Ther 18: 147−155, 2022

Yokoyama K et al.

dition of housemate or roommate>, and <contact withvisitors from infection hotspots>. In contrast, factors
with [reduced opportunities for assessment] included<home environment>, <mobility outdoors>, <instrumental activities of daily living (IADL) outdoors>, and<living conditions at home>. Many of these reports were
attributed to restrictions on the provision of OT outside
the facility. In addition, the content of [the changed
assessment methods] included <changes in the locationand time as appropriate> and <using telephone forabsent clients>. While the above changes in the content
of the assessment were mentioned, there were also responses of [no change from the pre-declaration period],
accounting for 51 (56.7%), 44 (47.3%), and 41 (42.3%)of the responses in Periods I, II, and III, respectively.
3.5. C hanges in the contents of treatment in OT owing to
COVID-19 (Table 2)
The factors involved in the [discontinuation oftreatment] due to the COVID-19 pandemic, such as<outdoor training and activities> and <group activities>,
were reported. Although infrequently reported, <high-intensity exercise>, <cooking training>, and <swallowing
and speech training> were also mentioned. Two respondents (2.3%) reported [total cancellation], that is they151

completely stopped OT in period III. In contrast, there
was an increase in [additional support incorporating
infection control] in light of the influences of COVID19, including <interventions aimed at preventing disuse
though self-restraint>, <outdoor training and activities>,<proposals and implementation for voluntary training>,and <interventions aimed at leisure and stress release>.
In addition, [changes in treatment methods including
infection control] were reported. These included <fixing
the location for zoning>, <fixing the time of day for eachstay and commute period>, <changing from day care
to home visit>, <reducing the number of participantsin group activities>, and <strategically placing people
and clients to avoid crowding and proximity>. Some respondents indicated [no change from the pre-declaration
period], accounting for 47 (61.0%), 42 (53.2%), and 33(37.5%) of the responses in Periods I, II, and III, respectively. These rates decreased over time.
3.6. Restrictions and measures other than changes in
the content of assessment and treatment owing to
COVID-19 (Tables 3 and 4)
Regarding restrictions other than the changes in
the content of assessment and treatment, [restrictions
on client participation] were often mentioned. The most

Table 2 Changes in the content of treatment in OT from pre-declaration
Number of record units
Category

Code

Period I(n=80)

Period II(n=76)

Period III(n=78)

5
5
1
1
0

7
4
2
1
1

7
5
2
1
2

Discontinuation of treatment

Outdoor training and activities
Group activities
High-intensity exercise
Cooking training
Swallowing and speech training

Additional support incorporating
infection control

Interventions aimed at preventing disuse through self-restraint
Outdoor training and activities
Proposals and implementation for voluntary training
Interventions aimed at leisure and stress release

3
1
1
0

(3.9%)(1.3%)(1.3%)(0.0%)

5
1
1
1

Subtotal

5
7
2
2
1
1

(6.5%)(9.1%)(2.6%)(2.6%)(1.3%)(1.3%)

8 (10.1%) 17 (19.3%)
8 (10.1%) 10 (11.4%)
1 (1.3%) 1 (1.1%)
1 (1.3%) 1 (1.1%)
2 (2.5%) 4 (4.5%)
2 (2.5%) 3 (3.4%)

Subtotal

Changes in treatment methods
including infection control

Fixing the location for zoning
Fixing the time of day for each stay and commute period
Changing from day care to home visit
Reducing the number of participants in group activities
Strategically placing people and clients to avoid crowding and proximity
Subtotal

Total cancellation(8.9%)(5.1%)(2.5%)(1.3%)(1.3%)(8.0%)(5.7%)(2.3%)(1.1%)(2.3%)

12 (15.6%) 15 (19.0%) 17 (19.3%)(6.3%)(1.3%)(1.3%)(1.3%)

7532(8.0%)(5.7%)(3.4%)(2.3%)

13 (16.9%) 14 (17.7%) 19 (21.6%)0

No change from the pre-declaration period(6.5%)(6.5%)(1.3%)(1.3%)(0.0%)(0.0%)

0(0.0%)

2(2.3%)

47 (61.0%) 42 (53.2%) 33 (37.5%)
Total

77 (100.0%) 79 (100.0%) 88 (100.0%)

OT: Occupational Therapy
Note. The Changes in the content of assessment in OT from pre-declaration were grouped into four categories. The number of record units for eachcategory and code were shown.

152

INFLUENCES OF COVID-19 PANDEMIC ON OT IN LONG-TERM CARE INSURANCE SERVICES

Table 3 Restrictions related to OT owing to COVID-19
Number of record units
Category

Code

Restrictions on client participation

Available facilities
Interactions with people outside the facility
Visits outside of the facility and overnight stay
Participation by people in poor physical conditions
Interaction between residents
Participation of new clientsContact with visitors from infection hotspots

Restrictions on OT operations

Limitation of rehabilitation time and frequency
The use of equipment and supplies
Cancellation or shortening of meetings and trainings
Limiting the scope of staff work
Time constraints due to infection control
The use of infection control items
Lack of manpower due to limitation of staff attendance
Reduced opportunities for explanation and consent to theclient and their family

Subtotal

Subtotal
Discontinuation of long-term careservices

Home-visit services
Day-care rehabilitation
Preventive services
Complete closure of the facility
Rehabilitation of residents
Stopping the use of other services
Subtotal

No restrictions
Total

Period I(n=81)

Period II(n=82)

Period III(n=82)

16 (15.2%)
11 (10.5%)
5 (4.8%)4 (3.8%)2 (1.9%)1 (1.0%)0 (0.0%)39 (37.1%)

16 (15.2%)
11 (10.5%)
3 (2.9%)4 (3.8%)2 (1.9%)2 (1.9%)1 (1.0%)39 (37.1%)

18 (16.2%)
14 (12.6%)
4 (3.6%)5 (4.5%)2 (1.8%)1 (0.9%)3 (2.7%)47 (42.3%)

6
5
4
5
2
2
2

(5.7%)(4.8%)(3.8%)(4.8%)(1.9%)(1.9%)(1.9%)

6
5
5
5
3
2
3

(5.7%)(4.8%)(4.8%)(4.8%)(2.9%)(1.9%)(2.9%)

8
6
4
6
3
2
3

(7.2%)(5.4%)(3.6%)(5.4%)(2.7%)(1.8%)(2.7%)

2(1.9%)

2(1.9%)

1(0.9%)

28 (26.7%)

31 (29.5%)

33 (29.7%)

10
5
2
4
2
0

10
4
2
2
2
0

10
3
2
2
2
1

(9.5%)(4.8%)(1.9%)(3.8%)(1.9%)(0.0%)(9.5%)(3.8%)(1.9%)(1.9%)(1.9%)(0.0%)(9.0%)(2.7%)(1.8%)(1.8%)(1.8%)(0.9%)

23 (21.9%)

20 (19.0%)

20 (18.0%)

15 (14.3%)

15 (14.3%)

11(9.9%)

105 (100.0%) 105 (100.0%) 111 (100.0%)

OT: Occupational Therapy
Note. The restrictions related to OT owing to COVID-19 were grouped into four categories. The number of record units for each category and code
were shown.

frequently reported codes were restrictions on <available facilities> and <interactions with people outside thefacility>. Other factors included restrictions on <visits
outside of the facility and overnight stay>, <participation by people in poor physical conditions>, <interaction
between residents>, <participation of new clients>,
and <contact with visitors from infection hotspots>. In
addition, [restrictions on OT operations] included <limitation on rehabilitation time and frequency>, <the useof equipment and supplies>, <cancellation or shorteningof meetings and trainings>, <limiting the scope of staff
work>, and <time constraints due to infection control>.
Furthermore, [discontinuation of long-term care services] were also reported, with <home-visit services>and <day-care rehabilitation> as the most commonly
discontinued services. Compared with the above-listed
restrictions, fewer reports were submitted regarding<preventive services>, <complete closure of the facility>, <rehabilitation of residents>, and <stopping the useof other services>.

Implementation of [thorough standard precautions]accounted for approximately 70% of the recorded units
for measures other than assessment and treatment.
The most frequently mentioned factors were <wearing
masks>, <practice of hand hygiene>, and <disinfectionof tools and common areas>, with more than 30 codesin any period. These were followed by <frequent ventilation>, <adjusting the environment to accommodatesocial distancing>, <gargling>, <minimal sharing oftools and equipment>, <sharing information about
infection control measures>, and <use of humidifiers>.
[Management of health conditions of the clients andhousemates] by <checking body temperature before
OT>, <checking the physical conditions>, <setting
the criteria for discontinuation of participation>, and<checking the physical conditions of family members
living together> was also reported. In addition to interventions for clients, [infection control measures by
occupational therapists] were also reported, and theseincluded <thorough management of physical condi-

Asian J Occup Ther 18: 147−155, 2022

Yokoyama K et al.

153

Table 4 Measures related to OT due to COVID-19
Number of record units
Category

Code

Period I(n=86)

Period II(n=85)

Period III(n=85)

Thorough standard precautions

Wearing masks
Practice of hand hygiene
Disinfection of tools and common areas
Frequent ventilation
Adjusting the environment to accommodate social distancing
Gargling
Minimal sharing of tools and equipment
Sharing information about infection control measures
Use of humidifiers

36 (20.1%)
35 (19.6%)30 (16.8%)
10 (5.6%)
9 (5.0%)2 (1.1%)1 (0.6%)
1 (0.6%)
1 (0.6%)36 (20.0%)33 (18.3%)
31 (17.2%)
11 (6.1%)
9 (5.0%)2 (1.1%)2 (1.1%)1 (0.6%)
1 (0.6%)38 (18.9%)
37 (18.4%)
33 (16.4%)
14 (7.0%)
10 (5.0%)
2 (1.0%)4 (2.0%)2 (1.0%)1 (0.5%)

Management of health conditionsof the clients and housemates

Checking body temperature before OT
Checking the physical conditions
Setting the criteria for discontinuation of participation

1041(5.6%)(2.2%)(0.6%)

123
1(6.7%)(1.7%)(0.6%)

123
3(6.0%)(1.5%)(1.5%)

Checking the physical conditions of family members living together

0(0.0%)

0(0.0%)

1(0.5%)

Subtotal
Thorough management of physical conditions
Use of personal protective equipment during OT
Fixing work content through reassignment

15
14
9
2

(8.4%) 16(7.8%) 12(5.0%) 10(1.1%)
4(8.9%) 19(6.7%) 12(5.6%) 11(2.2%) 5(9.5%)(6.0%)(5.5%)(2.5%)

Thorough implementation of infection control measures in private life

4

(2.2%)(1.7%)(3.0%)

Subtotal

Infection control measures by
occupational therapists

Subtotal
Changes in support methods inlight of infection control

Changes concerning individual support
Sharing information and obtaining consent by mail or remotely
Strengthening inter-professional cooperation
Subtotal

No measures
Total

125 (69.8%) 126 (70.0%) 141 (70.1%)

3

6

29 (16.2%)
3 (1.7%)2 (1.1%)2 (1.1%)29 (16.1%)
2 (1.1%)2 (1.1%)2 (1.1%)34 (16.9%)
2 (1.0%)3 (1.5%)2 (1.0%)7(3.9%)

6(3.3%)

7(3.5%)

3(1.7%)

3(1.7%)

0(0.0%)

179 (100.0%) 180 (100.0%) 201 (100.0%)

OT: Occupational Therapy
Note. The measures related to OT owing to COVID-19 were grouped into five categories. The number of record units for each category and code
were shown.

tions>, <use of personal protective equipment during
OT>, <fixing work content through reassignment>, and<thorough implementation of infection control measuresin private life>. However, the participants reported[changes in support methods in light of infection control], such as <changes concerning individual support>,<sharing information and obtaining consent by mail orremotely>, and <strengthening inter-professional cooperation>. Finally, [no measures] was rarely reported.

4. Discussion
We investigated the influences of COVID-19 on OT
in long-term care insurance facilities. Many facilities
performed independent measures, modifying or adding
content to assessments and treatments, while maintaining thorough infection control measures, even in theface of restrictions placed on participation and service
provision.

Our results show that the number of OT clientsin long-term care insurance facilities had decreased toapproximately 90% due to COVID-19. Of these, nearly
half of the studied facilities had no change in the numberof clients, suggesting that they were still able to provide
OT while taking infection control measures.
Regarding the location of OT in the long-term careinsurance service facilities, there was a decrease in thenumber of sessions conducted outside the facilities
during Period I. This is assumed to be due to the restrictions imposed by Hokkaido’s local emergency declaration that refrained citizens from going outdoors [4].
However, there was a slight decrease in the implementation of the program in visiting rooms/homes, within the
OT department, and in each facility after the emergency
declaration. Factors involved in treatment, such as fixing
the location using zoning and the time of day for eachstay and commute period and changing from day care tohome visit, were also reported. This suggested that the154

INFLUENCES OF COVID-19 PANDEMIC ON OT IN LONG-TERM CARE INSURANCE SERVICES

location of each treatment was carefully considered andchanged to minimize the risk of infection.
Regarding changes in the content of assessments
due to COVID-19, the number of recording units withno change decreased from Period I to Period III, indicating that the influences of COVID-19 were graduallyconsidered during assessments. From Period I, bodytemperature and physical condition were assessed. In
addition, especially from Period Ⅱ, the influences of
COVID-19 on physical and cognitive functions due todisuse syndrome and stress response were assessed.
When considering how to efficiently capture frailty
status in pandemic management settings where time andresources are limited, feasibility and ease of use are paramount [14]. It is necessary to recognize frailty as earlyas possible in the assessment of OT in daily life. Concomitantly, assessment factors that prevent the spreadof infection, such as awareness of infection control andassessment of housemates and visitors of clients, werealso reported. Although it was inferred that the contentsof the evaluation were important, it was also revealed
that the restriction imposed on outside visits due to
COVID-19 made it difficult to proceed with the assessment of outdoor activities and home environment. It canbe inferred that the content of the assessment was greatly restricted by COVID-19 in most facilities. Therefore,
OT should consider alternative means of assessment in
the context of infection spread and control.
With regard to the changes in the content of treatment due to COVID-19, it was found that programswith high risk of infection, such as outdoor training andgroup activities, were discontinued from Period I in response to the local declaration of emergency in Hokkaido [4]. However, these were conducted after changing
the treatment structure, such as changing the location towithin the unit or own room, or zoning between staying
and commuting, such that the risk of infection could be
minimized; such changes were apparent from Period
I onward. In addition, interventions to prevent disuse
were conducted from an early stage. During Period III,
outdoor training and activities with consideration for
the influences of infectious diseases increased, and there
were more reports of suggestions for voluntary training.
We consider the possibility that these measures may beeffective in ameliorating the decline in physical function
and activity related to disuse syndrome and the accumulation of stress associated with changes in lifestyle
due to self-restraint and other factors. Furthermore,
there were also reports of “no change” in the content oftreatment, and these influences tended to decrease gradually with time. This suggests that additional support
incorporating infection control and changes in treatment
methods are gradually being implemented in more facil-

ities.
Restrictions other than those in OT assessment
and treatment were categorized as restrictions onparticipation of the subject, on OT operations, and discontinuation of long-term care services. Although such
restrictions occurred, the clients were guaranteed theopportunity to participate in OT with sufficient COVID19 control measures through thorough implementationof standard precautions, such as the practice of handhygiene, use of masks, management of the clients’physical conditions, and changes in support methods.
Physical condition management for participation in OT
was implemented for housemates as well as the clients,
and careful infection control measures were undertaken.
In addition, it was revealed that occupational therapists
managed their physical conditions thoroughly and wore
personal protective equipment such as face shields andgloves. They were taking measures against COVID-19
by introducing individual support, using remote methods, and strengthening multidisciplinary cooperation.
These are similar to the results of a questionnaire survey
conducted by the Japanese Society for Dementia Careon infection prevention measures in hospitals, residential facilities, and day care facilities [15]. However,changes concerning individual support, criteria for discontinuation of participation, and fixing of work content
through reassignment were unique measures that wereidentified in this study and can be applied in other facilities according to the situation of the region, facility, or
condition of the client.
The limitation of this study is that because the questions were asked in an open-ended form for each time
period, some of the questions overlapped with otheritems or were omitted from later answers. In addition,
the target population of this study was clients in longterm insurance facilities in Hokkaido. Each facility’s
characteristics, such as facility service, commuting
service, and home-visit service, were not analyzed. Thebalance between urban and rural areas in Hokkaido issimilar to the population structure of Japan as a whole[16], although the population density of Hokkaido isapproximately one-fifth of the national average anddistances between cities are two to three times longer
than the national average [17]. COVID-19 in Hokkaido
occurred mostly in the urban area centered on Sapporo[4][5], and it is assumed that there are regional differences as far as the influences of COVID-19. Therefore,
further studies are needed to generalize the results ofthis study to other parts of Japan and worldwide and to
examine methods for demonstrating the effectiveness of
OT being influenced by COVID-19.

Asian J Occup Ther 18: 147−155, 2022

5. Summary and Conclusions
COVID-19 restricts the participation of clients in
OT and in services provided to them in long-term insurance facilities. However, the influences of COVID-19
on the lives of the clients must be assessed in addition to
general infection control measures and must be incorporated into the treatment contents accordingly. We recommend that the measures reported in this study be appliedin each clinical setting, and they should be adopted after
considering what methods are effective for taking suchmeasures.

Conflicts of Interest
There are no conflicts of interest to declare.

Acknowledgments
This paper was supported by Sapporo Medical University. The authors wish to thank all participants who
facilitated data collection.

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novel-coronavirus-2019/question-and-answers-hub/
q-a-detail/coronavirus-disease-covid-19.
[2] World Health Organization. Timeline: WHO’s COVID19 response [online]. Genève [cited 2021 Sep 2]. Available from: https://www.who.int/emergencies/diseases/
novel-coronavirus-2019/interactive-timeline#event-72.
[3] World Health Organization. COVID-19 Weekly Epidemiological Update [online]. Genève [cited 2021 Jun
13]. Available from: https://www.who.int/publications/m/item/weekly-epidemiological-update---29-december-2020.
[4] Suzuki N. Declaration of State of Emergency in Response
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file/emg/file1_en_1582888280.pdf.
[5] Hokkaido. COVID-19 Cases in Hokkaido (in Japanese)[online]. Sapporo [cited 2021 Jun 13]. Available from:http://www.pref.hokkaido.lg.jp/hf/kth/kak/hasseijoukyou.

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jaot.or.jp/files/news/covid19/COVID-19_OTgyoumu_
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theglobeandmail.com/politics/article-long-term-careconnected-to-79-per-cent-of-covid-19-deaths-in-canada/.
[12] Hwang J, Ryu HS, Kim HA, Hyun M, Lee JY, Yi HA.
Prognostic factors of COVID-19 infection in elderly patients: a multicenter study. J Clin Med. 2020;9(12): 3932.
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[14] Andrew M, Searle SD, McElhaney JE, McNeil SA,
Clarke B. Rockwood K, et al. COVID-19, frailty andlong-term care: Implications for policy and practice. J
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■ORIGINAL ARTICLE

Factors Affecting the Performance of Employment
Support for People with Higher Brain Dysfunction:
Analyzing Conditions at Medical Institutions andEmployment Support Organizations in Japan
Moritoshi Kitakami1, 2, Jun Yaeda3
1

Department of Occupational Therapy, Niigata University of Health and Welfare, Niigata, Japan
Niigata Prefectural Rehabilitation Center for Persons with Disabilities, Niigata, Japan
3
Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
2

Abstract: Objective: In Japan, the introduction of a project aimed at providing support for individuals with higher
brain dysfunction has resulted in a substantial increase in their employment rate. While this shows positive effects,
many such individuals still have difficulty finding employment and may face various difficulties in cases where employment is secured. This study aimed to clarify the factors that affect the performance of employment support for people
with higher brain dysfunction, with a focus on the conditions at medical institutions and employment support organizations in Japan.
Methodology: This study measures scores on the competency scale (WSC-HB) required for employment support
for people with higher brain dysfunction. An anonymous self-administered paper-based questionnaire was circulated
among a total of 1,384 occupational therapists, speech therapists, social workers, and employment support workers.
Factors affecting job performance were processed by hierarchical multiple regression analysis.
Results: The factors of “transdisciplinary learning (⊿R2=0.105, F(311)=7.699, p<0.01)” and “amount of knowledge (⊿R2=0.056, F(305)=6.854, p<0.01)” about employment support influenced the performance of employment support forpeople with higher brain dysfunction.
Conclusions: There are few opportunities to acquire knowledge about employment support for people with higher brain
dysfunction. Going forward, systematic professional training should, therefore, be implemented to cover issues such as
welfare, employment, and the medical features of higher brain dysfunction. This will help establish a system for providing quality employment support.
Keywords: higher brain dysfunction, employment support, human resource development, medical institution, employment support organization(Asian J Occup Ther 18: 157−164, 2022)

1. Introduction
Users of community employment centers for people
with disabilities have reportedly increased by a factorof 1.85 in Japan after the introduction of a project forhigher brain dysfunction support, which was implementReceived: 2 April 2021, Accepted: 20 March 2022
Corresponding to: Moritoshi Kitakami, Niigata University of Healthand Welfare 1398 Shimami-cho, Kita-ku, Niigata-shi, Niigata, 9503198, JAPANe-mail: mori.kitakami@gmail.com©2022 Japanese Association of Occupational Therapists

ed in fiscal 2002. This was followed by an extension
project in fiscal 2013. As a result, the employment rate
among this population has grown by a factor of 1.59,
moving from 34% to 54% [1]. This indicates that the
project has provided a successful support system targeted at employment and other aspects of life for people
with higher brain dysfunction, many of whom were
inadequately covered through previous systems. However, reports also show that 65% of people in Japan who
are affected by higher brain dysfunction in the primeof their lives do not find employment, and may face avariety of work-related difficulties, even in cases where
employment is secured [2]. Some of these problems that

158

EMPLOYMENT SUPPORT AND BRAIN DYSFUNCTION

have been reported include “work cannot be performed
well,” and that there are “interpersonal relationship troubles” [2]. A systematic review was previously conductedin the Netherlands among individuals who had sufferedstrokes caused by higher brain dysfunction. The review
showed that 39.3% had returned to work, but that approximately 60% of those with higher brain dysfunction
were still unemployed [3].
Concerning medical institutions in Japan, the main
providers of employment support for people with disabilities include occupational therapists (OTs), speechtherapists (STs), and social workers (SWs). They canalso employ and avail vocational counselors at employment support organizations and/or employment support
workers at employment/life-support centers. However,
it is difficult to provide employment support for people
with higher brain dysfunction in the context of a single
profession or organization. While the consensus is that
this requires a multidisciplinary approach involving
medical institutions and employment support organizations, such multidisciplinary collaboration is often
lacking [4-6].
Individual factors related to employment for people
with higher brain dysfunction include “activities of dailyliving capacity” and “family” [7]. However, this may
also be problematic due to several external issues, including a lack of knowledge about employment support
among medical institutions [8], a lack of skills related
to employment support among rehabilitation workers[9], insufficient vocational rehabilitation support [10],and the methods support staff use to provide assistance.
In this context, the Japanese Ministry of Health, Labourand Welfare is currently discussing the creation of asystematic framework designed to train workers on providing employment support to people with disabilities,
which has been deemed necessary due to a general lackof knowledge and skills related to employment support[11].
In a previous study among OTs who provided
employment support for people with higher brain dysfunction, the factors that promoted work performance
included (1) understanding the information provided
to companies, (2) number of staff, (3) awareness of theroles/functions of regional disability vocational centers,and (4) job satisfaction [12]. Meanwhile, research into
other areas of improvement in job performance haveemphasized the importance of collaborating with various
experts, which is also known as transdisciplinary learning [13]. Similar factors with positive effects include
workplace culture, interpersonal relations, organizational commitment, job commitment, and support systems[14,15].
However, there is currently a lack of knowledge

about employment support for people with higher brain
dysfunction [16]. Furthermore, there is insufficient clarity about which factors influence employment support
performance among professionals that provide these
services at medical institutions and employment support
organizations.
Objectives
This study aims to reveal the factors that affect
employment support performance among specialists
working at medical institutions and employment support
organizations that serve people with higher brain dysfunction. The goal was to produce findings that could be
used to establish systems that provide quality employment support for people with higher brain dysfunction
who desire entrance into the workforce.
Research Hypothesis
It is hypothesized that knowledge about employment support for people with disabilities, such as creating a conducive work environment (self-improvement,
support system, interpersonal relationships, economic
situation, job/organizational commitment), and higher
frequency of transdisciplinary learning, positively affectjob performance.
Operational Definitions
Higher brain dysfunction
This term refers to aphasia, apraxia, agnosia,
memory impairments, attention disorders, executivefunction deficits, and social behavioral disorders causedby brain injuries, such as stroke or head trauma.
Employment support worker
These are workers who perform duties related to
employment support at employment/life support centers
for people with disabilities
Transdisciplinary learningThis term refers to the crossing of organizationalboundaries in order to gain multidisciplinary knowledge
related to one’s current job.

2. Materials and Subjects
Subjects
Subjects included OTs, STs, SWs, and employment
support workers who offered services at employment/
life support centers for people with disabilities. All
subjects had experience providing employment support
to people with higher brain dysfunction at medical
institutions across Japan. More specifically, “experience
providing employment support” entails exchanging orAsian J Occup Ther 18: 157−164, 2022

sharing information between professions or organizations, participating in simulated work activities/training
conducted by the training or consultation departments ofmedical institutions, and providing consultation support
aimed at finding employment or supporting visits tocompanies or other entities. The target organizations
were medical institutions, base institutions for supporting the extension project on employment support forpeople with higher brain dysfunction, and work-related
accident hospitals across Japan that care for workers,
whose employees have published papers or presented
at conferences sponsored by the Japanese Society of
Vocational Rehabilitation or other organizations focusedon employment support for people with higher brain
dysfunction during the six-year period lasting from 2007
to 2012; this included 126 institutions for OTs and SWs,
and 124 institutions for STs. We also included all 316
employment/life support centers for people with disabilities across Japan. We requested two responses fromeach organization, and thus mailed questionnaires to a
total of 1,384 individuals.
Questionnaires
Survey respondents, including OTs, STs, SWs, andemployment support workers, were asked to completequestionnaires containing the Work Supporter’s Competency Scale for Higher Brain Dysfunction (WSCHB) [16] wherein they rated elements concerning theirjob performance according to a 4-point scale (1 = none,
2 = infrequently, 3 = often, 4 = always). The WSC-HB
consists of 44 items (four items on “basic knowledge ofhigher brain dysfunction,” eight items on “assessment,”
two items on “consultation support,” four items on“family support,” 17 items on “management,” six items
on “workplace assistance,” and three items on “accumulation of specialized knowledge”) related to the knowledge and skills required to provide employment support
to people with higher brain dysfunction. There werealso nine terms that respondents indicated their level ofknowledge about using a 4-point scale (1 = cannot explain, 2 = can explain simply, 3 = can explain generally,
4 = can explain fully; terms included disability pension,
trial employment system, quality of working life, special
affiliate company, school for people with disabilities todevelop vocational skills, law on promoting the employment of people with disabilities, workplace adaptation
trainers (job coaches), employment/life support centers
for people with disabilities, and natural support). The
scale was previously tested for both reliability and validity [16]. Respondents were also asked to provide basic
demographic information, including gender, age, monthsof experience, and working hours (mean hours per week,
including overtime). Transdisciplinary learning items in-

Kitakami M et al.

159

cluded both the frequency of participation in workshops(i.e., mean number of academic society meetings, training sessions, and number of seminars attended each year
on employment support for people with higher brain
dysfunction since graduating from a training institution)and frequency of presentations at academic conferences(i.e., number of conference presentations, including
poster presentations, given on employment support forpeople with higher brain dysfunction between April
2011 and March 2012). Finally, work environment items
included self-improvement (one question), support systems (four questions), interpersonal relationships (threequestions), economic status (one question), and job/organizational commitment (three questions), all of whichwere answered on a 4-point scale (1 = dissatisfied, 2 =slightly dissatisfied, 3 = slightly satisfied, 4 = satisfied).

3. Method
Data Collection
All anonymous, self-administered questionnaires
were distributed and collected by mail.
Survey Period
The survey was conducted from July 7–31, 2012.
Data Analysis
Descriptive statistics were calculated for the basic
demographic items (i.e., gender, age, months of experience, and working hours). To analyze the factors that
influenced the performance of employment support forpeople with higher brain dysfunction, the level of performance was set as the dependent variable in a four-model
hierarchical multiple regression, which was designed to
examine the influence of each factor on performance,
after taking the effects between variables into account.
Model 1 contained four variables — the basic attributesof gender, age, months of experience, and working
hours. Model 2 added two variables related to transdisciplinary learning —the frequency of participation inworkshops and frequency of conference presentations.
Next, Model 3 added five work environment factors— self-improvement, support system, interpersonal
relations, economic situation, and work/organizational
commitment. Finally, Model 4 added one variable — theamount of knowledge about employment support.
Variables that did not have normal distributions(Shapiro-Wilk test), ordinal scales, and nominal scales
were converted to dummy variables prior to the hierarchical multiple regression analysis. To convert theordinal scales and nominal scales to dummy variables,
values less than the mean were set to “0,” while thoseequal to or greater than the mean were set to “1” (Table

160

EMPLOYMENT SUPPORT AND BRAIN DYSFUNCTION

Table 1. Dummy variable transformation for hierarchical multiple regression analysis
Mean

Dummy variable transformation (n)Basic attributes
GenderAgeMonths of experience
Working hours per week

94.92
46.45

Male = 0 (36), Female = 1 (58)
20-30s = 0 (71), 40-60s = 1 (23)<95 = 0 (41), ≥95 = 1 (53)<47 = 0 (59), ≥47 = 1 (35)Transdisciplinary learning
Frequency of participation in workshops
Frequency of conference presentations

1.31
0.12

<2 = 0 (64), ≥2 = 1 (30)
<1 = 0 (82), ≥1 = 1 (12)Self-improvement
Support system
Interpersonal relationships
Economic status
Commitment

2.82
10.41
7.73
2.36
8.88

<3 = 0 (72), ≥3 = 1 (22)
<11 = 0 (62), ≥11 = 1 (32)
<8 = 0 (66), ≥8 = 1 (28)
<3 = 0 (79), ≥3 = 1 (15)<9 = 0 (69), ≥9 = 1 (25)Amount of knowledge*

21.84<22 = 0 (80), ≥22 = 1 (14)Working environment* For the nine terms related to knowledge, total scores were calculated (9–36 points) based on the ability to
explain each (1 = cannot explain, 2 = can explain simply, 3 = can explain generally, 4 = can explain fully).

1). In addition, correlation coefficients were used tocheck for multicollinearity between variables. If variables exhibited correlation coefficients (r) ≥ ± 0.9, then
one was excluded. If the variance inflation factor was ≥10 after inputting a variable, then it was excluded due tothe high possibility of multicollinearity.
The dependent variable (job performance) was
calculated based on the total scores (44–176 points)
obtained after adding scores from the 44 WSC-HB items(1 = never, 2 = infrequently, 3 = often, 4 = always). The
higher the total score of the 44 items of the WSC-HB,
the higher the degree of job performance for people
with higher brain dysfunction. For the five independent
variables on work environment, each item was scored(1 = dissatisfied, 2 = slightly dissatisfied, 3 = slightly
satisfied, 4 = satisfied) in order to calculate a total score:
self-improvement (one question: 0–3 points), support
system (four questions: 0–12 points), interpersonal
relationships (three questions: 0–9 points), economic situation (one question: 0–3 points), and job/organizational
commitment (three questions: 0–9 points). For the nineterms related to knowledge, total scores were calculated(9–36 points) based on the ability to explain each (1 =cannot explain, 2 = can explain simply, 3 = can explain
generally, 4 = can explain fully).
In summary, the hierarchical multiple regression
analyses were conducted as follows: First, we examinedthe effects of gender, age, months of experience, andworking hours on job performance (Model 1). Second,
we set the basic attributes used in Model 1 as control
variables in order to examine the effects of transdisciplinary learning, with the frequency of participation inworkshops and frequency of conference presentations
set as independent variables (Model 2). Third, we examined the effects of five work environment variables(self-improvement, support system, interpersonal relationships, economic situation, and job/organizational
commitment) by adding them to Models 1 and 2 (Model
3). Finally, we examined the effects of the knowledge
variable (model 4). All analyses were conducted using
the IBM SPSS Statistics software, version 17.0.
Ethical Considerations
All subjects were given written statements that thequestionnaires were anonymous and that no individual
responses would be published. They were also informedthat participation was completely voluntary, and that nonegative consequences would be incurred for declining
to participate. In this regard, they were told that returning a questionnaire by mail would be taken as consent toparticipate. This study was conducted with the approvalof the ethics committee on human research at the University of Tsukuba (East 24-4).

4. Results
Response Rate
The total number of responses collected equalled
325. Of the 325 respondents, 7 were not OTs, STs, SWs,or employment support workers (physical therapist,
nursery teacher, home helper, job coach), and thus were
excluded. Overall, data from 318 participants (overall
recovery rate of 23%) were included in the analysis. We
obtained questionnaire responses from 94 OTs (response

Asian J Occup Ther 18: 157−164, 2022

Kitakami M et al.

161

Table 2. Basic attributes and factors of OT, ST, SW, and employment support workers
Content

OT (%)

ST (%)

SW (%)

Employment support
workers (%)

Male
Female
20s
30s
40s
50s
60s

36（38.3）
58（61.7）
33（35.1）
38（40.4）
15（16.0）8（8.5）
0（0.0）
131.90±89.85
46.71±0.76

12（19.4）50（80.6）
23（37.1）
21（33.9）
12（19.4）
6（9.7）
0（0.0）
131.47±99.98
48.29±9.4917（36.2）30（63.8）
17（36.2）
18（38.3）
6（12.8）5（10.6）1（2.1）
84.89±71.34
47.79±10.08

62（53.9）53（46.1）
12（10.4）40（34.8）
39（33.9）21（18.3）
3（2.6）
49.10±44.00
44.68±6.71

Transdisciplinary learning
Frequency of workshop participation (286)b
Frequency of conference presentations (302)c

1.44±1.71
0.15±0.41

1.34±2.63
0.08±0.33

2.07±1.80
0.17±0.48

0.89±0.92
0.10±0.38

Work environmentd
Self-improvement (318)Support system (318)Interpersonal relationships (318)
Economic status (318)Commitment (318)2.81±0.81
10.77±2.42
7.49±1.94
2.36±0.76
8.64±1.54

2.69±0.86
10.53±2.12
7.98±1.65
2.37±0.87
8.85±1.27

2.83±0.87
9.74±1.91
7.34±1.67
2.49±0.86
9.06±1.29

2.82±0.78
10.31±2.01
7.96±1.66
2.31±0.85
9.03±1.67

Amount of knowledge (315)e17.35±5.18

15.96±4.84

22.26±5.4228.51±4.36

112.11±29.32

113.08±23.76

118.23±29.06

117.56±28.85

Item (n)Basic attributes
Gender (318)Age (316)

Months of experience (310)Working hours per week (310)a

Job performance (318)faMean working hours per week (including overtime)Mean number of academic conferences, workshops, and seminars on employment support for people with higher brain dysfunction attended
annually.
cNumber of conference presentations (including poster presentations) given on employment support for people with higher brain dysfunction
from April 2011 to March 2012.
d
Total scores for each item (1 = dissatisfied, 2 = slightly dissatisfied, 3 = slightly satisfied, 4 = satisfied): self-improvement (0-3 points), support
system (0-12 points), interpersonal relationships (0-9 points), economic status (0-3 points), commitment (0-9 points)eTotal scores on the ability to explain nine important terms related to employment support (1= cannot explain, 2 = can explain simply, 3 = can
explain generally, 4 = can explain fully) (9-36 points)f
Total scores for the 44 WSC-HB items (1 = never, 2 = infrequently, 3 = often, 4 = always) (44-176 points)b

rate of 37.3%), 62 STs (response rate of 25.0%), 47 SWs(response rate of 18.6%), and 115 employment support
workers (response rate of 18.2%).
Basic Attributes
Respondents included 127 men (39.9%) and 191
women (60.1%). The most common age group was
people in their 30s, accounting for 117 respondents(36.8%), followed by 20s, with 85 (26.7%). The mean
months of experience was 131 months (approximately
10 years) for the OTs and STs, 85 months (approximately
7 years) for the SWs, and 49 months (approximately 4
years) for the employment support workers. The mean
weekly working hours were longest for STs (48.29±9.49)
and shortest for employment support workers(44.68±6.71).
Factors Affecting Employment Support Performance
The frequency of participation in workshops andseminars was highest among SWs (2.07±1.80) andlowest among employment support workers (0.89±0.92),
while the frequency of conference presentations (including poster presentations) was highest among SWs(0.17±0.48) and lowest among STs (0.08±0.33) (Table 2).
Regarding the work environment, score rankings for the individual components were as follows;
self-improvement scores were highest among SWs(2.83±0.87) and lowest among STs (2.69±0.86); support
system scores were highest among OTs (10.77±2.42)
and lowest among SWs (9.74±1.91); interpersonal
relationship scores were highest among STs (7.98±1.65)
and lowest among SWs (7.34±1.67); economic statusscores were highest among SWs (2.49± 0.86) and lowest
among employment support workers (2.31±0.85); andfinally, commitment scores were highest among SWs(9.06±1.29) and lowest among OTs. The amount ofknowledge about employment support was highest for
employment support workers (28.51±4.36) and lowest

162

EMPLOYMENT SUPPORT AND BRAIN DYSFUNCTION

Table 3. Correlation coefficients between variables
Months ofexperience

Workshops Conferences
Working
SelfSupport Interpersonal Economic
Frequency of Frequency ofCommitment Knowledge
hours
improvement system relationships
statusparticipation presentations

Gender

Age

1
.05
.18**
.02

1
.24**
-.13*

1
.02

1

.07

-.09

.05

.03

1

.09

.12*

.06

-.02

.15**

1

Working environment
Self-improvement
Support system
Interpersonal relationships
Economic status
Commitment

-.01
.05
-.04
.05
.02

-.05
-.03
.06
.11
.1

.04
-.03
-.01
.1
-.06

-.01
-.07
-.08
.02
.01

.16**
.02
-.02
.07
.01

.14*
.07
.09
.07
.12*

1
.53**
.39**
.22**
.31**

1
.63**
.35**
.42**

1
.36**
.46**

1
.24**

1

Amount of knowledge-.17** .35**-.29**

-.08

.13*

.16**

.06

-.08

.08

.01

.11

Basic attributes
GenderAgeMonths of experience
Working hours per week
Transdisciplinary learningF requency of workshop
participationF requent of conference
presentations

1*p<.0.05 **p<.0.01

Table 4. Effects of variables on job performance in the hierarchical multiple regression analysis

Basic attributes
GenderAgeMonths of experience
Working hours per week

Model 1βModel 2βModel 3βModel 4
β

-.027
.069
-.089
.124*

-.009
.043
-.102
.128*

-.01
.043
-.095
.134*

-.058
-.044
-.021
.146*

.217**.214**.208**.196**.182**.163**

.059
.071
.041
-.085
.071

.047
.09
.05
-.085
.065

Transdisciplinary learning
Workshop participation
Conference presentations
Working environment
Self-improvement
Support system
Interpersonal relationships
Economic status
Commitment
Amount of knowledge
2

R
2
⊿R
***p<.0.05 **p<.0.01
β: standardized partial regression coefficient.269**.025.129**.105**

R2: coefficient of determinationfor STs (15.96±4.84) (Table 2).
As no variables showed correlation coefficients ≥0.9, all were included (Table 3). Further, all varianceinflation factors were ≤ 10, thus indicating the lack ofmulticollinearity. As mentioned, hierarchical multiple regression analyses were conducted with job performance
set as the dependent variable (four models). In Model1, working hours showed a significant main effect, witha positive standardized partial regression coefficient. In.156**.027.212**.056

2⊿R : increase in coefficient of determination.

Model 2, the frequency of workshop participation andfrequency of conference presentations showed significant
main effects, with positive standardized partial regression
coefficients for both; these two variables contributed toa significant increase in the coefficient of determination,with Model 2 over Model 1 (⊿R2=0.105, F(311)=7.699,
p<0.01). In Model 3, none of the five work environment
variables showed significant differences, nor did thecoefficient of determination show significant increases

Asian J Occup Ther 18: 157−164, 2022with respect to Model 2 (⊿R2=0.027, F(306)=5.152,
ns). In Model 4, knowledge showed a significant main
effect and increase in the coefficient of determination,with Model 4 over Model 3 (⊿R2=0.056, F(305)=6.854,
p<0.01) (Table 12). The coefficient of determination (R2)
was not high (0.212), but showed some level of fit (Table
4).

5. Discussion
In this study, we found that transdisciplinary learning and the amount of knowledge about employment
support were important factors for promoting employment support for people with higher brain dysfunction.
While these findings support those of previous research,
they did not support past findings on the work environment itself. In addition, the longer the working hours, thehigher the job performance. This is likely due to the factthat there is a higher probability of performing a varietyof duties with increased working hours. Therefore, theresults have shown that the degree of job performance
related to employment support for people with higher
brain dysfunction is positively influenced by the supporter’s individual knowledge and skills, working hours, andexperience outside the facility. The results also suggestthat environmental factors (self-improvement, support
system, interpersonal relationships, economic situation,
job/organizational commitment) may have little impact
on job performance.
Although we found that both transdisciplinary
learning and knowledge promoted employment support
performance, other studies have shown that there are few
opportunities to acquire knowledge about employment
support for people with higher brain dysfunction [17,18].
The Ministry of Health, Labour, and Welfare is currently
discussing how best to train human resources to provide
employment support for people with disabilities; however, it is insufficient to solely acquire knowledge andskills in one’s direct area of expertise. Rather, knowledge
and skills related to both welfare and employment arealso required [8]. The results of this study indicate thatwhen the participants put the knowledge learnt throughtransdisciplinary learning into practice, it leads to anincrease in job performance. We believe that continuing
to offer transdisciplinary learning and improving job
performance will gradually improve the employment
support skills of supporters. In transdisciplinary learning,
personal characteristics such as a positive attitude aboutstaying up to date on information, as well as about listening to opinions from other people, may affect the degreeof job performance. In the future, it will be necessary to
examine the impact of individual characteristics on thequality of job performance, with regard to transdisci-

Kitakami M et al.

163

plinary learning and employment support.
To address the issues highlighted in this study, there
should be a systematic approach to human resource development that includes knowledge and skills training on
issues of welfare, employment, medical knowledge concerning the symptoms of higher brain dysfunction. This
would help ensure the provision of quality employment
support for people with higher brain dysfunction whowant to enter the workforce. However, our hierarchicalmultiple regression analysis showed that the variables
had low explanatory power for job performance. In addition to the three variables we examined in this context(transdisciplinary learning, work environment, knowledge), we surmised that other factors also affect job performance, including the level of disability and vocational
ability of those seeking assistance, their job category, thecircumstances of the company where they will return towork, and legal restrictions on medical care and welfare.
In the future, it will therefore be necessary to verify
how job performance affects outcomes for people withhigher brain dysfunction, both directly and indirectly.
We believe that clarifying this will help to provide
high-quality employment support to people with higher
brain dysfunction.

6. Limitations
Since the questionnaire survey recovery rate ofthis study was low at 23%, there is a limit to the generalizability of the results. Our results are also difficult
to generalize because we did not survey all types ofprofessionals who provide employment support forpeople with higher brain dysfunction. While OTs, STs,
SWs, and employment support workers are important
actors who provide crucial services, such as employment
support for people with higher brain dysfunction, this is
not an issue that can be solved by individuals working
solely in the four occupations examined in this study.
However, it is difficult to survey other relevant occupations, including doctors, physical therapists, vocationalcounselors for people with disabilities, job center staff,
and public sector employees. This study was conducted
in 2012. Employment support for people with disabilities is susceptible to employment measures for suchindividuals, as well as revisions to the Japanese medical
welfare system. In the future, it will also be important tocompare the current situation with that of 2012, as well
as examine what kind of social background affects thejob performance of employment support. Further, job
performance is ultimately a subjective evaluation givenby the respondent, and does not include the quality of
employment support, satisfaction levels of the recipients,
or outcomes of employment support.

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EMPLOYMENT SUPPORT AND BRAIN DYSFUNCTION

7. Conclusions
As people with higher brain dysfunction often fellthrough the gaps allowed by previous systems in Japan,
the government implemented an extension project designed to provide relevant support, including provisions
targeted at their employment needs. However, around
60% of people with higher brain dysfunction still do notfind jobs. One reason for this is insufficient knowledge
and skills among the professionals who provide this
support. As such, this study clarified the factors that
affect employment support performance for people withhigher brain dysfunction. Our results clearly showed thatboth transdisciplinary learning and knowledge about employment support were crucial factors for promoting thistype of support. While there are now areas of relevant
specialization, collaborative efforts should be targeted at
the development of systematic human resource programs
aimed at employment support, specifically covering
issues related to welfare, employment itself, and the
medical features of higher brain dysfunction. This should
aid in the establishment of systems that can provide
quality employment support for people with higher brain
dysfunction who want to enter the workforce.

8. Ethics
This study was conducted with the approval of the
ethics committee on human research at the University ofTsukuba (East 24-4).

9. Conflict of Interest
The authors declared no potential conflicts ofinterest with respect to the research, authorship, and/or
publication of this article.

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to work after acquired brain injury? a systematic review.
Brain Inj. 2009;23(6):473-88.
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dysfunction - Use of vocational centers for people withdisabilities, and status of and problems related to cooperation with medical institutions. Japan Organization for
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[5] Maruishi M, Kawahara K, Murota Y, Sumihara S,
Momokawa A, Sawada K, Hashimoto Y, Kondo K. A
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Japanese J Occup Ther. 2006;40(10):1128-31.

■ORIGINAL ARTICLE

Initial Practice for the Introduction of a Gaze-Based
Augmentative and Alternative Communication Device
Shigeto Moriwaki
Department of Rehabilitation, Shimane University Hospital

Abstract: Background: Eye movement disorders of amyotrophic lateral sclerosis are unlikely to occur. For this reason,an increasing number of occupational therapists are have started introduction gaze-based AACDs. Although it is desirable to introduce AACDs as early as possible, the optimal method for introducing such devices remains unclear.
Objectives: This study aimed to clarify the initial practice for the introduction of a gaze-based AACD from an operational perspective.
Methods: The study participants were 16 healthy adults (12 males and 4 females; 30.9 ± 6.28 years). The following
three aspects were measured according to the two operation methods (gaze groups and switch groups): “physical function”, “mental function”, “computer operation”.
Results: No significant differences in physical or mental functioning were found between the gaze and switch groups.
The switch group input significantly more characters in the computer operation than did the gaze group (P = 0.02, mean
number of characters ± SD: 425.7 ± 156.5 vs. 234.9 ± 84.7, respectively). Furthermore, the switch group became accustomed to the operation significantly faster than the gaze group (P = 0.01, 9.1 ± 4.0 vs. 15.1 ± 2.7 minutes, respectively).
Conclusion: The initial training points for the introduction of gaze-based AACDs are as follows: The operating posture
may affect the ease of operation. Therefore, always check the operating environment. If you want to input many characters quickly or communicate your intentions in a timely manner, switch input is recommended. Give the patient at least
10–15 minutes per session of continuous practice to become comfortable with the operation.
Keywords: neurodegenerative disease, gaze-based augmentative and alternative communication devices, occupational
therapy, initial practice(Asian J Occup Ther 18: 165−171, 2022)

1. Introduction
Communication disorders is one of the mostdifficult challenges for people with neurodegenerative
disease [1]. Although the initial symptoms do not interfere with speech intelligibility or language functioning,as neurodegenerative disease progresses, many people
are unable to utilize spontaneous speech and written
communication to meet their daily communicationneeds, which has led to the increased use of gaze-based
augmentative and alternative communication devices(AACDs) in recent years [2]. In particular, the progression of amyotrophic lateral sclerosis (ALS) can lead
Received: 28 February 2021, Accepted: 27 June 2022
Corresponding to: Shigeto Moriwaki, Department of Rehabilitation,
Shimane University Hospital, 89-1 Enya-cho, Izumo, Shimane 6938501, Japane-mail: moriwaki@med.shimane-u.ac.jp©2022 Japanese Association of Occupational Therapists

to complete tetraplegia and the inability to breathe,swallow, or speak [3, 4]; however, in typical ALS, eyemovement disorders are unlikely to occur [5]. For thisreason, an increasing number of occupational therapists
are have started introduction gaze-based AACDs [6–9].
Occupational therapy for patients with ALS andother severe disabilities involves the following: 1) themaintenance of physical function and consideration of
psychological aspects due to the loss of physical andsocial functions, 2) complementary responses to lost
functions using self-help tools and welfare equipment
and devices, and 3) the maintenance and adjustment ofquality of life to aid the carrying out of social roles [10].
In other words, occupation therapy aims to maintainactivities of daily living using self-help devices andequipment while taking the psychological aspects ofthe patient into account. Communication is therefore
essential for expressing intention. As people with severe
disabilities and advanced disease such as ALS often
have difficulty expressing themselves verbally because

166

INITIAL PRACTICE FOR THE ALTERNATIVE COMMUNICATION DEVICEof tetraplegia and the inability to speak, support forverbal expression is extremely important. Occupational
therapists are equipped with assistive technologies thatallow such patients to express their intentions visually,
thereby supporting their pursuit of living a normal life.
Several studies have reported the effectiveness of
AACD implementation. Idemura et al. [11] found thatthe introduction of AACDs enabled patients with ALS toperform desired tasks and improved their performanceand satisfaction scores on the Canadian Occupational
Performance Measure. Marco et al. [12] reported thatthe use of eye-tracking communication devices not
only improved quality of life, but also was associatedwith a high level of user satisfaction. However, thosestudies reported the results of device implementation,
which is often challenging in practice. There are also
two methods of eye input devices: gaze and combined
use of switches. In most cases, gazing is utilized, andthe method of using switches together is often effective.
However, in both cases, the differences in operability
and the time it takes to get used to the operation are
unclear and have not been clarified.
Although it is desirable to introduce AACDs andcommunication aids as early as possible to predict thepatient’s disease state [13], the optimal method for
introducing such devices remains unclear. Therefore,
this study aimed to clarify the initial practice for the
introduction of a gaze-based AACD from an operational
perspective.

2. Methods
2.1 Research participants
The study participants were 16 healthy adults (12males and 4 females; mean age ± standard deviation[SD], 30.9 ± 6.28 years) who had experience operating aPC.
2.2 Gaze manipulation
The AACD used in this study was the Tobii Eye
Tracker 4C (Stockholm, Sweden). This relatively inexpensive device estimates the direction of the gaze byirradiating the pupil with near-infrared light and detecting the reflected light with a camera, and has recently
been used in a number of studies [14, 15]. Regarding
software, we used miyasuku EyeConSW (Unicorn Inc.,
Hirosima, Japan) [16], which specializes in gaze input
using two main operation methods. The first is using
gaze to select and decide on characters (gaze group),
and the second is using gaze to select characters and an
external switch to decide on characters (switch group).
This study compared these two operation methods.

2.3 Operating environment (Figure 1)
The operating posture was set with a head-up tilt of60°; the position of the AACD was set according to the
manufacturer’s instructions. Specifically, the distancefrom the AACD was set at 50 cm, and it was positioned
so that the computer monitor was in front of the participant [17]. The PC with the AACD was mounted in a
PC holder (Kawabata Iron Works Co., Ltd., Ishikawa,Japan) [18].
2.4 Operation
Using the AACD and associated software, we
input the History of Hiroshima Motorcycle Race for 30
minutes. The characters typed were hiragana in Japaneseand kanji. This is a book published by Koichiro Miho,an ALS sufferer, using only a line-of-sight input device[19]. In this study, the principal investigator designated apart of the book as the input. The books were displayedby the principal investigator, who printed them out andpasted them at the bottom of the computer screen.
2.5 Measurement and evaluation
For the assignment of the subject’s operation
method, we adjusted the experimental schedule of thesubjects and divided them into two groups: the first 8
subjects in the gaze group and the second 8 subjects inthe switch group. All subjects were before the experiment
began, the participants’ age, sex, years of experience
using computers, and presence of glasses or contactlenses were checked. After the experiment, the following
three aspects were measured according to the method of
operation: “physical function”, “mental function”, and“computer operation”.
The “physical function” items were blood pressure,
peripheral oxygen saturation, pulse rate, and muscle
hardness of the head and neck area (digital muscle
hardness; TDM-Z1., Chiba, Japan) [20]. The “mental
functioning items were salivary amylase levels [21] andsubjective fatigue (e.g., eyestrain, postural fatigue, andoverall fatigue based on a numerical rating scale). The“computer operation” items were the number of characters typed, the number of characters typed incorrectly,
and the amount of time the participants felt comfortablewith the operation. The number of characters typed
and the number of characters typed incorrectly werecounted by the principal investigator after the operation.
We asked the subjects to report the amount of time theparticipants felt comfortable with the operation during
the operation and asked them directly why they felt accustomed after the experiment. A timer was set up next
to the computer screen, and the principal investigator
checked the time when the subject reported the time.

Asian J Occup Ther 18: 165−171, 2022

Moriwaki S

167

no review was required. This study was conducted inaccordance with the Declaration of Helsinki. In addition,
informed consent was obtained from all participants
after they received both written and oral explanations of
the purpose and content of the study.

3. Results

Fig. 1. Operating environment.
The operating posture was set with a head-up tilt of60°. The distance from the AACD was set at 50 cm,
and it was positioned so that the computer monitor
was in front of the participant.
(A) Gaze to select and decide on characters (gazegroups).
(B) Gaze to select characters and an external switch
to decide on characters (switch groups).

2.6 Statistical analysis
The statistical analysis was conducted according
to the two operation methods (gaze and switch groups).
The chi-squared test was performed for sex and the presence of glasses or contact lenses, and after the means forthe other measurement items were calculated, the Mann–
Whitney test was used to compare the two groups. All
statistical analyses were performed with IBM SPSS
statistics analyses for Windows release 23 (IBM Japan
Ltd., Tokyo, Japan). All tests had a significance level ofp < 0.05.
2.7 Ethical considerations
This study applied for preliminary review by the
Medical Research Ethics Committee, Shimane University Faculty of Medicine and received a response that

The participants in the gaze group were six males
and two females (mean age ± SD, 32.4 ± 7.1 years;
mean experience with computer use ± SD, 12.63 ± 6.8
years). The participants in the switch group were also
six males and two females (mean age ± SD, 29.5.4 ± 5.5
years, mean experience with computer use ± SD, 10.13± 5.9 years).
The results of the comparison by method of operation are shown in Table 1. No significant differences inphysical or mental functioning were found between thegaze and switch groups. The switch group input significantly more characters in the computer operation than
did the gaze group (P = 0.02, mean number of characters ± SD: 425.7 ± 156.5 vs. 234.9 ± 84.7, respectively).
Furthermore, the switch group became accustomed tothe operation significantly faster than the gaze group(P = 0.01, 9.1 ± 4.0 vs. 15.1 ± 2.7 minutes, respectively).
The participants were also asked about the factorsthat made them feel accustomed to the software (Table2). Those in the gaze group responded that they wereable to understand the features, such as “I understood
how to use the predictive conversion” and “I figuredout where the characters were”. In addition, they also
acknowledged factors related to gaze movement, suchas “I can now move the cursor to where I want it to go”
and “I can feel the sensation to keep looking at it”.
Similar to the gaze group, the participants in theswitch group noted a accustom factor as they became
able to understand the features of the software. For
example, “I can understand the character layout”, “I
can understand the positional relationship of the control
panel”, and “I know where to find the characters”. The
factor that differed from the gaze group was related tothe operation of the switch (e.g., “I could understand thetiming of pressing the switch”).

4. Discussion
This study examined whether the operability of thesoftware differed depending on the operating method.
We divided the participants into two groups (gaze andswitch groups) and then compared physical and mental
functioning and PC operation. The results showed thatthe participants in the switch group input significantly

168

INITIAL PRACTICE FOR THE ALTERNATIVE COMMUNICATION DEVICE

Table 1 Comparison of measurements by operating method

N (%)
Age (years)
Sex (Male : Female)Computer use (Years)
Glasses/Contacts (Yes : No)
Physical Function
Blood pressure (mmmHg)
SystoleDiastole
Pulse (times)
SpO2 (%)
Muscle hardness (points)
Right
Left
Mental Function
Salivary Amylase (kU/1)
Fatigue level (points)
Eyesight
PostureWhole
PC operation
Number of inputs (characters)
Number of incorrect entries (characters)
Time to become familiar with the operation (minutes)

Gaze groups

Switch Groups

P-Value8(50)32.4 ± 7.1
6:2
12.63 ± 6.8
4:4

8(50)
29.5 ± 5.5
6:2
10.13 ± 5.9
5:3

0.38
0.72
0.45
0.62

120.4 ± 11.4
78.4 ± 9.9
67.4 ± 10.4
98 ± 1.3

119 ± 8.1
78.1 ± 8.8
71.6 ± 5.2
98.4 ± 1.1

0.64
0.83
0.19
0.39

51.6 ± 9.8
52.8 ± 9.4

48.75 ± 8.8
46.25 ± 8.2

0.79
0.25

17.9 ± 13

18 ± 13.4

0.79

5.6 ± 1.6
4.4 ± 1.9
6.3 ± 1.3

3.9 ± 1.9
4.4 ± 2.7
5.8 ± 2

0.10
0.96
0.65

234.9 ± 84.7
2.8 ± 4.2
15.1 ± 2.7

425.7 ± 156.5
1.38 ± 2.3
9.1 ± 4.0

0.02
0.37
0.01

*
*

Values are number or mean ± standard deviation.
Chi-square tests were performed to assess the differences between the two groups with respect to the sex andglasses and contact lenses. To comparatively evaluate age, years of computer experience, Physical Functions,
Mental Functions and personal computer operation, Mann-Whitney U tests were performed.
*P values < 0.05 were cosidered statistically sifnificant.

more text than did the gaze group. In addition, theswitch group became accustomed to the operation of thecomputer significantly faster than the gaze group.
4.1 I nfluence of physical and mental functioning(Table 1)
In this study, the a uniform operating posture wasused. As a result, no significant differences were foundin the assessment of physical and mental functioning. In
a previous study of the operation posture in relation togaze input, a head-up tilt of 60° was reported to be theleast physically and mentally burdensome [22].
The present study was conducted using the less burdensome posture involving a head-up tilt of 60°, which
we believe led to the finding of no significant differencesin physical and mental functioning. In other words, theappropriate operating posture was considered to be lessstressful on the body and mind, even though the operating methods were different. The control environment
for gaze input is extremely important [15]. Therefore,
proper positioning has the potential to reduce the impact
on physical and mental functioning.

4.2 Factors contributing to the high number of characters input in the switch group (Table 1)
The number of characters input in this study wassignificantly higher in the switch than in the gaze group.
The gaze group was instructed to gaze for 1 second to
determine the characters. By contrast, the switch group
could make a decision in less than 1 second because
they were instructed to press the switch at any time voluntarily. Therefore, we believe that allowing the participants to use a switch enabled them to input significantly
more characters, which resulted in the time difference
seen between groups.
4.3 Factors associated with familiarity with operation(Table 2)
The time to become accustomed to the operation
was about 15 minutes for the gaze group and about 9
minutes for the switch group, which represented a significant difference. Furthermore, being able to understandthe features of the software was the common factor
that allowed both groups to become accustomed to thesoftware. Specifically, they were able to understand thearrangement of the keys and the layout of the control

Asian J Occup Ther 18: 165−171, 2022

Moriwaki S

169

Table 2 Factors that made subjects feel comfortable with the operation by method (from subjects)
Switch Groups (N = 8)
When I could understood the timing of pressing the switch. When I found out that I could push in the middle.
When I could push the switch without putting pressure on your hands.
When I could understood the characters layout.
When I could get the hang of eye movement and cursor movement.
When I could operated while ignoring the red dot
When I stopped following the red dot with my eyes.
When I could understood the positional relationship of the control panel (screen layout).
When I knew where to find what characters.
Gaze groups (N = 8)
When I could now move the cursor to where I want it to go.
When I could feel the sensation to keep looking at it. When I was able to catch the sense of being able to push.
The part I was looking at often shifted, so I didn’t know the feeling I was used to.
When I understood how to use predictive conversion.
When I figured out where the characters are.
When I understood how to convert.
When I figured out the layout of the operation panel characters.
When the predictive conversion becomes available.

panel.
Operating a computer using gaze involves a series
of intentional eye movements, and eyes are easily fatigued [23]. Eye fatigue was scored as 3.9 in the switchgroup compared with 5.6 in the gaze group, indicatingthat eye fatigue tended to be lower in the switch thanin the gaze group. Therefore, the eye movements ofthe switch group had some leeway. We think that thismargin was a factor in the participants’ sense of habituation because those in the switch group were able tograsp the overall picture of the key layout and control
panel more quickly.
4.4 Application to initial training
Soofi et al. [24] attributed the problem of AACD
implementation in patients with ALS to the lack among
therapists of proper training in necessary skills andtechnology provision. For this reason, the authors
spent substantial time explaining the character input
methods to the participants. However, the participants
could not fully understand the input method until theyexperienced the actual operation. We therefore believethat it is important for participants to gain a good senseof the operation. Based on the results of this study, theinitial training points for the introduction of gaze-based
AACDs are as follows:ⅰ. Always check the operating environment.
The operating posture may affect the ease of operation. Therefore, it is also necessary to check whether the
posture allows ease of operation. In addition, checking
for eye fatigue is necessary to get a sense of familiarity
with the operation; therefore, this is particularly important as a check during operation.

ⅱ. If you want to input many characters quickly or communicate your intentions in a timely manner, switch
input is recommended.
In recent years, many patients have requested touse gaze-input AACDs. Depending on the nature of thepatient’s request, it may be necessary to recommend a
combination of switches. However, if a switch is used,
it is important to ensure that it is properly adapted to thepatient. Therefore, it is necessary to evaluate not only
computer, but also switch operation.
ⅲ. Practice for at least 10–15 minutes per session.
Explain the equipment and control panel thoroughly
before the practice. Give the patient at least 10–15 minutes of continuous practice to become comfortable withthe operation. Some patients may start the first practicesession after receiving an explanation of the operationof the AACD, but then give up within 5 minutes, sayingthat it is too difficult. This makes it more difficult to geta sense of the operation. Therefore, it appears best to
aim for 10–15 minutes or more to become accustomed
to the operation.
4.5 Limitations
The limitations of this study are twofold. First,
the participants in this study were healthy individuals.
Therefore, the results regarding physical and mental
functioning may differ in patients with ALS. In thiscase, experiments should be carried out with caution, as
previous studies have shown that such investigations arecarried out in patients who are aware of their communication needs [25]. Second, when operating a computer
using a switch, the body part and type of switch operation varies from patient to patient. Since this study was

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INITIAL PRACTICE FOR THE ALTERNATIVE COMMUNICATION DEVICE

conducted using a uniform operating method, the results
may have differed depending on the operability of theswitch. Therefore, the operability of the switch also
needs to be evaluated and analyzed.

5. Conclusions
This study focused on the operation of a gaze-based
AACD and examined differences in physical and mental
functioning and computer operability. The results indicated no differences in physical or mental functioning.
However, it was possible to input significantly morecharacters when operating the computer using a switch.
The results also indicated that it was necessary to practice continuously for 10–15 minutes or more to get used
to the equipment.
In the future, we would like to improve the accuracy of these results by analyzing the operability ofthe switch and conducting research involving actual
patients. In addition, we plan to clarify the social factors
necessary for the smooth introduction of AACDs fromthe perspective of occupational therapists.

Acknowledgments
The authors would like to thank for the rehabilitation therapists of their cooperation in conducting
this study. This study utilized part of the results from
hospital medical education and research grant funded byshimane University Hospital in FY 2018.

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■ORIGINAL ARTICLE

The Importance of Motor Imagery Ability
in Determining the Optimal Focus of Attention
During Motor Practice
Junichi Inatomi1, 3, Satoko Kataoka1, Sanae Hatada1, Yutaka Yano1, 3,
Kenji Hagihara1, Masatoshi Katsura1, Hideaki Takebayashi2,
Masahiro Yamaguchi3
1

Department of Occupational Therapy, Tosa Rehabilitation College, Kochi, Japan
Department of Physical Therapy, Tosa Rehabilitation College, Kochi, Japan3
Department of Physiology, Kochi Medical School, Kochi University, Kochi, Japan
2

Abstract: Background: Outcome of motor practice is influenced by focus of attention. Paying attention to the environment (external focus) has been reported to be more effective than paying attention to body movements (internal focus).
On the other hand, internal focus was reported to be more effective for novice sports players, indicating that the optimal
focus differs among individuals. Outcome of motor practice is also reported to be influenced by motor imagery ability,
where subjects with higher motor imagery ability show better outcomes. However, the possible relation between optimal focus of attention and motor imagery ability is not yet known.
Methods: In this study, we evaluated the motor imagery ability of healthy young students using a mental rotation task,
and divided the subjects into low-motor-imagery and high-motor-imagery groups. The subjects performed the Functional Reach Test, which reflects balance ability, and performance was examined during and after repeated practice withdifferent focuses of attention.
Results: Internal focus was more effective than external focus for the low-motor-imagery groups, while internal focus
and external focus were similarly effective for high-motor-imagery groups.
Conclusion: These results indicate the relation between optimal focus of attention and motor imagery ability, and suggest the importance of evaluating motor imagery ability in choosing optimal focus of attention for motor practice.
Keywords: motor imagery, focus of attention, motor practice(Asian J Occup Ther 18: 173−180, 2022)

Introduction
During motor practice, occupational therapists instruct learners to pay attention to specific targets. Focus
of attention can be divided into two types. With an
external focus of attention (EF), learners pay attention
to the environment such as goals of the movement. Withan internal focus of attention (IF), learners pay attention
to the body parts involved in the movement. The focus
Received: 3 March 2022, Accepted: 27 June 2022
Corresponding to: Masahiro Yamaguchi, Department of Physiology,
Kochi Medical School, Kochi University, 2500-2 Ootsuotsu, Kochi
781-5103, Japane-mail: yamaguchi@kochi-u.ac.jp©2022 Japanese Association of Occupational Therapistsof attention is important for optimizing the outcome of
motor practice, and the majority of studies have shownthat an EF is much more effective than an IF [1]. An
EF has been reported to be effective in various motor
tasks, including balancing tasks [2]. EF is consideredadvantageous over IF because the latter may impede theautomatic control of movement [3].
However, some studies have indicated that an IF
can be effective, especially for novices. While highly
skilled golfers performed better with an EF than an IF,
low-skilled golfers performed better with an IF [4]. An
IF was also shown to be more appropriate for novices
during the early stage of motor learning [5, 6]. Peh et al.
[6] explained this observation as follows. Novices atthe early stage of learning must acquire a functional
movement pattern so that the movements of relevant

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MOTOR IMAGERY ABILITY AND ATTENTION FOCUS IN MOTOR PRACTICE

Fig. 1. Procedure of this study.
Among 73 candidates, 40 subjects were selected by the correct rate in the mental rotation task. They were divided into a low
motor imagery (LMI) group (n = 20) and a high motor imagery (LMI) group (n = 20) according to the reaction time of the task (1 stgrouping). Then all the subjects conducted a pre-test of motor task (Functional Reach Test), and each group was further divided
into an internal focus group and an external focus group (2nd grouping). The resultant four groups (n = 10 each) did not significantly differ in the age, sex, correct rate of mental rotation task, and outcome of the pre-test. The four groups received 5 days ofpractice in the motor task with corresponding focus instruction (Practice) and conducted the motor task without instruction ondays 6 and 13 (Retention).

body parts co-occur appropriately, and thus need to pay
close attention to the movement of their body parts.
While such an argument provides an attractive neuralbasis for the optimal focus of attention, it is not evident
how occupational therapists and subjects can choose
the optimal focus of attention in various kinds of motor
practices in daily life and restoration from injuries anddiseases.
To find the optimal focus of attention for individual
subjects, information on their motor imagery ability
might be helpful. Motor imagery represents initial generation of action plans and movement programs, and isregarded as particularly important for performing motor
tasks [7]. Furthermore, the outcome of motor practice
is influenced by motor imagery ability. Individuals who
easily generate motor imagery can better acquire new
movements [8], and motor imagery training improves
performance of a motor learning task [9, 10]. Thus, theoutcome of motor practice is thought to be influenced
both by the motor imagery ability and the focus of attention, which raises the possibility that the optimal focus
of attention and motor imagery ability are correlated.
The purpose of this study is to clarify the importance of assessing motor imagery ability in determining
optimal attentional focus in motor practice. We here
examined whether the effectiveness of motor practicewith EF or IF differs according to the motor imagery
ability of subjects. We evaluated motor imagery ability

by mental rotation task [11], in which subjects are presented with pictures of limbs and indicate whether they
are left or right limbs as quickly as possible. Using thistask we divided subjects into low-motor-imagery andhigh-motor-imagery groups. As a motor task for practice, we used the Functional Reach Test (FRT), which
represents balance ability that is considered fundamental
to various aspects of motor activity [12].

Methods
1. Subjects
Figure 1 shows the procedure of this study. Initially,
73 healthy right-handed college students (41 males, 32
females) with an average age of 19.3 ± 1.1 years (range:
19–24 years) were recruited as candidates of the subjects. The candidates performed the mental rotation task(see the following section), and those who scored above
80% of the correct rate on the task, which is the threshold indicating reliable test performance, were selected
as subjects [11, 13]. As a result, 40 healthy right-handed
college students (22 males, 18 females) with an averageage of 19.3 ± 1.0 years (range: 19–24 years) were selected. They were divided into a low motor imagery (LMI)
group (n = 20) and a high motor imagery (HMI) group(n = 20) according to the reaction time of the task, by
setting the threshold time to assign an equal number ofsubjects into the two groups (1st grouping). Then all theAsian J Occup Ther 18: 173−180, 2022

Name N et al.

175

Fig. 2. Example of photographs used in the mental rotation task.
Thirty-two photographs were randomly displayed on a computer display. The photos consisted of the backs and palms of theleft and right hands, and dorsal and plantar surfaces of the left and right feet, and were rotated by 0, 90, −90, or 180 degrees.
Subjects were requested to answer whether the hands/feet were left or right as quickly as possible.

subjects conducted a pre-test of motor task (Functional
Reach Test: FRT), and each group was further divided
into an internal focus group and an external focus group(2nd grouping).
None of the subjects had prior experience with thetask used in this study (mental rotation task and FRT),
and all of them were naive to the purpose of the experiment. Before participating in the study, all subjects gave
informed consent. The study was approved by the Institutional Review Board of Tosa Rehabilitation College(TRC; registration No. TRC 201802). The procedures
used to collect the data followed all ethical standards ofthe Declaration of Helsinki.
2. Evaluation of motor imagery ability
To evaluate motor imagery ability, candidates ofthis study performed a mental rotation task [11]. In thistask, subjects are presented with pictures of limbs at various angles and asked to indicate whether they are leftor right limbs as quickly as possible; those with higher
motor imagery ability have shorter reaction times [7].
The task was conducted using the Multi-PAS System(Q’sfix Corporation, Tokyo, Japan). Thirty-two photographs were randomly displayed on a computer display;
the photographs consisted of the backs and palms of theleft and right hands, and dorsal and plantar surfaces ofthe left and right feet, and were rotated by 0, 90, −90, or
180 degrees (Fig. 2). The subjects were asked to indicate
whether each photograph was of the right or left hand (orfoot) as accurately and quickly as possible, by pressing
a button corresponding to the right or left side. During
the task, subjects sat in a chair and held the pushbutton
switch corresponding to the right and left side in theright and left hand, respectively, so that they could press
the button immediately after their decision. Since thebutton-pressing was detected by a photo sensor, thelatency from the button-pressing to the detection wasless than 1 msec.
First, the rate of correct responses was determinedfor each subject, and those with an accuracy below 80%
were excluded from the study. Then, the average reaction time (ms) was determined for each subject retainedin the study. A threshold reaction time of 1,485 ms was
set to divide the 40 subjects into equal (n = 20) shorter
reaction time (HMI) and longer reaction time (LMI)
groups.
After performing an initial FRT (pre-test), each
HMI and LMI group was further divided into IF and EF
groups by using a random grouping function of Microsoft Excel software.

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MOTOR IMAGERY ABILITY AND ATTENTION FOCUS IN MOTOR PRACTICE

3. Motor task
As a motor task, we used the Functional Reach Test
(FRT), in which a subject pushes a bar forward with
one arm as far as possible in a standing position and the
maximum distance reached is measured. The FRT correlates with the center of pressure excursion (COPE) andrepresents balance ability that is considered fundamental
to various aspects of motor activity [12]. Subjects
performed FRT using a commercially available device(GB-210; OG Wellness, Okayama, Japan) according to
the instructions of Duncan et al. [12] and Fujisawa et al.
[14]. The subjects stood in an upright position and thenpushed a bar with their right hand as far as possible. In
the starting posture, the medial edges of both plantar
surfaces of the feet were kept 15 cm apart, and the rightupper arm was held horizontally from the acromion
to the fingertips, with the forearm in middle position,and elbow joint and finger joints fully extended. The
maximum reaching point was measured in mm. Subjects
were instructed to push the bar slowly, and to keep theirfingers in contact with the bar throughout the task, andtheir heels in contact with the floor. The forward shift in
the COPE, which indicates a shift in the center of gravity (COG) of the body, was measured (in mm) during
the FRT using a force plate (Anima Corporation, Tokyo,
Japan). Because it correlates with the COPE, the FRT is
considered to be a precise and stable balance assessment[12]. There were no outliers according to the Grubbs–
Smirnov test, which was performed after all of the data
had been collected.
In the initial FRT (pre-test), the FRT was conducted
2 times. The maximum reaching point was measured
during both attempts, and the larger value was used in
the analysis. When practicing the FRT, the subjects in
the IF groups were instructed to stretch their arms as far
as possible, while those in the EF groups were instructedto push the bar as far as possible. The instruction wasgiven verbally in every task. This task was conducted 10
times a day for 5 consecutive days (days 1–5). The maximum reaching point of the FRT was measured during
all attempts, and the largest value on each day was usedin the analysis.
For the retention task performed on days 6 and 13,
the FRT was completed twice without practice and thelarger value was used in the analysis. The COPE wasmeasured twice on days 6 and 13, and the larger value
was used in the analysis. COPE measurement was notconducted during the practice period, to avoid prolongation of the entire time length of the practice (10 timesof task per day), which may affect the outcome of thepractice.

4. Questionnaire
A questionnaire was administered at the end of thesession to investigate whether the subjects attention wasappropriately focused during the session. Subjects wereasked to indicate whether they paid more attention totheir own bodies or to the external environment during
the session. The focus of attention was considered appropriate when subjects of IF groups paid more attention
to their own bodies and those of EF groups paid more
attention to the external environment.
5. Statistics
Profiles of 4 groups (LMI-IF, LMI-EF, HMI-IF
and HMI-EF) were compared by one-way ANOVA or
chi-square test with the post-hoc Bonferroni multiple
comparison test. For the comparison of FRT reaching
distance and COPE between IF and EF, measurements
were conducted repeatedly in the same subjects during
practice and retention periods (within-subject factor),
while IF and EF were conducted in different subjects(between-subject factor). Thus, two-way repeatedmeasures ANOVA (one repeated measures factor and
one non-repeated measures factor) was adopted for thisanalysis. Furthermore, to confirm the effect of motor
practice, FRT of each day during practice and retention
periods was compared with that of pre-test by using
Dunnett’s multiple comparison test. To compare FRT
on each day between IF and EF groups, two-tailed t-test
for between-subject data was first performed and the obtained p-values were adjusted for multiple testing by the
Benjamini-Hochberg adjustment [15, 16]. The adjusted
p-values were used for the analysis in Fig. 3.
Statistical analyses were conducted using SPSS
software (version 27; IBM Corp.). Statistical significance was set at p < 0.05.

Results
1. Profiles of four groups with different motor imagery
and focus of attention in motor practiceTable 1 shows the profiles of the four groups(LMI-IF, LMI-EF, HMI-IF and HMI-EF). They did not
significantly differ in the age, sex, correct rate of mental
rotation task, initial FRT or initial COPE. The fourgroups differed in the reaction time of the mental rotation task. The HMI groups had shorter reaction times
during the mental rotation task than the LMI groups, andthe reaction time did not differ between the LMI-IF and
LMI-EF groups, or between the HMI-IF and HMI-EF
groups. Detailed F and p values for the comparison ofeach group profile and post-hoc Bonferroni test values
for the reaction time of mental rotation task were shownin Table 2.

Asian J Occup Ther 18: 173−180, 2022

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177

Table 1 Profiles of the four groups differing by motor image ability and focus of attention type while practicing. MR, mental rotation task.
Low motor imagery (LMI)

Age
Sex (male, female)
MR: correct rate (%)
MR: reaction time (msec)
FRT (mm)
COPE (mm)One - way ANOVA/χ2

High motor imagery (HMI)

Internal focus (IF)(n = 10)External focus (EF)(n = 10)

Internal focus (IF)(n = 10)External focus (EF)(n = 10)p value

19 ± 0.04, 6
90.9 ± 6.7
1981.4 ± 366.9
328.7 ± 31.4
50.4 ± 14.6

18.9 ± 0.3
6, 4
88.4 ± 5.5
1964.4 ± 243.1
325.6 ± 31.9
51.8 ± 11.9

19.5 ± 1.25, 592.8 ± 5.4
1026.7 ± 362.8
338.4 ± 34.3
51.1 ± 13.9

19.6 ± 1.57, 390.0 ± 5.0
1064.1 ± 223.9
334.7 ± 35.7
51.4 ± 16.1

p = 0.33
p = 0.57
p = 0.57
p < 0.01
p = 0.85
p = 0.99

Table 2 Detailed statistical results for the comparison of the four groups in Table 1.
one-way ANOVA: Degrees of freedom, F value, p valueχ2: Degrees of freedom, Chi-square, p value
AgeSex

F (3,36) = 1.17, p = 0.33
χ2(3) = 2.02, p = 0.57

MR: correct rate

F (3,36) = 0.68, p = 0.56

MR: reaction time

F (3,36) = 27.52, p < 0.01

FRT
COPE

F (3,36) = 0.27, p = 0.85
F (3,36) = 0.03, p = 0.99

2. Motor practice for the low motor imagery groups
As Fig. 3 shows, the LMI-IF and LMI-EF groups
showed consistent improvement in the FRT during
both the practice and retention periods (F7,126 = 35.04,
p < 0.001 for time course; two-way ANOVA). For both
LMI-IF and LMI-EF groups, FRT performance of alldays of practice and retention periods (days 1, 2, 3, 4,
5, 6 and 13) was significantly better than that of pre-test( p < 0.001 for all days; Dunnett’s multiple comparisontest).
Notably, the improvement was significantly moreevident in the LMI-IF group than the LMI-EF group(F1,18 = 5.029, p = 0.038 for focus of attention; two-way
ANOVA). Comparison of FRT on each day between thetwo groups revealed that the performance of LMI-IF
group was better than that of LMI-EF group on days 4
and 5 of the practice period and days 6 and 13 of the retention period (asterisks in Fig. 3; t-test with BenjaminiHochberg adjustment; adjusted p = 0.037 for day 4,
0.032 for day 5, 0.046 for day 6, and 0.044 for day 13).
There was a significant interaction between time courseand focus of attention (F7,126 = 3.241, p = 0.003 for interaction; two-way ANOVA).
The LMI-IF and LMI-EF groups showed consistentimprovement in the COPE during the retention periods(in mm; LMI-IF: 69.7 ± 22.3 for day 6, 60.0 ± 16.1 for

Bonferroni test: Groups and p value–––
LMI-IF vs. LMI-EF, p = 1.00
LMI-IF vs. HMI-IF, p < 0.01
LMI-IF vs. HMI-EF, p < 0.01
LMI-EF vs. HMI-IF, p < 0.01
LMI-EF vs. HMI-EF, p < 0.01
HMI-IF vs. HMI-EF, p = 1.00––

day 13; LMI-EF: 58.4 ± 16.2 for day 6, 56.9 ± 12.6 forday 13) (F2,36 = 12.42, p < 0.001 for time course; twoway ANOVA). However, the degree of improvement in
the two groups did not differ significantly (F1,18 = 0.493,
p = 0.491 for focus of attention; two-way ANOVA).
There was no interaction between time course and focus
of attention (F2,36 = 2.373, p = 0.108 for interaction; twoway ANOVA).
To confirm whether the subjects paid proper attention during practice, they were asked to confirm theirfocus of attention after all sessions were completed. All
subjects in the LMI-IF group declared that they paid
attention to their bodies throughout the sessions. In the
LMI-EF group, 9 out of 10 subjects declared that they
focused on the external objects throughout the session.
The remaining subject said that he paid attention to both
his body and the external object. However, because hisinternal attention was oriented toward his heels to keepthem on the floor, and not toward the extending arm, he
was considered to have adhered to the instructions andwas thus included in the analysis.
3. Motor practice for the high motor imagery groups
Subjects in the HMI groups were allowed to practice the FRT as per the LMI groups. The HMI-IF and
HMI-EF groups showed consistent improvement in the

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MOTOR IMAGERY ABILITY AND ATTENTION FOCUS IN MOTOR PRACTICE

Fig. 3. Functional Reach Test (FRT) in the low-motor-imagery groups.
The FRT reaching measurements during thepractice and retention periods are shown for the internal focus of attention (IF, ●) and external focus ofattention (EF, □) groups. Data are the mean ± standard
deviation (SD) (n = 10 for each group). FRT was
significantly better in the IF group than the EF group(two-way ANOVA), and the difference was evident
on days 4, 5, 6 and 13 (*adjusted p < 0.05; t-test with
Benjamin-Hochberg adjustment).

FRT during both the practice and retention periods (Fig.
4) (F7,126 = 20.00, p < 0.001 for time course; two-way
ANOVA). For both HMI-IF and HMI-EF groups, FRT
performance of all days of practice and retention periods(days 1–13) was significantly better than that of pre-test( p < 0.001 for all days, Dunnett’s multiple comparisontest). However, the extent of the improvement did not
differ between the groups (F1,18 = 0.575, p = 0.458 for
focus of attention; two-way ANOVA). Comparison of
FRT on each day between the two groups showed nosignificant difference (t-test with Benjamini-Hochberg
adjustment). There was no interaction between timecourse and focus of attention (F7,126 = 0.558, p = 0.789
for interaction; two-way ANOVA).
The HMI-IF and HMI-EF groups showed consistentimprovement in the COPE during the retention periods(in mm; HMI-IF: 59.0 ± 8.7 for day 6, 59.8 ± 9.9 for day
13; HMI-EF: 64.5 ± 18.7 for day 6, 62.7 ± 9.0 for day13) (F2,36 = 5.037, p = 0.012 for time course; two-way
ANOVA); the extent of the improvement did not differ
significantly between the groups (F1,18 = 0.596, p = 0.450
for focus of attention; two-way ANOVA). There was nointeraction between time course and focus of attention(F2,36 = 0.151, p = 0.860 for interaction; two-way
ANOVA).
In the questionnaire completed after the final session, all subjects in the HMI-IF group declared that theyFig. 4. FRT in the high-motor-imagery groups.
The FRT reaching measurements during the practice and retention periods are shown for the IF (●) andEF (□) groups. Data are the mean ± SD (n = 10 foreach group). FRT did not significantly differ between
IF and EF groups (two-way ANOVA).

paid attention to their bodies throughout the sessions.
In the HMI-EF group, 8 out of 10 subjects declared thatthey attended to external objects throughout the sessions. While the remaining two subjects stated that they
paid attention both to their bodies and external objects,
their internal attention was oriented toward their heels
and not toward the extending arm. Therefore, they wereconsidered to have adhered to the instructions and were
included in the analysis.
Overall, the analyses showed that an IF was more
effective than an EF with respect to FRT practice performance for the LMI subjects. The results indicated theimportance of using an optimal focus of attention during
motor practice according to motor imagery ability.

Discussion
This study evaluated the motor imagery ability ofhealthy young students using a mental rotation task. In
the LMI groups, IF was markedly more effective thanEF with respect to FRT performance. By contrast, inthe HMI groups, the effectiveness of IF and EF did not
differ significantly. These results indicate that IF is more
effective for subjects with poor motor imagery ability,
and suggest the usefulness of evaluating motor imagery
ability in choosing an appropriate focus of attention
during motor practice.
During the initial stage of motor learning, the attention of learners is not focused on the content of the task,
but on their own body movements. Learners improve
the accuracy of their movements by coordinating theAsian J Occup Ther 18: 173−180, 2022

various parts of the body and adjusting the timing andstrength of the movements [17]. Analysis of brain activity also showed that the activity of the superior parietal
lobule, which is considered to relate to the body schema[13], is enhanced at the onset of motor learning [18].
These reports support the view that bodily information
is particularly important during the early stage of motor
learning. LMI subjects in this study resemble those at
an early stage of motor learning and rely heavily on
body imagery for motor movements. An IF is thought todirect the attention of LMI subjects to their body partsand help to improve their motor practice. In contrast,
HMI subjects may be already proficient at integrating
the bodily information necessary for executing motor
tasks. Because EF promotes a more automatic modeof motor control via use of the unconscious, fast andreflexive processes, EF as well as IF might be useful for
HMI subjects who do not need to pay close attention totheir body parts [1].
Several methods are commonly used to evaluate
motor imagery ability [19]. The mental rotation task
was used in this study for the following reasons. First,
an fMRI study reported that the superior parietal lobule,which is known to be involved in motor imageries, isactivated during the task [13]. Second, the mental rotation task does not rely heavily on language; in contrast,
questionnaires, and interviews such as the Motor Imagery
Questionnaire [19] depend heavily on language comprehension, which might differ significantly among subjects. Third, the mental rotation task encompasses manykinds of movements, whereas the mental chronometrytask [20] represents a highly specific movement pattern
and thus might not be suitable as a general evaluation of
motor imagery ability. Fourth, the mental rotation task
is often novel for subjects. On the other hand, the situations described in questionnaires and interviews, and the
movements engaged in during the mental chronometrytask, might be familiar to some subjects and this could
bias the results. A previous report evaluated individuals’ motor imagery ability by using the movement
imagery questionnaire and showed the relation between
modality-dominance of motor imagery and effects offocus of attention but did not show differences in the
improvement of motor performance between different
focuses of attention [21]. The discrepancy between thisreport and our study might be due to the difference inthe method of motor imagery evaluation or motor task
for practice.
A drawback for the mental rotation task is that astandard reaction time threshold discriminating low andhigh motor imagery ability is not yet established [7, 14].
Thus we here set a threshold to assign an equal numberof subjects to LMI and HMI groups. It would be ideal

Name N et al.

179

to find a fixed threshold to judge whether each person
has low or high motor imagery ability. Accumulation ofstudies with similar test design and subjects may enable
the identification of the standard threshold.
Other limitations of this study are as follows. First,
the mental rotation task might not be effective for thepractice of other types of motor tasks. While the FRT
used in the present study is a simple task under a stablesituation, some motor tasks require that attention be paid
to the external environment or other people, and theability to comprehend spatial information. Improvementon such tasks might require an evaluation of other thanmotor imagery ability. Second, the improvement in
COPE did not differ significantly between the LMI-IF
and LMI-EF groups, although FRT and COPE are believed to be correlated [12]. This discrepancy might bedue to the postural control strategy used during the FRTpractice. Fujisawa et al. [14] reported that, during the
FRT, some subjects showed improvement in the reaching distance without moving the COG, by using a “hipstrategy” instead of an “ankle strategy” [22]. The FRT
and COPE are well correlated under the latter but not theformer strategy [23]. It is possible that many subjects inour study used the hip strategy. Because the hip strategy
results in a more fixed posture with less movement, itis preferable that subjects be encouraged not to use thehip strategy in view of the purpose of motor practice. In
future experiments we plan to prevent the subjects frompulling back their buttocks using their hip joints, by
having them stand against a wall.

Conclusion
The present study indicated that choosing the focus
of attention is important in motor practice, and that evaluation of motor imagery ability is useful for determining
the optimal focus of attention during motor practice.
Further understanding of the appropriate combinationof motor evaluation and attention focus during practicewould improve motor performance in daily life andrestoration from injuries and diseases.

Conflicts of interest
est.

The authors declare that there is no conflict of inter-

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

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MOTOR IMAGERY ABILITY AND ATTENTION FOCUS IN MOTOR PRACTICE

Acknowledgements
We would like to thank all the subjects who volunteered for this study.

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R. A Study of Postural Optimization during Functional
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■ORIGINAL ARTICLE

Improvement of Upper Limb Coordination
by Upper Limb Target-Tracking for Patientswith Cerebellar Ataxia: A Case Series Study
Satoshi Tabata1, Tomonori Nomura2
1
2

Rehabilitation Center, Niigata University Medical and Dental Hospital
Department of Occupational Therapy, Niigata University of Health and Welfare

Abstract: Objective: Few intervention studies have focused on upper limb function in patients with cerebellar ataxia.
This study aimed to evaluate the influence of upper limb target-tracking task training on upper limb coordination inpatients with cerebellar ataxia.
Methods: Six patients with cerebellar-type multiple system atrophy underwent training (20 min/day for 10 days),which involved using the left and right index fingers to track a target that moved at a constant speed on several kinds ofsimple figures. The evaluation was conducted using the iPad® Application for Evaluating Ataxia (iPatax), Scale for theAssessment and Rating of Ataxia (SARA), and Simple Test for Evaluating Hand Function (STEF).
Results: The coefficient of variation of the velocity of iPatax showed a tendency to decrease after training with thestraight line and circle test, indicating the stability of upper limb movement speed. However, the SARA score did notchange after training. The total time of STEF was shortened for the left and right hand after training in all cases, indicating improvements in the accuracy of motion and motor performance of the upper limbs.
Conclusion: Upper limb target-tracking task training may be useful for improving upper limb coordination in patientswith cerebellar ataxia. In addition, iPatax can be used to detect smaller changes in symptoms that are not reflected in
SARA.
Keywords: cerebellar ataxia, upper limb coordination, upper limb target-tracking task training, case series study(Asian J Occup Ther 18: 181−190, 2022)

1. Introduction
Spinocerebellar degeneration (SCD) is a generalterm for progressive degenerative diseases with ataxia as
the main symptom. Ataxia involves lesion formation in
the nerve cells of the spinal cord, brainstem, cerebrum,and cerebellum. SCD comprises clinical symptoms,
pathological findings, or several genetically distinct
disease types, with cerebellar ataxia occurring in several
disease types [1]. Cerebellar ataxia is caused by ataxiaof the limbs and trunk, postural reflex disorder, and gait
disturbance and decreases overall activities of dailyliving (ADL). Moreover, as dysmetria and coordination
Received: 9 January 2021, Accepted: 7 April 2022
Corresponding to: Satoshi Tabata, Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754 Asahimachi-dori, Chuoku,
Niigata 951-8520, Japane-mail: satoshitaba.np4@nuh.niigata-u.ac.jp©2022 Japanese Association of Occupational Therapists

disturbance impair fine motor movement, hand movements deteriorate, making the use of tools difficult [2].
There is no effective pathophysiologic treatment for
cerebellar ataxia, with rehabilitation mainly aimed at
improving and maintaining symptomatic treatment ofeach symptom and physical function.
Walking speed, stride, and lateral swaying during
walking were reportedly reduced by limb muscularstrength training, cooperative motion training, andbalance training in patients with cerebellar ataxia, withimprovements in motor performance and ADL [3].
However, few studies have focused on upper limb
function. Upper limb training for cerebellar ataxia
involves loading with a weight or compression with anelastic bandage. However, its effect has not been sufficiently verified. One reason for this is that no method
has been established that is capable of specifically andquantitatively evaluating cerebellar ataxia in the upper
limbs. Conventional neurological examinations havebeen developed to evaluate upper limb ataxia; however,182

UPPER LIMB TRAINING FOR CEREBELLAR ATAXIA

Table 1 Patient characteristics.
Sex, age, disease type, duration of disease, and past medical history are indicated for all cases.
Case ID

Sex

Age

Type of disease

Duration of disease (months)

Past medical history

case Acase Bcase Ccase Dcase Ecase F

female
male
male
male
femalefemale

67
67
60
70
50
76

MSA-C
MSA-C
MSA-C
MSA-C
MSA-C
MSA-C

14
14
29
36
29
50

hypothyroidism, diabetes mellitus
diabetes mellitus, dyslipidemia
sleep apnea syndrome
hypertension

MSA-C: Multiple system atrophy with predominant cerebellar ataxia

results are difficult to quantify. Therefore, we developed
the iPad® Application for Evaluating Ataxia (iPatax) as a
new system to quantitatively evaluate upper limb ataxia
in patients with cerebellar ataxia [4]. In this system, theiPad (Apple Inc., Cupertino, CA) utilizes a target-tracking task program that keeps track of the target moving
at a constant speed using the fingers and is based on themeasurement of the distance (space gap) between thefinger and indicator, denoting the speed of the finger.
This allows the convenient evaluation of upper limb
movement function. Interestingly, we confirmed thatthe coefficient of variation (CV) of the tracking speedwith fingers decreases during the inspection process [4].
A decrease in CV suggests that the target-tracking task
improves upper limb coordination. This target-tracking
task training requires visual information to track
the finger at a constant speed. Further, the tracking
movement requires information from deep sensation.
Repeating this training that requires visual and deep
sensation feedback may form an internal model in the
cerebellum and allow smooth movement to be learned.
[5]. However, it is important to confirm the influenceof target-tracking task training for fingers on cerebellar
ataxia.
Therefore, this study aimed to examine intensive
upper limb target-tracking task training for patientswith cerebellar ataxia to verify the change in upper
limb coordination. It was hypothesized that upper limb
target-tracking task training could improve upper limb
coordination in cerebellar ataxia. We conducted a caseseries study as a pilot study to verify this hypothesis.

2. Methods
2.1. Subjects
This study included six patients (three male andthree female; age, 50–76 years; duration of disease,
14–50 months) who had multiple system atrophy withpredominant cerebellar ataxia (MSA-C) and were admitted to Niigata University Medical and Dental Hospital
between April 2018 and January 2019 (Table 1). Table 1

shows the past medical history of all patients. However,no medical history affecting cognitive function wasnoted. All patients were right-handed. All participants
provided written informed consent prior to the study.
The study was conducted in accordance with the Declaration of Helsinki, and the study protocol was approvedby the ethics committee of Niigata University (approval
no. 2017-0326).
2.2. Procedures
The patients performed a 20-minute upper limb
target-tracking task training for 10 days. They underwent
cerebellar ataxia evaluation and upper limb function
evaluation before and after training. In the intervention
period, upper limb function training was conducted forupper limb target-tracking task training alone. Physicaland occupational therapies were also performed at thesame time.
2.3. Intervention
Upper limb target-tracking task training
TraceCoderTM (System-network, Japan) is a device
for evaluating upper limb coordination. In this study, weused this device as a training tool to improve upper limb
coordination. In this training, a target point, which was
1.5 cm in diameter, was displayed on a 10.6-inch tablet
screen. The target point started from a point on the left
side of the screen and constantly moved at a speed of 12mm/s to the right. The patients were asked to track thispoint with their right or left index fingers. The training
tasks were performed by tracing the four patterns ofsine, rectangular, triangular, and spiral waveforms on
the tablet. The patients’ posture during training was
the chair-sitting position. The tasks of four patterns of
unilateral upper limb were conducted twice, and training
tasks were performed with the left and right upper limbs.
The training time was 10 minutes each for the right andleft upper limbs, for a total of 20 min/day for 10 days
(Fig. 1).

Asian J Occup Ther 18: 181−190, 2022

Fig. 1. Upper limb target-tracking task training.
This figure shows a patient tracking a sine wave
with the right hand. A 1.5-cm-diameter index point
was displayed on the 10.6-inch tablet PC screen,
starting from the left side of the screen. The target,
which moved at a constant speed of 12 mm/s to theright, was tracked with the index finger.

Name N et al.

183

2.4. Outcome measures
2.4.1. Evaluation of cerebellar ataxia
2.4.1.1. iPatax
iPatax is a program that instruments the Visually
Guided Tracking straight Movement Test (VGTMTstraight) and Visually Guided Tracking circle Movement
Test (VGTMT-circle) based on the eye-tracking method
operating on a 9.7-inch iPad screen developed by theauthors (Fig. 2). In VGTMT-straight, a target point witha diameter of 1.5 cm is displayed on the iPad screen,
moving at a constant speed of 5 cm/s along a 15-cmlong straight line. In VGTMT-circle, a target point witha diameter of 1.5 cm is displayed on the iPad screen,
moving around a 10-cm-diameter circle in 6 seconds.
The subjects were instructed that their index fingers
follow immediately above the target point before the examination. Both tests were conducted with the right andleft index fingers for 1 minute each. In both tests, thedistance between the visual target and the finger (spatial
displacement), velocity, and acceleration were measured
every 0.03 seconds. Thereafter, the examination timeof 60 seconds was divided into three sections: P1 (3 toFig. 2. Examination using iPatax (Jun T. 2015).
(A) The visually guided tracking-straight movement test. A 1.5-cm-diameter point was displayed on the iPad screen, which
moved at a constant speed of 5 cm/s on a 15-cm-long straight line. (B) Screen involving the explanations and conditions of
examination for the visually guided tracking-straight movement test. (C) Image under examination. The patients were instructed
to track the target directly as much as possible with either the left or right index finger. (D) This figure shows the visually guided
tracking-circle movement test. A 1.5-cm-diameter point was displayed on the iPad screen, which moved around a circle that was
10 cm in diameter for 6 s.

184

UPPER LIMB TRAINING FOR CEREBELLAR ATAXIA< 20 s), P2 (≥ 20 to < 40 s), and P3 (≥ 40 to ≤ 60 s). CV(standard deviation of population/average value) of the
distance, velocity and acceleration of the finger in eachsection was calculated. In the previous study of iPatax, astrong correlation was noted between CV of the smallest
speed among the three sections mentioned above and thescore of Scale for the Assessment and Rating of Ataxia(SARA) [3]. In this study, CV of the smallest speed
among the three sections was used as an outcome measure in conformity with a previous study [4]. The valueof CV was presented as a percentage (%CV). A decreasing %CV with both tests indicated a stable change inupper limb coordination.
2.4.1.2. SARAOne of the clinical outcome measures was SARA
[6], which has been proven to be a valid measure of disease severity in spinocerebellar ataxias [7]. The SARA
score includes 8 items: 3 items rating gait and posture, 1
item for speech disturbances, and 4 items for limb-kinetic functions.
2.4.2. Evaluation of upper limb function
The Simple Test for Evaluating Hand Function(STEF) (SAKAI Medical, Japan) is an examination used
for evaluating the patient’s ability to pinch, grasp, andtransfer objects [8]. STEF comprises 10 object-moving
tasks, using objects with different shapes and sizes (large,
medium-sized, and small balls; large, medium-sized,
circular, and small blocks; and clothes, coins, and pegs).
These tasks require different levels of hand dexterity. In
each object-moving task, the subjects were required topick up one set of these objects one by one from a storage space and move them into a target area as quickly
as possible. If the patient completed the task within theset time limit, a score was provided according to thetime required to complete the task based on a predetermined table for scores and time. The maximum scoreof each object-moving task was 10 points, and the total
maximum score for STEF was 100 points. However, thescore calculated at 100 points cannot sufficiently compare changes in movement accuracy and agility. Therefore, we compared the total time (seconds) required forthe 10-item test in this study. STEF was evaluated forthe left and right upper limbs.

3. Results
3.1. Changes in the tracking trajectory at the first (Day 1)
and final (Day 10) training
Figures 3 and 4 show the trajectory of the target
tracking with the right hand for the sine and triangularwave tasks as an example of the training. In the firsttraining, the tracked trajectory tended to deviate fromthe baseline. In addition, the tracked trajectory tended to
be a dotted line, indicating that the speed was unstable.
However, at the final training, deviations from the baseline tended to decrease in all cases in the trajectories
tracked; the trajectories were often indicated by a solidline, suggesting a stable speed.
3.2. Changes in velocity CV by iPatax
Figure 5 shows the change in the %CV of both the
VGTMT-straight and VGTMT-circle. In the VGTMTstraight, the left and right %CV of all cases decreased
after training compared to baseline measures. In the
VGTMT-circle, the left and right %CV, excluding
the right hand of case C and the left hand of case E,
decreased after the training compared to baseline
measures. The average value (standard deviation) of%CV in the subjects was 68.43 (12.31) for baseline and57.95 (9.65) after training on the right hand of VGTMTstraight. The baseline was 79.03 (14.26) and 66.32 (4.63)
on the left hand after training. On the right hand of the
VGTMT-circle, the baseline was 56.38 (9.52) and training was 48.77 (6.41). The baseline was 61.46 (12.12) inthe left hand, and training was 57.87 (9.73).
3.3. Changes in SARA
Figure 6 shows the changes in SARA. SARA
demonstrated no change in total score after training
compared to baseline measures in all cases. The averagevalue (standard deviation) of SARA score was 17.08(10.21) points for both baselines and after training.
3.4. Changes in the total time of STEF
Figure 7 shows the change in the total required timefor STEF. In all cases except for the left hand of case E,
the total time was shorter after training than that of baseline measures for both hands. The average value (standard deviation) of the total required time in the subjects
was 204.8 s (87.1) for baseline and 177.1 s (85.3) after
training on the right hand. On the left hand, the baseline
was 250.1 s (90.8) and 214.4 s (78.3) after training.

4. Discussion
The target-tracking training task to improve the CVof iPatax velocity seems to be an effective training toolfor improving upper limb coordination, and a largerscale study with more extensive outcome measures iswarranted to verify its full effects.
4.1. 
Changes in trajectory with upper limb targettracking task training
The trajectory at the first training showed several

Asian J Occup Ther 18: 181−190, 2022

Name N et al.

Fig. 3. Changes in trajectory at the first (Day 1) and final (Day 10) upper limb target-tracking task training (sine wave).
The figure shows the trajectory of all the cases who trained with the sine wave task for the right hand. The left and right lines
show the first trainings (Day 1) and final trainings (Day 10), respectively. In the left line, we observed a deviation from baseline
measures and a dotted line. However, the right line shows a decrease in the dotted line and less deviation from the baseline.

185

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UPPER LIMB TRAINING FOR CEREBELLAR ATAXIA

Fig. 4. Changes in trajectory at the first (Day 1) and final (Day 10) upper limb target-tracking task training (triangular wave).
The figure shows the trajectory of all the cases who trained with the triangular wave task for the right hand. The left and rightlines show the first trainings (Day 1) and final trainings (Day 10), respectively. As in Fig. 3, in the left line, we observed a deviation from baseline measures and a dotted line. However, the right line shows a decrease in the dotted line and less deviation fromthe baseline.

Asian J Occup Ther 18: 181−190, 2022

B

120

120
100

80

80

%CV

100

%CV

A

Name N et al.

60

60

40

40

20

20

0

C
120

Baselinecase Acase B

0

After trainingDcase C

120

80

80

%CV

100

%CV

100

60

40

20

20

Baselinecase Acase B

0

After trainingcase A
caseCEcase

case Bcasecase
D F

case Acase E

After trainingcase Bcase Fcase Cmean

case D

60

40

0

Baseline

Baselinecase Cmean
case
A

After trainingcase Dcase Bcase Ccase D

Fig. 5. The change in the %CV using iPatax at baseline and after training.
This figure shows the change in the %CV in the right and left hands of the velocity of VGTMT-straight and VGTMT-circle
using iPatax at baseline and after training. A) VGTMT-Straight (right-hand), B) VGTMT-Straight (left-hand), C) VGTMT-Circle(right-hand), D) VGTMT-Circle (left-hand) . The solid line in the figure shows the average value of %CV in the six subjects. The
average value (standard deviation) is shown baseline and after training. Figure A was 68.43 (12.31) for baseline and 57.95 (9.65)
for after training. Figure B was 79.03 (14.26) for baseline and 66.32 (4.63) for after training. Figure C was 56.38 (9.52) for baseline and 48.77 (6.41) for after training. Figure D was 61.46 (12.12) for baseline and 57.87 (69.73) for after training.

40
40

point

30
30
20
20
10
10

00

Baseline
Baseline
case
caseAAcase
caseEE

case
caseBBcase
caseFF

After
After training
training
case
caseCC
mean
mean

case
caseDD

Fig. 6. The change in SARA score at baseline and after training.
This figure shows the change in SARA score atbaseline and after training. The solid line in the figure
shows the average value of the six subjects. This
figure shows the change in SARA score at baseline
and after training. The solid line in the figure shows
the average value of the score in the six subjects.
The average value (standard deviation) of SARA
score was 17.08 (10.21) points for baseline and 17.08(10.21) points for after training.

187

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UPPER LIMB TRAINING FOR CEREBELLAR ATAXIA

A

B

400

400

40

350
300

350
300

30

250

200

sec

sec

250
20

150

200
150

100

100

10

50

50

0

Baselinecase Acase B

0

After training
Baselinecase A
case
caseCEcase Bcase
case DF

0

Baseline
After training

After trainingcase Ccase Amean

case Ccase Dcase Bcase D

Fig. 7. The change in the total time of STEF at baseline and after training.
This figure shows the change in the total time of STEF in the right and left hands after training and baseline. A) Right hand,B) Left hand. The solid line in the figure shows the average value of the six subjects. The average value (standard deviation) of
the total required time is shown baseline and after training. Figure A was 204.8 s (87.1) for baseline and 177.1 s (85.3) for after
training. Figure B was 250.1 s (90.8)for baseline and 214.4 s (78.3) for after training.

areas deviating from the reference line, which wasdisplayed as a broken line. However, in the training on
the 10th day, the deviation from the baseline decreased,
and the trajectory was demonstrated as a solid line.
This solid line indicated improved speed stability. In
this training, observing the graphic tasks displayed andthe tracked trajectory is crucial. This is because errors
between the reference line of the graphic tasks and thetraced trajectory are recorded as visual feedback, allowing participants to learn the correct tracking motion. Itoet al. [9] reported that erroneous motion was inhibited byrepeated training, and stable motion with less error waslearned. It is believed that errors in learning are facilitated by cerebellar feedback control. Dendrites of Purkinjecells and basket cells of the cerebellum, which are most
crucial to motor learning, respond only to some inputs,
and most are inactive [10]. Therefore, it is possible toactivate inactive cells and synapses. However, Payoux
et al. [11] reported that cerebellar activity declined, andthe activities of the supplementary motor cortex andparietal lobe increased during finger motion among
patients with MSA-C. The supplementary motor area
is activated by unfamiliar motion tasks, inducing motor
learning [12]. Because this training was short-term,
motor learning may have been insufficient. Therefore,
the change in trajectory caused by training may involve
not only feedback control by the cerebellum but also
motor learning in motor-related cortical areas.

4.2. Changes in velocity CV by iPatax
In this study, it was confirmed that the CV ofvelocity decreased after training. In the past iPatax research, the CV of velocity decreased in the second halfof the test time, and the task was gradually performedsmoothly by motor learning [4]. Similarly, in this study,
it is considered that, after the training, motor learning
was induced because the CV of velocity decreased, andthe task could be performed more smoothly. Cerebellar
ataxia is believed to be an abnormality in the temporal
pattern generation of agonist, antagonistic, and synergistic muscle activities. It is important to evaluate this
temporal measurement abnormality [4]. Generally, forexamining upper limb ataxia, point check and trace
examinations using writing instruments are often
used. However, these examinations are insufficient forquantification and cannot assess temporal measurement
abnormalities. The CV of velocity by iPatax used in thisstudy markedly reflects the temporal measurement abnormality of cerebellar ataxia and was highly correlatedwith SARA, which is used to evaluate ataxia severity [4].
This decrease in CV means that the movement velocity
was stable, indicating an improvement of upper limb
coordination in cerebellar ataxia. In VGTMT-circle,
in all except two cases, there was a tendency for CV
to decrease after training, implying that the training
could stabilize the velocity of movement and improve
cerebellar ataxia. In addition, it has been reported thattraining involving curves is more complicated than thatinvolving a straight line and the difficulty level is higher

Asian J Occup Ther 18: 181−190, 2022

in drawing tasks in cerebellar ataxia [13]. In the results
following this training, not only VGTMT-straight, which
is a relatively simple task, but also the more complicated
VGTMT-circle exhibited a decrease in the CV of velocity.
4.3. Change in SARA score
SARA is widely used internationally as an evaluation method for cerebellar ataxia because it correlates
well with the stage of SCD and is an excellent measureof severity [6]. However, the SARA annual rate ofchange of SCD is only 1.1–2.1 out of 40, and this lackof sensitivity is a drawback [14]. In this study, theSARA score did not change, and this could be because
the evaluation by SARA could not sufficiently detect thesymptom change due to the short duration of the training. Moreover, we reported that using iPatax, in addition
to SARA, could evaluate minute symptomatic changes[4]. In this study, as well as in previous studies, SARA
seemed able to detect a small change in symptoms that
could not be detected.
4.4. Change in the total time of STEF
Exercise-training intervention for patients withcerebellar ataxia has been shown to improve gait speed
and stride [15, 16]. Rodríguez-Díaz et al. [15] showed
an improvement in gait, standing, and sitting balance
via 19 exercise-training programs aimed at improving
limb muscle strength and coordination for 24 weeks
for patients with SCD. Ilg et al. [16] showed improvements in walking speed, stride, lateral swaying, andbalancing ability after intensive walking for 4 weeks
for 10 patients with cerebellar degenerative disease. It
is suggested that these exercise-training effects improvethe motor performance of walking and dynamic balanceability by improving intra-limb coordination for theknee and ankle joints. Based on these facts, we proposedthat repeating the upper limb target-tracking task training improved intra-limb coordination for the shoulder
and elbow joints and had a positive effect on STEF
performance. However, in this study, the training’s effecton ADL was not evaluated. We aim to improve ADL inpatients with cerebellar ataxia with this training.

5. Limitations and Future Studies
Because SCD, including MSA-C, is a degenerative
disease of the cerebellum, reversible changes cannot be
expected. It is still unclear whether deterioration of thecerebellum will compensate for impaired or prolonged
motor learning depending on the intensity of rehabilitation or the intervention method. Since this study
is a case series, there is no control group. As a result,

Name N et al.

189

statistical analysis is not possible, and the effect of theintervention is insufficiently verified.
In the future, we will examine the effective task
content of upper limb target tracking and its sustained
effect longitudinally. Next, you need to set up a control
group and statistically prove the effectiveness of thistraining. The mechanism of effect of this training is elucidated by diagnostic imaging and neurophysiologicalmethods. In addition, since all patients had no historyof neurological diseases other than MSA-C, they wereable to fully understand the content of the upper limb
target-tracking task training. However, since MSA-C
shows a decline in cognitive function as the symptoms
progress, it is necessary to grasp the degree of cognitive
function and verify the degree of understanding of training and its effect.

6. Summary and Conclusions
The present study demonstrated that upper limb
target-tracking task training decreased the CV ofvelocity in tracking movements and improved upper
limb performance in patients with cerebellar ataxia. Our
results suggest that this training may help improve upper
limb coordination in patients with cerebellar ataxia.
Moreover, iPatax detected smaller changes in symptoms
that were not reflected in SARA.

Conflict of interest
The authors have no conflicts of interest to declare.

Acknowledgments
This work received support from the Japan Occupational Therapy Association research grant. We would
like to thank Editage (www.editage.jp) for English language editing.

References[1] Shoji T. Algorithm for Diagnosis of Spinocerebellar
Degeneration. In: Shoji T, Masatoyo N, editors. Actual
approach to neurological practice: cerebellum and ataxia,
1st ed. (in Japanese). Tokyo: Nakayama Publisher Inc.
2013; 75–83.
[2] Naomi H. Rehabilitation of spinocerebellar degeneration:
actual occupational therapy for spinocerebellar degeneration (in Japanese). MB Med Reha (Medical Rehabilitation). 2008; 93(1): 17–21.
[3] Marquer A, Barbieri G, Pérennou D. The assessment
and treatment of postural disorders in cerebellar ataxia: asystematic review. Ann Phys Rehabil Med. 2014; 57(2):67–78.

190

UPPER LIMB TRAINING FOR CEREBELLAR ATAXIA[4] Jun T. Quantitative assessment of motor coordination of
ataxia by iPad® (in Japanese). Niigata Igakkai Zasshi.
2015; 129(1): 10–20.
[5] Atsushi G. Approach for ataxia (in Japanese). J Kansai
Phys Ther. 2014; 14(1): 1–9.
[6] Schmitz-Hübsch T, du Montcel ST, Baliko L, BercianoJ, Boesch S, Depondt C, et al. Scale for the assessment
and rating of ataxia: development of a new clinical scale.
Neurology. 2006; 66(11): 1717–20.
[7] Weyer A, Abele M, Schmitz-Hübsch T, Schoch B, Frings
M, Timmann D, et al. Reliability and validity of the scale
for the assessment and rating of ataxia: a study in 64
ataxia patients. Mov Disord. 2007; 22(11): 1633–7.
[8] Kaneko T, Muraki T. Development and standardization of
the hand function test. Bull Allied Med Sci Kobe. 1990;
6(1): 49–54.
[9] Ito M, Kano M. Long-lasting depression of parallel fiberPurkinje cell transmission induced by conjunctive
stimulation of parallel fibers and climbing fibers in the
cerebellar cortex. Neurosci Lett. 1982; 33(3): 253–8.
[10] Shinji K, Takahiro I, Saeka T. Cerebellar plasticity andmotor learning. In: Shoji T, Masatoyo N, editors. Actual
approach to neurological practice: cerebellum and ataxia,
1st ed (in Japanese). Tokyo: Nakayama Publisher Inc.
2013; 42–55.
[11] Payoux P, Brefel-Courbon C, Ory-Magne F, Regragui W,

Thalamas C, Balduyck S, et al. Motor activation in multiple system atrophy and Parkinson disease: a PET study.
Neurology. 2010; 75(13): 1174–80.
[12] Deiber MP, Wise SP, Honda M, Catalan MJ, Grafman J,
Hallett M. Frontal and parietal networks for conditional
motor learning: a positron emission tomography study. J
Neurophysiol. 1997; 78(2): 977–91.
[13] Ueda N, Hakii Y, Koyano S, Higashiyama Y, Joki H,
Baba Y, et al. Quantitative analysis of upper-limb ataxia
in patients with spinocerebellar degeneration. J Neurol.
2014; 261(7): 1381–6.
[14] Jacobi H, Bauer P, Giunti P, Labrum R, Sweeney MG,
Charles P, et al. The natural history of spinocerebellar
ataxia type 1, 2, 3, and 6: a 2-year follow-up study. Neurology. 2011; 77(11): 1035–41.
[15] Rodríguez-Díaz JC, Velázquez-Pérez L, Rodríguez
Labrada R, Aguilera Rodríguez R, Laffita Pérez D,
Canales Ochoa N, et al. Neurorehabilitation therapy inspinocerebellar ataxia type 2: a 24-week, rater-blinded,
randomized, controlled trial. Mov Disord. 2018; 33(9):1481–7.
[16] Ilg W, Synofzik M, Brötz D, Burkard S, Giese MA,
Schöls L. Intensive coordinative training improves motor
performance in degenerative cerebellar disease. Neurology. 2009; 73(22): 1823–30.

■CASE REPORT

Effect of the Perceptive Exploration Approachon Upper Extremity Movement Disorder in Patientswith Acute Stroke Hemiparesis: Case Series Study
Masato Sato
Department of Rehabilitation, Hashimoto Municipal Hospital

Abstract: Introduction: The perceptive exploration approach is a therapy for upper extremity movement disorders
in patients with acute stroke hemiparesis. It facilitates the organization of actions in terms of perceptual information
exploration and motor control, and may help develop the functional use of the upper extremities. The purpose of thisstudy was to determine whether the perceptive exploration approach is effective in improving upper extremity movement disorders in patients with acute stroke hemiparesis.
Methods: I used pretest-posttest data to examine the therapeutic effects of the perceptive exploration approach in eighthemiparesis patients. In addition to a standard occupational therapy program, the therapy included a tailored perceptive
exploration activity based on the assessment of patient-specific upper extremity function. I examined three main outcome measurements: Fugl-Meyer Assessment (FMA), and amount of use (AOU) and quality of movement (QOM) inthe motor activity log (MAL).
Results: Outcome data measured before and after therapy showed improvement in all patients. FMA scores for motor
function ( p = 0.01, Δ = 0.55) and sensory function ( p = 0.02, Δ = 0.59) assessment were significantly improved, and theeffect size was moderate. AOU ( p = 0.01, Δ = 0.81) and QOM ( p = 0.01, Δ = 0.80) in the MAL were also significantly
improved, and the effect size showed a large change.
Conclusion: The present results suggest that the perceptive exploration approach may be useful for the recovery of
upper extremity movement in patients with acute stroke hemiparesis.
Keywords: hemiparesis, acute stroke, paralyzed upper extremity, perceptive exploration activity(Asian J Occup Ther 18: 191−194, 2022)

Introduction
Restoration of the functional use of the affected
upper extremity is one of the goals of occupational therapy (OT) for many stroke hemiparesis patients. Currently, rehabilitation in acute stroke patients concentrates
on impairment-oriented approaches [1]. In acute stroke
therapy, it is important to focus on functional recovery
while utilizing both natural recovery and tissue reproduction of the central nervous system [2]. I have foundthat the perceptive exploration approach, an impairmentoriented approach, facilitates the readaptation of stroke
Received: 28 October 2021, Accepted: 27 April 2022
Corresponding to: Masato Sato, Department of Rehabilitation, Hashi­
moto Municipal Hospital, 2-8-1, Ominedai, Hashimoto, Wakayama,648-0005, Japane-mail: sato.my1005@gmail.com©2022 Japanese Association of Occupational Therapists

patients and patients with developmental disabilities
to activities of daily living (ADLs). This approach is atherapy that uses daily items and tools as therapeuticmeans to extract the perceptual information necessary
to perform daily tasks; it facilitates the organization ofactions based on sets of motor skills [3, 4]. Exploration
to obtain perceptual information and motor control,
which is a feature of this therapy, are important for thedevelopment of functional use of the upper extremities[5]. The purpose of the present study was to clarify
whether the perceptive exploration approach is effectivein improving upper extremity movement disorders inpatients with acute stroke.

Subjects
The subjects were stroke hemiparesis patients who
underwent occupational therapy at Hashimoto Municipal Hospital in 2021 (Table 1). The participation criteria

192

EFFECT OF THE PERCEPTIVE EXPLORATION APPROACH IN STROKE PATIENTS

were the following: (1) diagnosis of stroke, (2) paralytic
symptoms of one upper extremity, (3) no severe disturbance of consciousness or cognitive impairment thatinterferes with clinical assessment. All subjects provided
their informed consent before participation.

MethodProcedure
Each patient underwent a pretest and a posttest
to examine the effect of the perceptive exploration
approach on the paralyzed upper extremity. Therapy
consisted of a standard OT program (40 minutes daily)
and a tailored perceptive exploration activity (5 days
per week). The standard OT program consisted of facilitation of muscle activity and coordinated multi-joint
movement, tactile and proprioceptive input, and soft
tissue mobilization. The perceptive exploration activity
was based on patient-specific upper extremity function.
The perception information essential for task performance was extracted from the tactile-motor sense by thepatient with the assistance of an occupational therapist,and it was carried out in such a way that motor skills
could be demonstrated [3, 4]. For hand motor skills, themanipulation functions for accomplishing the task werecategorized into 10 items, and the activity task and thetarget to be used were updated according to the recovery
stage of the patient’s upper extremity function. Motorskills based on the fundamental movement of the handinclude reaching, holding, moving, releasing, throwing,
picking, stroking, scratching, wiping, and varied prehension.
Outcome measurements
1) Fugl-Meyer Assessment: FMA
The FMA was used to measure upper extremity
motor function, sensory function, range, and pain.
2) Motor activity log: MAL
For the MAL, the amount of use (AOU) and qualityof movement (QOM) were used to measure the use behavior of paralyzed hands in ADLs.
Data analysis
The Wilcoxon t-test was used to compare outcome
data measured at the start and end of each patient’s OT:
a p value of < 0.05 was considered to indicate statisticalsignificance. To verify the effect of therapy, the effectsize was calculated using Glass’s Δ [6]. In addition,
since there is a bias due to spontaneous recovery in theacute phase, I analyzed the amount of change using theminimal clinically important difference (MCID) [7].

Results
Outcome data measured before and after therapy
showed improvement in all patients (Table 2). Upperextremity motor function measured by FMA significantly improved from 28.3 ± 25.8 to 42.5 ± 26.3 ( p =0.01, Δ = 0.55) and sensory function likewise improved
significantly from 6.6 ± 5.4 to 9.8 ± 3.3 ( p = 0.02, Δ =0.59). However, the effect size was moderate. Regarding
range and pain, all those with a score of 24 or less on
the pretest showed improvement. AOU measured by the
MAL was significantly improved from 1.4 ± 1.6 to 2.7± 2.1 ( p = 0.01, Δ = 0.81), and QOM was significantly
improved from 1.4 ± 1.5 to 2.6 ± 2.1 ( p = 0.01, Δ = 0.80).
The effect size also showed a large change in both cases.
The functional change of paralyzed upper extremity in
ADLs has been recognized to patient-specific changes tothe manipulation of tools from holding the objects.

Discussion
In this study, I used the perceptive exploration approach to treat hemiparesis patients with upper extremity
movement disorder after acute stroke, and analyzed thetherapeutic effect of this approach from the viewpoint of
the MCID.
The MCID of FMA after the acute phase has beenreported to be 4.25–7.25 [8]. The MCID of the FMA ofmotor function in this study was 14.2 ± 0.5, and all patients showed changes exceeding the MCID. Regarding
sensory function, range, and pain, many subjects scoredhigher after therapy than before, but there was a ceiling
effect, and they did not achieve changes beyond theMCID. In addition, the MCIDs of AOU and QOM in the
MAL are reported to be 0.5 and 1.0–1.1, respectively[9, 10]. The MCID of AOU in this study was 1.4 ± 0.4,
and that of QOM was 1.2 ± 0.6. These results indicatethat the perceptive exploration approach is effective
in facilitating the recovery of upper extremity motor
function, although spontaneous recovery in the acutephase may also occur, and there may be a ceiling effectof assessment. Nevertheless, the present results suggestthat this approach may be effective in facilitating the use
behavior of paralyzed hands in patients with a mild tomoderate degree of upper extremity paralysis.
However, the patient’s age and damaged part / area
are predisposing factors that affect the recovery of paralysis, so the sample size should be increased to verify
the therapeutic effect, and further research is required in
randomized controlled trials.

2.60
2.50

AOU
QOM

FMA (score)

MAL (score)

3.28
3.28

53
12
24
24

76
F
R
I
lacunar
L
3
20

B

3.43
3.21

60
12
24
24

66
F
R
H
subcortical
R
2
14

C

2.00
2.25

45
9
22
22

68
F
L
H
subarachnoid
R
7
49

D

0.00
0.00

4
0
24
24

66
F
R
I
corona radiata
L
2
30

E

0.00
0.00

0
0
24
24

71
M
R
I
lacunar
R
2
28

F

50
53
60
45
4
0
6
8
28.3
25.8

63
66
66
59
14
7
13
52
42.5
26.3
0.01
0.55

Post

13
13
6
14
10
7
7
44
14.2
0.5

Variation

12
12
12
9
0
0
2
6
6.6
5.4

Pre
12
12
12
12
4
8
6
12
9.8
3.3
0.02
0.59

Post
0
0
0
3
4
8
4
6
3.2
2.1

Variation

Sensory

18
24
12
22
24
24
24
20
21.0
4.3

Pre
23
24
12
23
24
24
24
22
22.0
4.1
0.05
0.23

Post

Range

5
0
0
1
0
0
0
2
1.0
0.2

Variation
19
24
12
22
24
24
24
20
21.1
4.2

Pre

22
24
12
24
24
24
24
24
22.3
4.2
1.00
0.29

Post

Pain

3
0
0
2
0
0
0
4
1.2
0.0

Variation

2.6
3.3
3.4
2.0
0.0
0.0
0.0
0.0
1.4
1.6

Pre

0.00
0.00

6
2
24
24

H

4.6
4.9
4.9
3.8
0.5
0.3
0.5
2.2
2.7
2.1
0.01
0.81

Post

AOU

2.0
1.6
1.5
1.8
0.5
0.3
0.5
2.2
1.4
0.4

Variation

2.5
3.3
3.2
2.3
0.0
0.0
0.0
0.0
1.4
1.5

Pre

4.6
4.6
4.9
3.8
0.3
0.3
0.3
1.9
2.6
2.1
0.01
0.80

Post

QOM

1.4 ± 1.6
1.4 ± 1.5

28.3 ± 25.8
6.6 ± 5.4
22.5 ± 2.3
22.6 ± 2.1

5/3
2.6 ± 1.8
25.1 ± 11.6

69.8 ± 4.8
3/5
7/1
2/6

Mean ± SD

MAL (score)

0.00
0.00

8
6
20
20

78
F
R
I
medial medullary
L
2
18

FMA: Fugl-Meyer Assessment; MAL: motor activity log; AOU: amount of use; QOM: quality of movement; SD: standard deviation.
Δ: delta is an indicator of effect size. The effect size was considered to be small at values of 0.2–0.5, medium at values of 0.51–0.8, and large at values above 0.8.

A
B
C
D
E
F
G
H
Mean
SD
p-value
Effect size (Δ)

Pre

Motor

FMA (score)

Table 2 Effect of therapies on the main outcome measures.

G
67
M
R
I
lacunarR
2
28

M: male; F: female; R: right; L: left; H: hemorrhage; I: infarction;
FMA: Fugl-Meyer Assessment; MAL: motor activity log; AOU: amount of use; QOM: quality of movement; SD: standard deviation.

50
12
18
19

66
M
R
I
lacunarR
1
14

Age (years)
Gender (M/F) (number)
Dominant hand (R/L) (number)Type of stroke (H/I) (number)
Lesion site
Hemiparetic side (R/L) (number)Time post-stroke (days)
Rehabilitation period (days)

Motor
Sensory
Range
Pain

A

Case

Table 1 Subject’ attributes.

2.1
1.3
1.7
1.5
0.3
0.3
0.3
1.9
1.2
0.6

Variation

Asian J Occup Ther 18: 191−194, 2022
Sato M
193

194

EFFECT OF THE PERCEPTIVE EXPLORATION APPROACH IN STROKE PATIENTS

Conclusion
The present results suggest that the perceptive exploration approach may be useful to help patients withacute stroke hemiparesis recover from upper extremity
movement disorders.

Acknowledgments
The author would like to thank the patients for their
participation.

References[1] Carey LM, Matyas TA. Frequency of discriminative
sensory loss in the hand after stroke in a rehabilitation
setting. J Rehabil Med. 2011; 43(3): 257–63.
[2] Kawahira K, Shimodozono M, Etoh S, Kamada K, Noma
T, Tanaka N. Effects of intensive repetition of a new
facilitation technique on motor functional recovery of thehemiplegic upper limb and hand. Brain Inj. 2010; 24(10):1202–13.
[3] Sato M, Mikami Y, Asakura Y, Katayama K, Tajima F. An
intervention to overcome eating difficulties in a patientwith autism spectrum disorder -a case study. Asian J
Occup Ther. 2021; 17(1): 65–8.

[4] Sato M, Shiosaki A, Samoto Y, Yoshimura R. An intervention to overcome locomotion difficulties in a patientwith oculomotor nerve palsy: a case study. Asian J Occup
Ther. 2021; 17(1): 79–82.
[5] Shumway-Cook A, Woollacott M. Motor Control: Translating Research into Clinical Practice, 3rd ed. Philadelphia, Lippincott Williams and Wilkins, 2007.
[6] Glass GV, McGaw B, Smith ML. Meta-analysis in social
research. 1st ed. Beverly Hills, Sage Publication Inc,
1981.
[7] Jaeschke R, Singer J, Guyatt GH. Measurement of healthstatus: Ascertaining the minimal clinically importantdifference. Control Clin Trials. 1989; 10(4): 407–15.
[8] Page SJ, Fulk GD, Boyne P. Clinically important differences for the upper-extremity Fugl-Meyer Scale in people
with minimal to moderate impairment due to chromic
stroke. Phys Ther. 2012; 92(6): 791–8.
[9] van der Lee JH, Wagenaar RC, Lankhorst GJ, Vogelaar
TW, Devillé WL, Bouter LM. Forced use of the upper
extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Stroke. 1999; 30(11):2369–75.
[10] Lang CE, Edwards DF, Birkenmeier RL, Dromerick AW.
Estimating minimal clinically important differences ofupper-extremity measures early after stroke. Arch Phys
Med Rehabil. 2008; 89(9): 1693–700.

■CASE REPORT

Tau-U Analysis Demonstrated the Effect of
the Therapeutic Use of Ultrasound on Shoulder Rangeof Motion in Flexion: A Case Study
Yoichiro Horikawa1, 2, Takuma Yuri3, 4, Masaya Ueda1, 3, Yuma Nagata1, 5,
Atsuko Noda2, Yasuo Naito1
1

Graduate School of Comprehensive Rehabilitation, Osaka Prefecture University
Kyowakai Medical Corporation Kyowakai Hospital
3
Rehabilitation Unit, Kyoto University Hospital4
Graduate School of Health Sciences, Yamagata Prefectural University of Health Sciences
5
Department of Psychiatry, Course of Integrated Medicine, Osaka University Graduate School of Medicine
2

Abstract:
Introduction: Ultrasound (US) has been used to improve range of motion; however, there is no consensus on its therapeutic effects. This study aimed to explore the therapeutic effects of US in combination with exercise and mobilization
on range of motion based on a single-case design.
Methods: The patient was a 40-year-old man who had a fracture of the greater tuberosity of the right humerus andpresented with limited shoulder range of motion in flexion postoperatively. In addition to standard treatment (exercise
and mobilization), US was performed as an additional intervention. The therapeutic effect of US was examined using
Tau-U.
Results: The range of motion of the shoulder flexion significantly increased in the period when standard treatment and
US were combined compared to that in the period when only standard treatment was administered ( p < 0.001). The
effect size was high (tau-U = 0.758).
Conclusion: The use of US improved shoulder range of motion during flexion. The Tau-U analysis can be useful to indicate the effect of intervention in a single-case design.
Keywords: ultrasound, Tau-U, single-case experimental design(Asian J Occup Ther 18: 195−198, 2022)

1. Introduction
Ultrasound (US) has been used in patients withfrozen shoulder and adhesive capsulitis [1]. US provides
heat on not only the surface but also the deeper ligaments and joint capsules. Therefore, US is expected to
be used in conjunction with exercise therapy to improvejoint range of motion (ROM) and reduce pain [1].
However, the efficacy of the therapeutic use of US
remains controversial. Desmeules et al. reported that US
Received: 26 February 2022, Accepted: 27 June 2022
Corresponding to: Yoichiro Horikawa, Graduate School of Comprehensive Rehabilitation, Osaka Prefecture University, 3-7-30, Habikino,
Habikino-City, Osaka, Japane-mail: syd03018@edu.osakafu-u.ac.jp©2022 Japanese Association of Occupational Therapists

has no additional effect on ROM when used in combination with physical therapy [2]. Balci et al. also demonstrated that no significant difference in the improvementof ROM was observed compared with placebo US [3].
Therefore, it remains unclear whether US can improve
the ROM and reduce pain.
Some rehabilitation studies have used Tau-U analysis to examine whether the improvement in outcome
after the intervention can be interpreted as a result of
the intervention in a single-case design [4]. The present
study aimed to investigate the therapeutic effects of
US combined with exercise and mobilization on ROM
based on a single-case design.

2. CaseA 40-year-old man presented with a fracture of the

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TAU-U ANALYSIS IN A CASE STUDY

Fig. 1. X-ray images of the right humerus before (a) and after (b) surgery.

greater tuberosity of the right humerus and had limited
ROM in shoulder flexion after surgery. The surgery was
performed with osteosynthesis to the greater tuberosityof the right humerus after injured 16 days (Fig. 1). He
had worked in the construction industry prior to injury.
To return to work, he needs to use electric tools with his
affected arm approximately 150° elevated. However,
he elevated his arm up to 90° and experienced pain,
although he had received standard interventions comprised of stretching for shoulder extensor and adductor
muscles and ROM exercises approximately 1 month
postoperatively. Therefore, US was performed as additional treatment. The gleno-humeral joint capsule androtator cuff tendons were targeted.

3. Methods
The standard intervention, namely stretching and
ROM exercises of the glenohumeral joint, was administered in five sessions (twice a week for 4 weeks), andUS was performed in 10 sessions (twice a week for 8
weeks). US was applied to the anterior–posterior aspectsof the affected glenohumeral joint at a dose of 1.5 W/cm2
with a frequency of 1 MHz for 5 min continuously,
based on the previous study [1]. After coating the skinwith an aquasonic gel, US was delivered by moving
the probe over the anterior and posterior regions of the
glenohumeral joint in slow, overlapping strokes.
We defined the last five sessions in which thepatient received standard treatment, namely, stretching
and ROM exercises of the glenohumeral joint, as thebaseline phase (Phase A), and the period from the startof the combination of standard treatment and US to thetime when the patient returned to work was defined as
Phase B. The primary outcome was ROM in flexion,
which is required for returning to work. The end feelingof flexion after treatment was subjectively evaluatedas the secondary outcome. Tau-U, which allowed us to
identify the effect of the intervention on the outcomesbased on a comparison between the baseline and intervention phases, was used to compare Phases A and B [6].
The Tau-U analysis was conducted on a free single-caseexperimental design-analysis website: https://manolov.
shinyapps.io/overlap [7]. Tau-U indicates the effectsize, which was defined in the present study based on
the study reported by Vannest (2015): < 0.20, small,
0.20–0.60, moderate, 0.60–0.80, large; and > 0.80, verylarge [8]. As the Tau-U coefficients showed no significant difference in Trend A, the analysis (A vs. B + Trend
B) was used [9].
After oral and written explanations of the case were
provided, written informed consent for this study was
obtained.

4. Results
Figure 2 and Table 1 show the ROM outcomes in
the flexion and Tau-U results, respectively. The ROM
outcomes in flexion ranged from 90° to 100° during
Phase A. However, those during Phase B increased from100° to maximally 135°. Tau-U analysis indicated that
there was no significant trend during Phase A (Tau-U =0.100, p > 0.999), whereas Phase B showed a significant
trend with a mild effect size (Tau-U = 0.556, p = 0.025).
There was a significant difference in the primary outcome of shoulder joint flexion between Phases A and B( p < 0.001). In addition, the effect size, Tau-U, was high(Tau-U = 0.758).
As for the secondary outcome, the patient had lesspain when he raised his arm after all sessions (PhaseB) compared to that in Phase A. After session 15, thepatient was able to return to work.

Asian J Occup Ther 18: 195−198, 2022

Horikawa Y et al.

197

Table 1 Tau-U analysis results.

Tau-U**
p

Trend A

Trend BA vs B + Trend B*

0.1
n.s.

0.55560.02480.7579p < 0.01

n.s. = not significant; p = p-value* Because of Trend A was not significant, we used A vs B + Trend B.
** Tau-U indicates the effect size. “A 0.20 improvement may be considered a small change, 0.20 to 0.60 a moderate change, 0.60 to
0.80 a large change, and above 0.80 a large to very large change,depending on the context” (Vannest, 2015, p.408).

Fig. 2. Treatment results in relation to Phase A and B.
The vertical axis shows the active shoulder flexion
angle and the horizontal axis shows the session
number. Visual aids computed on a free single-caseexperimental designs (SCED)-analysis website:
https://manolov.shinyapps.io/overlap.

5. Discussion
Tau-U analysis can address problematic trends andcan be directly interpreted as an indicator of improvement [6]. Based on the results of our case, no trend wasobserved in Phase A, in which only standard treatment
was administered in the last five sessions. A significant
increase in ROM was observed in Phase B, in which
standard treatment was performed in combination with
US. This suggests that US prompted improvement inshoulder ROM in flexion.
Jellad et al. reported that the range of motion of
the shoulder flexion was 140° one month after surgery
in the patients with greater tuberosity fracture [5]. Ourcase was able to elevate 90° of shoulder flexion one
month after surgery. This relatively slow improvement
in shoulder flexion in our case enhanced us to suspectsome limiting factor around gleno-humeral joint suchas the potential adhesive capsulitis. Dogru et al. showedthat stretching with US is more effective than stretchingalone for limited ROM [1]. In this regard, Leung et al.
maintained that the combination of deep heating andstretching exercises significantly improves shoulder
ROM [10]. These findings also support that the increasein ROM observed in our study was derived from the useof US in combination with exercise therapy.
Some studies have reported that US can reduce pain[1]. Therefore, the increase in ROM in our case could
also be explained by the pain relief effect of US.
A limitation of this study was its single-case design.
Therefore, the effectiveness of US for ROM cannot beinterpreted as a general conclusion. Recent rehabilitation studies have used Tau-U analysis to complement
visual analysis [4, 11]. These single-case studies will be
helpful in finding validated criteria for interventions thatremain controversial. Another limitation is that we wereunable to prove which tissue was affected by the US andcontribute to the increase in flexion. However, there arefacts that the range of motion of the flexion improved
during the period when the US intervention around the
glenohumeral joint added. Therefore, we assume that
the US affect some limiting factor around gleno-humeral
joint such as the potential adhesive capsulitis.
In summary, US prompted an improvement inshoulder ROM during flexion. Tau-U analysis can be auseful tool to demonstrate the effect of intervention in asingle-case design.

Conflict of Interest
None declared.

Acknowledgements
This study was supported by a Grant-in-Aid for
Research Activity Start-up (Grant number 21K21223).

References[1] Dogru H, Basaran S, Sarpel T. Effectiveness of therapeutic ultrasound in adhesive capsulitis. Joint Bone Spine
2008; 75: 445–50.
[2] Desmeules F, Boudreault J, Roy J-S, et al. The efficacyof therapeutic ultrasound for rotator cuff tendinopathy:
A systematic review and meta-analysis. Phys Ther Sport
2015; 16: 276–84.
[3] Balci TO, Turk AC, Sahin F, et al. Efficacy of therapeutic
ultrasound in treatment of adhesive capsulitis: A prospective double blind placebo-controlled randomized trial. J
Back Musculoskelet. 2018; 31: 955–61.
[4] Hung J-W, Chang Y-J, Han W-Y. Game technology toincrease range of motion for adolescents with cerebral
palsy: a feasibility study. Int J Disabil Hum De. 2017; 16:
267–74.

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TAU-U ANALYSIS IN A CASE STUDY[5] Jellad A, Bouaziz MA, Boudokhane S, et al. Isolated
greater tuberosity fracture: Short-term functional outcome
following a specific rehabilitation program. Ann Phys
Rehabilitation Medicine. 2012; 55: 16–24.
[6] Parker RI, Vannest KJ, Davis JL, et al. Combining
Nonoverlap and Trend for Single-Case Research: Tau-U.
Behav Ther. 2011; 42: 284–99.
[7] Krasny-Pacini A, Evans J. Single-case experimental designs to assess intervention effectiveness in rehabilitation:
A practical guide. Ann Phys Rehabilitation Medicine
2018; 61: 164–79.
[8] Vannest KJ, Ninci J. Evaluating Intervention Effects in

Single‐Case Research Designs. J Couns Dev. 2015; 93:403–11.
[9] Brossart DF, Laird VC, Armstrong TW. Interpreting
Kendall’s Tau and Tau-U for single-case experimental
designs. Cogent Psychology. 2018; 5: 1–26.
[10] Leung M, Cheing G. Effects of deep and superficial heating in the management of frozen shoulder. J Rehabil Med
2008; 40: 145–50.
[11] Erhardsson M, Murphy MA, Sunnerhagen KS. Commercial head-mounted display virtual reality for upper
extremity rehabilitation in chronic stroke: a single-casedesign study. J Neuroeng Rehabil. 2020; 17: 154.

■ORIGINAL ARTICLE

Conditions and Situations of Occupation-Based
Practice for Patients with Severe Acute
Cerebrovascular Accident: A Qualitative Study
Katsuma Ikeuchi, Seiji Nishida, Yasushi Orita, Chiaki Sakamoto
Prefectural University of Hiroshima

Abstract: Introduction: Occupation-based practice (OBP) is seldom performed for people with severe acute cerebrovascular accidents (CVA). This study aimed to explore the conditions and situations in which occupational therapists(OTs) provide OBP to patients with severe acute CVA.
Methods: Semi-structured interviews with eight OTs were conducted to determine OBP for patients with severe acute
CVA. The participants were OTs who had conducted OBP for patients with CVA in an acute care setting. Data wereanalyzed using inductive analysis. The procedures were: (i) to create verbatim records, (ii) to separate the verbatim
records by context and to code while comparing the differences and commonalities of each code, (iii) to create subcategories, and (iv) to create categories by grouping together the subcategories with concepts that have similarities.
Results: The participants (OTs) reported that they have performed OBP for patients with severe acute CVA patients
when (1) environments are available to perform occupations, (2) OTs establish good quality teamwork with multidisciplinary professionals, (3) OTs emphasize patient-centered practice, (4) patients express their wishes to do occupations, (5) patients and families are getting to ready to resume occupation, (6) patients’ occupations are actionable andmeaningful.
Conclusion: The OTs’ belief, the supportive environment, the client and family oriented toward occupations, and theidentification of actionable and meaningful occupations were critical for the OTs to implement OBP for the severe acute
CVA patients. These results could provide OTs with insights for promoting OBP in acute settings, especially working
with patients with severe acute CVA.
Keywords: severe, acute cerebrovascular accident, occupation-based practice, qualitative study, interview(Asian J Occup Ther 18: 199−207, 2022)

1. Introduction
Fisher [1] recommended that occupation-focusedpractice (OFP), occupation-based practice (OBP) be
undertaken within the occupational therapy process.
In Japan, occupational therapy was defined as occupation-focused therapy, guidance, and support [2]. Theseemphasize the occupational therapists (OTs) do OFP,
OBP. Wolf et al. [3] recommended OBP for adults withcerebrovascular accidents (CVA), which is one of thefamiliar diseases for OTs, to improve their activities ofReceived: 15 April 2021, Accepted: 7 April 2022
Corresponding to: Katsuma Ikeuchi, Prefectural University of Hiro­shima, 1-1 Gakuen-cho, Mihara-city, Hiroshima-ken 723-0053, Japane-mail: ikeuchi@pu-hiroshima.ac.jp©2022 Japanese Association of Occupational Therapists

daily living (ADL) in the inpatient or home setting. The
American Occupational Therapy Association [4] also
recommends OBP for adults with CVA to improve ADL
in the home setting (categorized as grade A treatment).
OTs often treat patients with CVA in their acutephase. Patil et al. [5] investigated the use of gardening
as a meaningful occupation in the initial rehabilitationof people with CVA. Bungay et al. [6] investigated theperceptions of patients with CVA regarding the impactof participating in a group dance session in an acute care
hospital. The main advantages of these practices wereas follows: (i) skills training, (ii) source of emotional
support, (iii) opportunities for social interaction, and (iv)recalling of past experiences, which gives hope for the
future. What these two studies have in common was thatthey investigated the effects of performing specific occupations such as gardening and dancing. Furthermore,

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OCCUPATION-BASED PRACTICE FOR SEVERE ACUTE CEREBROVASCULAR ACCIDENT

regarding the acute CVA setting, there is no research on
individualized occupations, which is important in patientcentered occupational therapy, nor is there research thatexamines other aspects apart from the impact of OBP.
One Australian report [7] found that 58% of OTs
assessed more than 75% of their clients with occupationbased assessments, and another Danish report [8] foundthat only 9% of OTs used a standardized occupationbased assessment. Therefore, although the studies by
Patil [5] et al. and Bungay [6] et al. show the need forpatients with acute CVA to perform occupations, in fact,
the percentage of OBP given to them varies from survey
to survey.
Bigelius et al. [9] reported a study in which theAssessment of Motor and Process Skills (AMPS) (anoccupation-based assessment) was implemented in
Swedish acute patients who were independent in their
ADL before their admission and had no cognitive impairment. Thus, this study [9] was an occupation-based
assessment for people with mild, acute CVA. Ikeuchi etal. [10] clarified the conditions, situations, and processes of OBPs for patients with acute CVA. They foundthat an occupation-centered evaluation was smoothly
performed when the degree of disability was mild. Thisfinding indicates that that while occupation-centeredevaluation was smoothly performed when the degreeof disability was mild, little OBP was performed when
the degree of disability was severe. However, Ikeuchi
et al. [10] also reported that OBP after certain recovery
was accepted in severe cases. Thus, to perform OBP for
people with severe CVA, it is necessary to understandwhen OBP should be provided, which remains unclear.
This study, therefore, aimed to explore the conditions
and situations in which occupational therapists provide
OBP to patients with severe acute CVA.
The terms in this study are defined as follows:
Occupation [11] refers to daily activities that a person
wants to, needs to, or is expected to do. Occupationbased [1] makes use of a person’s engagement in
occupation as the method of our evaluations and interventions. Conditions and situations refer to patients andfamilies, occupations, environments (include OTs andmulti-disciplinary professions) conditions and reactions
that affect OBP by OTs. The acute phase was defined aswithin four weeks of onset, and “severe” was defined
as meeting one of the following conditions: (i) Japan
Coma Scale with II or III consciousness disturbance; (ii)
Brunnstrom recovery stage (Br-stage) with either item
below IV and (iii) Japanese version of modified Rankin
Scale scoring 4 or 5.

2. Methods
2.1 Study Design
The research design was a qualitative study using
interview data using inductive approaches.
2.2 Participants
Convenience sampling was used to recruit participants. We asked to interview OTs who had been interviewed in a previous study [10] and other OTs recommended by them. The requirements for OTs interviewed
in the previous study [10] to refer to other OTs were as
follows: (i) have done OBP for patients with acute CVA
within the past three years, or (ii) have presented in
occupational therapy related conferences and articles on
OBP for people with acute CVA.
2.3 Data Collection Method
The first author conducted individual and semistructured interviews using the online tool Zoom andasked questions about the OBPs practiced by the participants of OTs. The interviewer had conducted qualitative research dealing with interview data on several
occasions. Before the interview, we confirmed that theparticipants understood the concept of OBP correctly. In
addition, we asked participants from previous studies, somany participants were familiar with the interviewers.
However, several participants had never met me before
because I asked another participant, who was introducedby participants of the previous study, to be interviewed.
An IC recorder was used to document the interviews
with the consent of the participants. Referring to the previous study by Ikeuchi et al. [10] mentioned above, theinterview items were as follows: (i) basic information
about the patient (name of the disease, age, ADL ability,
presence of disability, etc.), (ii) details of the OBP, andif necessary, the thoughts of OTs and other multidisciplinary professions, the patient’s preferences, and efforts
made to provide the OBP (Supplemental material).
Interviews were conducted from May to October 2020,
once for each participant.
2.4 Analysis Methods
We conducted inductive analysis to perform theanalysis. First, we extracted the data on the conditions
and situations of OBP from the interview data. The
subsequent analysis procedures were (i) to create verbatim records from the records of the interview data,(ii) to separate the verbatim records by context and tocode titles indicating contents, (iii) to create them into
subcategories while comparing the differences andcommonalities of each code, (iv) to create categories bygrouping together subcategories with concepts that have

Asian J Occup Ther 18: 199−207, 2022

similarities. Interventions for patients were confirmed
to meet this study’s definition of “occupation-based”,
and the above process was carried out until the authors
agreed with the results of the analysis. Furthermore,
three of the four authors had experience in qualitative
research.
2.5 Member Checking
We conducted member checking to confirm thereliability of the analysis. Specifically, we emailed final
reports include the raw data, codes, subcategories andcategories to all participants of OTs and asked them ifthey agreed with the results when they considered theirown experiences with people around them. As a result,all participants e-mailed us back. All of participants
were agreeable with final reports. However, a participant
stated that he felt uncomfortable although he was agreeable. He stated that the final reports included categories
and subcategories that were not specific to patients withsevere acute CVA.
2.6 Funding Sources and Research Ethics
In the execution of this research, a grant from thePriority Research Project of the Prefectural Universityof Hiroshima in the 2020 fiscal year. The study was approved by the Research Ethics Committee of the Prefectural University of Hiroshima (approval number: Issue
20MH007), and written consent was obtained from allparticipants prior to the interview.

3. Results
3.1 Characteristics of Participants (OTs)
A total of eight participants (OTs), including fivemales and three females, participated in this study.
None of the OTs refused to be interviewed. The median
number of years of experiencing an acute CVA domain
in OT practice was 5.5 (range, 3–32) years, with four
participants having less than five years of experience,
two participants having more than five years and lessthan 10 years of experience, and two participants having
more than 10 years of experience (Table 1). The median
number of years of experience as an OT was 8.5 years(range, 3–33 years). Each participant was employed at
different workplaces.
3.2 D uration of the Interview and Characteristics ofPatients
The duration of the interview was an average of
43.5 (range, 30–65) minutes. The 12 patients’ information were provided by the participants, and theirinterview data on the conditions and situations of OBP
were included in the analysis. The diagnoses of patients

Ikeuchi K et al.

201

Table 1 Characteristics of participants (occupational therapists).
No.

Sex

Years experiencing
an acute CVA domain

Years of experience asan occupational therapist

A
B
C
D
E
F
G
H

FemaleMale
Female
Male
Male
Male
Male
Female

8
11
3
3
32
3
3
9

8
11
8
7
33
11
3
9

5.5

8.5

Medianincluded nine cases of cerebral infarction, two casesof cerebral hemorrhage, and one case of subarachnoid
hemorrhage; of all the patients, three were in their 50s,
one was in his 60s, five were in their 70s, and three werein their 80s (Table 2). Two patients had Japan Coma
Scale-II or higher, six patients had Br-stage III or lower,and 12 patients had a score ≥ 4 on the Japanese versionof the modified Rankin Scale at the beginning of OBP.
The occupations in OBPs included self-care, housework,music appreciation, and plant cultivation.
3.3 Results of Analysis
Codes, categories, and subcategories were createdfrom the interview data on OBP conditions and situations (Table 3). In the following portions, [ ] indicates
categories, and < > indicates subcategories. The six
categories created are as follows: [environments whereoccupations can be done], [multi-disciplinary professionals who establish good quality teamwork with OTs],[OTs who emphasize patient-centered practice are in
charge of patients], [patients who express their wishes to
do occupations], [patients and families who are getting
to ready to resume occupations], and [actionable andmeaningful occupations].
(1) [Environments where occupations can be done]
This category was structured by four subcategories
with 12 codes. In this category, the environments andrules of the hospital, the tools used by the patients,
places where the patients responded well, and the family
members who supported the patient’s occupation, were
included.
<Hospital environments and rules that can provide occupations>This subcategory included data on physical environments or hospital rules for patients for performing
occupations. This meant that the OTs were allowed tobring in their food and use knives at any time. The OTs

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OCCUPATION-BASED PRACTICE FOR SEVERE ACUTE CEREBROVASCULAR ACCIDENT

Table 2 Characteristics of patients whom participants narrated in the interviews.
No.

Sex

Age

Major diagnosis

JCS

Br-stage

mRS

1
2
3
4
5
6
7
8
9
10
11
12

FemaleMale
Male
FemaleFemaleMale
FemaleFemaleMale
Female
Male
Male

80’s
60’s
70’s
50’s
70’s
70’s
50’s
70’s
50’s
70’s
80’s
80’s

Cerebral infarction
Cerebral hemorrhage
Cerebral infarction, traumatic brain injury
Cerebral infarction
Cerebral infarction
Cerebral infarction
Subarachnoid hemorrhage
Cerebral infarction
Cerebral hemorrhage
Cerebral infarction
Cerebral infarction
Cerebral infarction

Not applicableNot applicableNot applicableNot applicableNot applicableNot applicableNot applicableII
III
Not applicableNot applicableNot applicable

I–II
Not applicableNot applicableNot applicableII
II–IIIIII
IINot applicable
IV
V

4
5
5
4
4
4
4
5
5
4
4
4

JCS: Japan Coma scale, Br-stage: Brunnstrom Recovery Stage, mRS: Japanese version of modified Rankin Scale
In the severe definition was defined as meeting one of the following three points: (i) Japan Coma Scale with II or III consciousness disturbance; (ii) Br-stage with either item below IV; (iii) Japanese version of modified Rankin Scale scoring 4 or 5. The“applicable definition of severity” indicates which of the definitions (i) to (iii) was met by each patient.

also had access to a kitchen where patients could cook.
Participant A’s narrative is described as follows: “In thehospital where I work, we do not have strict rules about
handling knives. We have an environment where if wewant to cook, we can do it immediately.”<Patients can use the tools they used before admission>
This subcategory included the ability to use thetools that the patients had used at home before admission, during acute rehabilitation. The patient’s family
members brought the patient’s tools to the hospital.
Participant A’s narrative is described as follows: “I wasable to use the same beauty lotion that the patient wasusing at home during the occupational therapy session,
which allowed me to develop specific strategies with thepatient.”<Places where patients respond well>This subcategory included some places where theOTs observed good responses from the patients, such as
the patient being satisfied or having less assistance withelimination. This was focused on location. Participant
C’s narrative is described as follows: “When the patient
went to the actual toilet and saw the toilet seat, the patient was able to move more quickly than expected, andwith less assistance.”<Family members supporting the patients to do occupations>This subcategory included the patient’s families
supporting the patients by visiting the hospital, observing the rehabilitation, and praising the patients. Participant A’s narrative is described as follows: “When thepatient’s grandchild observed the occupational therapy
session, the patient with right hemiparesis held a knife

with her left hand to cut vegetables. When the patient’s
grandchild saw her cut vegetables, she praised thepatient.”(2) [Multi-disciplinary professionals who establish goodquality teamwork with OTs]
This category was structured by two subcategories
that created six codes. In this category, participants
talked about collaborating with trusted multidisciplinary
professionals such as nurses, physical therapists, andspeech therapists, and also supporting multi-disciplinary
professionals who experience difficulties in dealing withpatients.
<Cooperative and reliable multi-disciplinary professionals>
This subcategory included multi-disciplinary professionals supportive of OBP and the OTs’ trust in thosemulti-disciplinary professionals. Participant C’s narrative is described as follows: “When I told the nurse thatthe patient and I had cooked together, the nurse asked
the patient what kind of food she had cooked. The nurse
talking about the occupations with the patient was beneficial to OBP.”<Some medical professionals experience difficulty inresponding>This subcategory referred to the difficulty that somemedical professionals experience in responding to patients who could not communicate. Participants showed
them the patient’s original competence and the improved
response elicited by the OBP, which relieved the feelingof difficulty in responding. Participant C’s narrativeis described as follows: “There were nurses who were
struggling to deal with a patient with delirium who sud-

Asian J Occup Ther 18: 199−207, 2022

Ikeuchi K et al.

203

Table 3 Conditions and situations of OBP.
Category

Environments whereoccupations can be done

Multi-disciplinary
professionals whoestablish good quality
teamwork with OTs

Subcategory
Hospital environments
and rules that can
provide occupations

The hospital is permitted to bring food items
There is an environment where occupations can be provided quickly
There is a kitchen for practice in the hospital
Knives can be used whenever OTs want to use it

Patients can use thetools they used before
admission

Patients can use the tools they used at home before admission
A patient’s daughter brings patients the tools

Places where patients
respond well

There is a place where patients are satisfied
The patient responds well to the ward
The amount of assistance is less if practice is conducted in the bathroom that the patientsnormally use

Family members
supporting the patientsto do occupations

Grandchildren praise the food made by patients in practicePatients’ much-loved grandchild comes to the hospital to visit
Grandchildren’s visit motivates patients to cook

Cooperative and reliablemulti-disciplinary
professionals

High awareness of the work that nurses haveSTs can help in OTs’ practices
There are PTs that OTs trust
Nurses have a conversation with patients about a dish they madeSome medical
professionals experience
difficulty in responding

There are multi-disciplinary professionals who cannot communicate well with patients
Some multi-disciplinary professionals think that the amount of patient care is too much

OTs who emphasize patient-centered practice
are in charge of patients

Patients who express
their wishes to do
occupations

Patients and families
who are getting to readyto resume occupations

Actionable andmeaningful occupations

Code

There are OTs who always take care of occupations
There are OTs who emphasize the importance of doing challenges together with patients

Patient has a strong
intention to resume
occupations

Patients want to enable occupations
Patients want to enjoy a hobby again
Patients are eager to become better at what they can do
Patients prioritize occupations rather than walking
The patient frequently mentions cooking

Patients have goodunderstanding andapplication

Patients have excellent understanding and application skills
Patients voluntarily confirm the content of instruction

Patients’ consent to
OTs’ explanations andsuggestions

Patients tolerate changes in the way they perform occupations
Patient agrees with OT’s explanation

Improvement in patient’s motivation
Patient has positive emotions while using the computer
Changes in the positive
statements and behaviors Increase the number of times patients use their paralyzed handof patients and families
Increase in patients’ statements about life after hospital discharge
Family members become more proactive in talking to OTs
Early improvements in paralysis are observed
Patients can stay safe while drains are inserted
Improvement in mental
and physical function,
Patients can keep doing occupations longer
ability and risk reduction Speech becomes clearer
Patients’ ability to walk improves
Actionable occupations
that are appropriate forpatients

OTs want to increase the number of occupations patients can perform
OTs prioritize occupations that the patient has experience in
There are a variety of occupations that can be adjusted
OTs choose an occupation that patients do not need to be moved for
There are some creative options OTs and patients can perform

Occupations leading toleaving the bed

Intervention with a purpose to get up
Thinking about what occupations will help patients to get up

OT: occupational therapist, ST: speech therapist, PT: physical therapist

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OCCUPATION-BASED PRACTICE FOR SEVERE ACUTE CEREBROVASCULAR ACCIDENT

denly rose. I invited nurses to observe the occupational
therapy session and explained the relationship between
the patient’s desires and behavior to them.”(3) [OTs who emphasize patient-centered practice are in
charge of patients]
This category was structured by a subcategory thatcreated two codes. In this category, the participants’ own
policies as OTs were included. The participants talked
about how they always valued collaboration with the patients and their occupations. Participant A’s narrative is
described as follows: “I believe it is one of my strengths
as an OT that I can try to challenge with a patient theoccupations that she has difficulty doing after the onset
of CVA.”(4) [Patients who express their wishes to do occupations]This category was structured by three subcategories
that created nine codes. In this category, strong intention, comprehension, application, and consent of patientsto resume occupations were mentioned.
<Patient has a strong intention to resume occupations>This subcategory included patients’ desires and priorities regarding occupations after experiencing a CVA.
Participant D’s narrative is described as follows: “Thepatient strongly said, ‘Because my husband does not do
the housework, I have to do the housework, so I want tobe able to do the housework that I used to do before I
had the stroke.’ ”
The participants also perceived that the patients’high frequency regarding specific occupations indicatedthat they had strong feelings about important occupations. In other words, the participants felt the patients’strong willingness to resume occupations based on
their comments. Participant G’s narrative is describedas follows: “There were so many conversations aboutcooking than comments about the right upper limb thatis paralyzed.”<Patients have good understanding and application>
In some cases, the participants decided to implement OBP based on the patient’s ability to understandand apply, and not based on their words. Participantsalso felt that the confirmation of the patient’s spontaneous attitude would encourage them to continue
with the OBP. Participant D’s narrative is described asfollows: “The patient I was assigned to experienced
lightheadedness whenever she was standing or walking.
During a shopping activity, she spontaneously took
items that were placed in various positions. That is, she
explored where they could safely take the goods.”<Patients’ consent to OTs’ explanations and suggestions>This subcategory included cases in which the participants were able to confirm the patient’s intentions
after the patient agreed with the OTs’ explanations andsuggestions. Participant G’s narrative is described asfollows: “I was in charge of a patient who was impatient
to be discharged from the hospital as soon as possible totake care of her husband. Since the patient still needed
assistance in her daily life, I explained to her that sheneeded to be able to perform her own daily activities
first, rather than trying to achieve early discharge, towhich she agreed.”(5) [Patients and families who are getting to ready toresume occupations]This category was structured by two subcategories
that created ten codes and included: changes in the statements and behaviors of the patients and their families,
improvement of the patient’s mental and body function,ability, and risk reduction.
<Changes in the positive statements and behaviors ofpatients and families>
After the start of occupational therapy, the OBP
conditions and situations appeared to be due to changes
in the patients’ and families’ positive statements andbehaviors. Participant F’s narrative about the patientsis described as follows: “I think the reason for starting
OBP was that patients gradually started to think about
what they would do with their lives after being discharged from the hospital.”<Improvement in mental and physical function, ability,
and risk reduction>
This subcategory included improvements in thepatient’s mental and physical functions, ability, and risk
reduction, which encouraged the OTs to initiate OBP.
Therefore, the improvements in functions and abilities,
as well as the reduction in risks, prompted the initiationof OBP. The narrative of Participant B who treated aperioperative patient who was being managed with adrain is described as follows: “When the risk is still highright after the drain is inserted, I asked the patient for
about his favorite computer. After that, he was able tobegin to spend time safely even while being managedby drains, so I decided to do computers with him during
occupational therapy.”(6) [Actionable and meaningful occupations]This category was structured by the two subcategories that created seven codes. In this category, participants discussed the following types of occupations:Occupations that OTs wanted their patients to do wereAsian J Occup Ther 18: 199−207, 2022

feasible and prompted the patients to leave their hospitalbed.
<Actionable occupations that are appropriate for patients>
Participants reported that they thought of actionableoccupations that their patients should perform. Participant C’s narrative is described as follows: “We decided
to begin with the occupations that he had been performing before his admission to the hospital, so we started
with practicing toileting.”
Another participant reported that there were occupations that patients could perform based on theirabilities and the environment of the rehabilitation
room. Participant D’s narrative is described as follows:“Since the patient’s gait was quite unsteady, she initiallywashed dishes in the kitchen, which did not require her
to walk.”<Occupations leading to leaving the bed>
Participants reported that some occupations were
aimed at getting out of bed and standing up. Participant
E’s narrative is described as follows: “This is the storyof a patient who could scarcely leave her bed due toheadaches after a subarachnoid hemorrhage. I promised
her that if she was able to get up and go to the rehabilitation room, we would make her favorite sweet pudding
together.”

4. Discussion
The analysis showed that the conditions andsituations for OBP for patients with severe acute CVA
appeared to be composed of three elements: (i) environments such as physical environments, multi-disciplinary
professionals around the patients, and the OTs, (ii)patients and families, and (iii) occupations.
4.1 C onditions and Situations about Environments
Around Patients
Three categories [environments where occupations
can be done], [multi-disciplinary professionals whoestablish good quality teamwork with OTs], [OTs whoemphasize patient-centered practice are in charge ofpatients] included aspects of environments such as
the physical environments people around the patients
including the patients’ families, multi-disciplinary professionals, and the OTs.
Occupational performance [12] is defined by threeelements: environments, patients and families, and occupations. In this study, we obtained several narratives
about the physical environment and family members,
such as the tools available to patients and family members visiting the hospital. This indicates that the ability

Ikeuchi K et al.

205

of a patient to perform occupations is greatly influenced
by these environments. Since the participants reported
that there were specific environments that the patientsfound comfortable to do occupations in, it can be assumed that suitable environments for doing occupations
would lead to OBP.
Rosbergen et al. [13] explored the perceptions andexperiences of the nursing and allied health professionals involved in implementing an enriched environment
to enhance the physical, social, and cognitive activities
in an acute CVA unit. They reported the need for
teamwork, including frequent communication between
departments, to provide an enriched environment. In
this study, there were narratives about multi-disciplinary
professionals who were cooperative in OBP and whom
the participants trusted, and the narratives about OTs’
support through OBP for multi-disciplinary professionals who were having trouble dealing with the patients
who were unable to communicate. Both the studies byRosbergen et al. [13] and this study indicate that it isessential for OTs to collaborate with multi-disciplinary
professionals. As narrated by Participant C: “There were
nurses who were struggling to (…).” OTs could notice
the meaning of patients’ needs and behaviors that could
not be noticed by other professionals because they
performed occupations with patients. Thus, establishinggood teamwork with multi-disciplinary professionals
can guarantee the patients perform occupations.
The policy of the participants was also importantfor OBP to be implemented. Schell et al. [14] describedas follows: “clients are, of course, an essential component of OT intervention, but OT practitioners are alsopart of the equation. (…) Occupational therapy is arelational practice; thus, practitioners’ characteristics
and habits enter into practice.” It goes without sayingthat the OTs’ thoughts are reflected in their occupational
therapy practice. The participants in this study emphasized the importance of patients’ occupations and theircollaboration. To implement OBP, OTs need to resolve
to support their patients’ occupations.
4.2 Conditions and Situations about Patients andFamilies
There are two categories based on patients’ aspects.
First, we describe the category of [patients who
express their wishes to do occupations], which indicated that clients should have a strong desire to do
occupations and that the client’s response should begood or self-initiating. This result is the same as thatof a previous study [10]. Occupational therapy aims toenable clients to participate in the occupations they want
to do personally, and the things they need to do or are
expected to do socially and culturally [15]. In occupa-

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OCCUPATION-BASED PRACTICE FOR SEVERE ACUTE CEREBROVASCULAR ACCIDENT

tional therapy, OT respects and partners with patients,
values their subjective experiences of their participation,
and appreciates people’s knowledge, hopes, dreams, andautonomy [15]. Therefore, a patient’s strong will andgood understanding can be powerful factors for patientsand OTs to collaborate and promote the patient’s participation in occupations. It was shown that OTs should
evaluate the patient’s intentions and occupations, even
if the patient is a person with severe acute CVA and forwhom it will be difficult to implement OBP.
Second, we describe the category of [patients andfamilies who are getting to ready to resume occupations]. This does not mean that OBP should be initiatedafter confirming complete improvement of paralysis orrisk reduction, but it suggests that improvement of paralysis or risk reduction may promote the implementationof OBP. This is because we can understand from narrative of Participant B in the same category who was ask
his patient about the patient’s favorite computer when
the risks were still high participant B may have conducted an occupation-focused practice before the initiationof OBP. Occupation-focused [1] is defined as having
an occupation as the proximal focus of the evaluationor the proximal intent of the intervention, regardless ofwhether or not an occupation is performed, which is distinct from OBP. Thus, it may be important to encourage
patients and families to recall and talk about important
occupations to prevent patients from forgetting theiroccupations, rather than completely disconnecting occupations from patients when OBP is not performed.
4.3 Conditions and Situations about Occupations
There was one category of [actionable and meaningful occupations] regarding the aspect of occupations.
First, we describe the subcategory <actionable occupations that are appropriate for patients>. This included
occupations that were appropriate for the patients’abilities and strategies for the patients to perform occupations. It is suspected that this subcategory was createdbecause patients with severe CVA had become significantly less abled than they were before the onset of thedisease. There was also a code in which OTs prioritizedoccupations in which the patient had experience. Patil etal. [5] emphasized that occupational participation allows
patients with acute CVA to consider life in general andremember past occupational identities and occupational
preferences. This indicates that performing occupations is related to time. Yoshikawa [16] considered theconnection with time to be one of the key elementsof meaningful occupations. Therefore, it appears thathaving meaningful occupations that connect patients
to time, such as the past and the future, is an importantcondition for OBP.

Second, we describe the subcategory <Occupations
leading to leaving the bed>. In Japan, CVA is sometimes
the second event [17] leading to being bedridden, andin the Japanese guidelines for the management of stroke2015 [18], positive early sit-to-stand, gait training, selfcare training, among others, are recommended as grade
A treatment. However, there are quite a few patients
who are delayed leaving the bed due to headache ornausea, therefore the OTs need to assist patients to perform activities such as sitting and standing, but also tomaintain and improve the patient’s motivation by trying
to leave the bed for occupation.
4.4 Research Limitations and Future Challenges
The range of years that participants worked withpatients experiencing acute CVA was 3–32 years. There­
fore, we interviewed OTs with a wide range of experience, although many of the participants were young. The
disability and degree of disability of the patients attended to by the participants were diverse. These included
patients whose ADL was low at the start of OBP due todizziness and headaches and who were able to walk at
the time of rehabilitation session; patients whose paralysis was severe, but their higher cerebral function was
not problematic, and patients whose consciousness was
disturbed and motor paralysis were both severe. Therefore, we think that Participant F stated that he felt uncomfortable, although he was agreeable during member
checking. This participant dealt with patients who had
the most severe loss of consciousness or motor paralysis. We believe that the results of the member-checking
were influenced by the fact that the results of theanalysis were more applicable to patients with milder
conditions than those described by participant F in theinterview. Although severe conditions were defined inthis study, patients with many types of disabilities anda wide range of disabilities were included in the analysis. For this reason, occupations that are not generally
adapted for the severe person, such as housework andplant cultivation, were also listed. In the future, studies
restricted to patients with a marked deterioration in both
psychosomatic functions and patients with consciousness disorders, are required.
Based on the results of this study, it could be inferred that (1) the occupational therapist’s competencein accurately sensing the patient’s wishes and changes
in recovery and subsequently identifying actionable andmeaningful occupations and (2) the physical and humanenvironment in the OTs’ workplace have a significant
impact on whether OBP is implemented. This indicatesthat the competence of OTs and the workplace environments might be important factors in enabling the implementation of OBP. All eight participants (OTs) wereAsian J Occup Ther 18: 199−207, 2022

employed at different workplaces and met the eligibility
criteria for this study. Therefore, we infer that the participants in this study are somewhat competent, although it
is not clear how the physical and human environmentsof the participants’ workplaces affect the implementation of the OBP. It might be beneficial to determine theimpact of the physical and human environments of theirworkplaces on the implementation of OBP in the futurestudies.

5. Conclusion
The conditions and situations of OBP for patientswith severe acute CVA included three elements: environments, patients/families, and occupations. The
environments included physical environments that aresuitable for performing occupations, multi-disciplinary
professionals who establish good quality teamwork with
OTs, and OTs who emphasized patient-centered practicethat was in charge of patients. Patients/families include
those who express their wishes to do occupations or are
getting to ready to resume occupations. Occupations
were those that are actionable and meaningful. If these
conditions and situations exist, OBP can be performed
even in patients with severe acute CVA. We would liketo present these findings to OT occupations in the acutecare setting and offer the results of this study to providea reference for clinical practice.

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2015.

■ORIGINAL ARTICLE

Sense of Difficulties Experienced
by Japanese Occupational Therapists
in Cancer Rehabilitation
Yumi Kagaya1, Tomoaki Asano2, Megumi Tsugaruya2, Takashi Ishikawa2
1
2

Akita Kousei Medical Center
Graduate School of Health Sciences, Akita University

Abstract: Objective: This study aimed to identify the difficulties experienced by occupational therapists during cancer
rehabilitation, and explore potential solutions.
Methods: Eighteen occupational therapists with experience in cancer rehabilitation were interviewed, and the interviews were analyzed and synthesized using qualitative research methods.
Results: A total of 206 primary, 60 secondary, and 12 tertiary category themes were identified. These themes were discussed from three perspectives: “Related to the practice of occupational therapy,” “Related to occupational therapists
themselves,” and “The environment surrounding the occupational therapist.”
Conclusions: Occupational therapists in Japan have multiple difficulties in cancer rehabilitation because few of themspecialize in cancer. Therefore, their sense of difficulties could be reduced by improving their pre and post graduate education as well as for nurses who had similar problems.
Keywords: qualitative study, cancer rehabilitation, sense of difficulties(Asian J Occup Ther 18: 209−220, 2022)

Introduction
Cancer has been the leading cause of death inJapan since 1981. However, the mortality rate has been
declining annually, and more than half of cancer patients
can now be cured. To maintain and improve the qualityof life of people living with cancer, Japan is promoting
high-quality rehabilitation that improves motor function
and prevents a decline in living functions [1].
The third phase of the Japanese National Plan for
the Promotion of Cancer Control, which started in 2017,
stipulates that cancer rehabilitation should be conductedin outpatient clinics and local medical institutions fromthe perspectives of recovery, maintenance of functions,and reintegration into society. From the perspective ofsocial reintegration and social cooperation of cancer
patients, it has also been indicated that cancer patients
Received: 10 August 2021, Accepted: 20 May 2022
Corresponding to: Tomoaki Asano, Graduate School of Health Sciences, Akita University, 1-1-1, Hondo, Akita, 010-8543 Japane-mail: tasano@hs.akita-u.ac.jp©2022 Japanese Association of Occupational Therapists

should receive high-quality cancer care regardless of
where they receive treatment [2]. This means that cancer
rehabilitation should be conducted at home and in longterm care facilities. Therefore, occupational therapists
who work in cancer hospitals, at home, or in long-termcare facilities, are expected to have additional opportunities to be involved in cancer rehabilitation.
Occupational therapists are involved in preventative, convalescent, maintenance, and palliative cancer
rehabilitation [3]. The main types of cancers covered arebrain tumors, head and neck cancers, lung cancer, breast
cancer, and bone and soft tissue tumors. Treatment
includes surgery, chemotherapy, radiation therapy, andpalliative therapy [4]. Thus, occupational therapists needa great deal of knowledge because of the wide rangeof cancer stages and treatment methods. In addition,
cancer treatment is constantly advancing; therefore,
current knowledge is required. However, Miki statedthat the system for conducting undergraduate education
on cancer is insufficient, and that the effectivenessindex of occupational therapy for cancer is not clear [5].
Nishi­kori also reported that occupational therapists are
confused about participating in cancer rehabilitation be-

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SENCE OF DIFFICULTIES IN CANCER REHABILITATION

Table 1 Interview guideNo.

Questions

1
2
3
4
5
6
7
8
9
10
11

What sense of difficulties do you have with cancer rehabilitation?
What sense of difficulties do you have in setting goals?
What sense of difficulties do you have in communicating with cancer patients and their families?
What sense of difficulties do you feel in cooperation with doctors, nurses, and other professionals?
How do you explain occupational therapy to cancer patients and their families?
What sense of difficulties do you have in sharing informed consent, goals and programs of occupational therapy?
What sense of difficulties do you feel about your knowledge and skills?
What sense of difficulties do you have in working with patients at the end of life?
What sense of difficulties do you feel about the environment, system, and regional cooperation?
Compared with rehabilitation for other diseases, what difficulties do you feel?
Please tell us about the patients with cancer you have had difficulty in dealing with, including the reason why they asked
for occupational therapy.
Please tell us about any other difficulties you have experienced throughout the whole process.

12

cause of their lack of knowledge and experience [6]. In
addition, during the palliative phase, the psychologicalburden on occupational therapists is high because they
face death more often.
In the field of nursing, there have been many studies on the sense of difficulty in cancer nursing, and it has
been reported that many nurses feel a sense of difficulty[7–11]. However, there are no reports on the difficulties
experienced by occupational therapists in occupational
therapy for cancer. Clarifying the difficulties experienced by occupational therapists when they are involvedin cancer rehabilitation is likely to suggest how they canovercome their difficulties, solve problems, and workon rehabilitation tailored to each patient. Additionally,
clarification of the core difficulty will contribute to preand post-graduate education on cancer rehabilitation,and high-quality cancer rehabilitation practice, which isclearly stated in the national policy.
The objectives of this study were to identify the difficulties experienced by occupational therapists duringcancer rehabilitation, and explore potential solutions.

Data Collection
Based on the interview guide (Table 1), semi-structured face-to-face individual interviews were conductedwith occupational therapists regarding the difficulties
they perceived when providing cancer rehabilitation.
The interviews were conducted individually. The content of the interview guide was developed with reference
to the Difficulties in Cancer Nursing Scale for Nurses
developed by Sasahara and Onodera, and with the super­
vision of an occupational therapist who is an expert ineducation and qualitative research. Sense of difficulty
was defined as a mental burden, such as problems anddifficulties in practicing cancer rehabilitation.
In addition to the sense of difficulty, we collected
information on the attributes of the participants, such asage, sex, years of clinical experience, type of institution
they belonged to, type of work, ward they worked in,number of cancer patients per stage they had been in
charge of, and whether they had any training opportunities related to cancer. The interviews were conducted
between November 2016 and April 2017.

Methods

Data Analysis
Qualitative content analysis was used to analyze
the interview content. This method analyzes messages
obtained from interviews and questionnaires, and makes
valid contextual inferences based on the context by extracting, categorizing, and hierarchizing issues [12].
All interviews were recorded on an integrated
circuit (IC) recorder with the consent of the participants,
and verbatim transcripts were generated. Subsequently,
we coded the concepts of the sense of difficulty that
could be read from the verbatim transcripts. Codes
were categorized based on their similarities. A higher
category was created if there was a relationship between
the categories and the categories were organized into a

A qualitative research method was used in thisresearch design. Prior to commencement of the study,
human ethics approval was obtained from the ethicalreview committee of the university to which the firstauthor belonged.
Recruitment of participants
The research plan and request form were sent toall hospitals providing occupational therapy for cancer
in Prefecture A. Eighteen occupational therapists who
responded to this request were interviewed by the firstauthor. Written consent was obtained from all of them.

Asian J Occup Ther 18: 209−220, 2022

Asano T et al.

211

Table 2 Characteristics of participants

A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R

Age

GenderClinical experience

Type of institution

Interview time

Early fifties
Late twenties
Late thirties
Late twenties
Early thirties
Early thirties
Early fifties
Early fifties
Late forties
Early forties
Late thirties
Late thirties
Late fifties
Late thirties
Late thirties
Early forties
Early thirties
Late thirties

FemaleFemaleMale
Female
Male
Male
Male
FemaleMale
Male
FemaleFemaleFemaleFemaleMale
Male
FemaleFemale30 to 35 years
5 to 10 years
10 to 15 years
5 to 10 years
10 to 15 years
5 to 10 years
30 to 35 years
30 to 35 years
20 to 25 years
15 to 20 years
15 to 20 years
15 to 20 years
25 to 30 years
10 to 15 years
10 to 15 years
10 to 15 years
10 to 15 years
15 to 20 years

Cancer control center hospital
Cancer control center hospital
Cancer control center hospital
Cancer control center hospital
Cancer control center hospital
Cancer control center hospital
Cancer control center hospital
Cancer control center hospital
Cancer control center hospital
General hospital
General hospital
General hospital
General hospital
Home rehabilitation station
Home rehabilitation station
Home rehabilitation station
Long-term care facilities
Long-term care facilities

28 m 14 s
23 m 44 s
41 m 46 s
51 m 19 s
41 m 52 s
41 m 20 s
39 m 34 s
51 m 12 s
48 m 00 s
48 m 01 s
58 m 38 s
45 m 06 s
51 m 21 s
35 m 51 s
38 m 31 s
44 m 05 s
29 m 59 s
35 m 11 s

39 ± 9 years(mean ± SD)

16 ± 8 years(mean ± SD)

hierarchical structure.
To ensure the validity of the analysis results obtained in this way, they were presented to the research
participants and revised until the validity of the content
was obtained. In addition, triangulation was conductedunder the supervision of two occupational therapists
with more than 20 years of experience in research andeducation in the field of physical disabilities, and one
occupational therapist with extensive experience inqualitative research.

Results
The 18 interviewees included 10 women and 8
men, with a mean clinical experience of 16 ± 8 years.
The average interview time was 42 minutes and 41 seconds. The detailed attributes of the interviewees and theinterview times are listed in Table 2.
In total, 721 codes were obtained. Each code wasaggregated into 206 primary categories based on similarities, and the primary categories were further aggregatedinto 60 secondary categories. Finally, the secondary
categories were aggregated into 12 third level categories: “Sense of difficulties related to the occupational
therapy program,” “Sense of difficulties related to goal
setting,” “Sense of difficulties in dealing with mental
health,” “Sense of difficulties in responding to medical
conditions,” “Sense of difficulties in communication,”“Sense of difficulties in informed consent,” “Sense ofdifficulties in the mental health of occupational therapists,” “Sense of difficulties related to knowledge, skills,

41 m 52 s

and experience,” “Sense of difficulties related to family
support,” “Sense of difficulties related to home support,”“Sense of difficulties related to the environment,” and“Sense of difficulties with multidisciplinary cooperation” (Table 3).
Sense of difficulties related to the occupational therapy
programThis category consisted of three subcategories:
Presentation of the unique program and effects of occupational therapy, appropriate decisions on when toadminister occupational therapy, and introduction of an
appropriate occupational therapy program.
Some of the participants noted, “I felt that it wasdifficult to separate physical therapy and occupational
therapy, or rehabilitation for physical functions wasinevitably demanded more and more. Then, I wondered
what occupational therapy was all about,” and “I sometimes asked myself if the approach I had taken was
really for the benefit of the patients.”
Sense of difficulties related to goal settingThis category consisted of four subcategories: Sharing of goals between patients and families, occupational
therapists and health care professionals, matters related
to goal planning, sharing of goals between patients andfamilies, and sharing of goals among multiple professions.
One participant said, “I felt that it was difficult tobridge the gap between our motivation and the patients.
For example, we wanted the patient to move even212

SENCE OF DIFFICULTIES IN CANCER REHABILITATION

Table 3 Concepts and structures derived from the interview analysis
Tertiary category (number of secondary categories)
Secondary category (number of primary categories)• Primary category (number of codes)
1. Sense of difficulties related to the occupational therapy program (3)• Reluctance to carry out the program due to the deadly disease (5)Presentation of the unique program and effects of occupational• Thought of whether enough occupational therapy could havetherapy (2)provided to patients with little time to left (12)• Presentation of the difference between occupational therapy and• Confusion about what I can do as occupational therapist for patients
physical therapy (4)with little time left to live (3)• Presentation of the effects of occupational therapy (3)• Timely execution of the program according to the patient’s physicalcondition (2)Appropriate decisions on when to occupational therapy (1)• Devising a program when the patient is aware of functional decline• Appropriate decisions on when to occupational therapy (4)(1)
Introduction of an appropriate occupational therapy program (6)• Confusion about whether the program is appropriate (10)
2. Sense of difficulties related to goal setting (4)• Difficulties in setting goals according to life expectancy (6)Sharing of goals between patients and families, occupational• Difficulties in setting goals according to the stage of the disease (1)therapists, and health care professionals (7)• Occupational therapy itself must become a goal (2)• Inability to talk to patients about realistic, achievable goals (7)• Difficulties in setting clear goals (11)• Inability to determine if goals are appropriate for the patient (1)• Difficulties in goal setting when patient wishes are unknown (3)• Adjustment when the patient’s wishes are too high compared to the• Lack of clarity about the difference between the goals of physicalmedical condition (10)therapy and occupational therapy (1)• Adjustment when the family’s wishes are too high compared to the• Difficulties in setting goals when the disease is worsening (5)medical condition (5)• Difficulties in setting high goals (5)• Inability to determine if goals are appropriate for the patient (1)• Difficulties of setting a goal with little time left to live (4)• Adjustment for there is a disagreement in opinion between patientand occupational therapist (3)Sharing of goals between patients and families (2)• Adjustment for there is a disagreement in opinion between patient• Adjusting for differences between occupational therapy goals andand medical staff other than occupational therapist (2)family wishes (1)• Adjustment when patient and family have different wishes (11)Matters related to goal planning (12)• Difficulties in goal setting for patients with low motivation (2)Sharing of goals among multiple professions (1)• Difficulties in goal setting for patients with unannounced prognosis• Adjustment when the goals of other medical professionals are high(1)(1)
• Difficulties in goal setting for patients with no relatives (1)3. Sense of difficulties in coping with mental health (2)How to work with patients who are not active in occupational
Emotional support for patient distress (10)therapy (7)• Emotional support for depression in patients (3)• How to work with patients who are not motivated (5)• Emotional support for patients with limited life expectancy (6)• How to work with patients who have decreased motivation (6)• No one to take care of the feelings of patients who have no relatives• How to work with patients who refuse occupational therapy (5)(2)• How to work with dependent patients (2)• Fear of the word “cancer” itself (2)• How to work with patients who are unstable and unmotivated to• Emotional support for mentally unstable patients (7)receive occupational therapy (5)• Emotional support for patient and family anxiety (3)• How to work with patients who do not find value in occupational• Emotional support for patients when they are depressed (4)therapy (3)• Emotional support for young patients (4)• Emotional support for patients who have lost their purpose in life (4)• Emotional support for patients and their families when they becomeaware of functional decline (8)• Emotional support for patients who have been shocked by theannouncement of cancer (3)4. Sense of difficulties in coping with medical conditions (8)• Program contents in case of worsening medical conditions (2)Accurate judgment of the patient’s condition (7)• Failure to meet patient’s expectations due to worsening medical• Difficulties of occupational therapy according to patients’condition (3)nutritional status (1)• Pressure ulcer control for terminally ill patients (1)• Difficulty in determining prognosis (5)• Drastic changes in medication status at the end of life (1)Coping with inadequate control of pain and numbness (3)• There is a high possibility of sudden deterioration of the disease (6)• Coping with inadequate control of pain and numbness when
• Determining medical conditions when performing occupational
physical pain is high (13)therapy on my own (6)• Emotional support for patients with severe pain (1)• Gradual worsening of the disease (18)• Coping with Patients with Severe Numbness (1)• Significant change in medical condition (14)Implementation of programs for worsening of disease conditions (5)• Program does not proceed as planned due to deteriorating medical
condition (5)• Unable to actively pursue the program due to deteriorating medical
condition (5)Coping with metastatic bone cancer (6)• Occupational therapy for patients with bone metastases (2)• Risk management for patients with bone metastases (3)• Difficulties in teaching daily life while suffering from wearing a
corset in pain (1)Asian J Occup Ther 18: 209−220, 2022

Asano T et al.

Table 3
• Determining possible ADL activities for patients with bonemetastases (4)• Determining the degree of loading for patients with bone metastases(3)• Rehabilitation for patients with pathological fractures (2)213Continued.

Difficulties of avoiding the risk of falling while respecting thepatient’s wishes (1)• Difficulties of avoiding the risk of falling while respecting thepatient’s wishes (1)Coping with other coexisting diseases, complications, and side
effects (5)• In patients with dementia, it is difficult to determine whether they
are feeling unwell or demotivated (1)• Patient self-management of lymphedema (3)• Coping with a patient with delirium (1)• Coping with changes in physical condition due to side effects ofmedication (3)• Implementation of occupational therapy for patients with othercomorbidities (5)Difficulties specific to cancer (1)• Difficulties in coping with the unique characteristics of cancer (1)Coping with patients with little time left to live (1)• Coping with patients with short life expectancy (8)5. Sense of difficulties in communication (7)• Difficulties in coping with uninformed patients when they begin to
Wording that considers the feelings of patients and their families (11)have doubts about their condition (2)• Coping with family members and patients who express concerns (4)• Communicate with uninformed patients so that they do not realize• Coping with a patient who brings up the topic of death (3)their illness (14)• Be nervous about hurting the patient with careless words (6)• Difficulties in talking to patients when they become pessimistic (6)Occupational therapists do not have time to spare (1)• Consideration to avoid mentioning the disease (4)• Lack of time to talk to the patient (2)• Difficulties in speaking encouragingly to patients (4)• Be considerate of the content of conversations so that family
Communication with families (3)members are not discouraged (4)• Communicating with family members who have limited visitation• Coping with patients who think they will get better even though(2)
their condition is worsening (3)• How to tell the family that the patient is doing well (1)• Consideration for conversation content when the patient’s condition• Family visiting hours do not coincide with occupational therapist’s
worsens (3)working hours (2)• Coping with patients when they become emotional (1)• Consideration for the content of the words directed at the patient (11)Questions from patients and families about their condition andtreatment (2)Patients have factors that make communication difficult (3)• Questions from family members about the patient’s condition and• Difficulties in guessing the patient’s thoughts when the patients dotreatment (3)not express their feelings (6)• Questions from patients about their condition and treatment (6)• Communicating with patients with cognitive decline due to brain
tumors or dementia (3)Establishing a relationship with patients (1)• Communicating with patients with oral and laryngeal cancer (1)• Not being able to have in-depth conversations with patients until
you have a deeper relationship with them (3)Communication with uninformed patients (3)• Difficulties in coping with having to tell family members things
that cannot be told to uninformed patients (1)6. Sense of difficulties in informed consent (5)Helping patients and their families understand that getting better is
not the only rehabilitation (1)• Helping patients and their families understand that getting better is
not the only rehabilitation (2)Informed consent for occupational therapy (2)• Difficulties in communicating the need for occupational therapy topatients (2)• Difficulties in communicating the role of occupational therapists (3)Explanation of the rehabilitation plan to uninformed patients (1)• Explanation of the rehabilitation plan to uninformed patients (1)Insufficient explanations regarding the start of rehabilitation by thedoctor (1)• Insufficient explanations regarding the start of rehabilitation by thedoctor (1)Informed consent when the patient does not understand (2)• Difficulties in obtaining informed consent for patients who refuse
occupational therapy for financial reasons (1)• Difficulties in obtaining informed consent from patients withdementia and few family visits (2)7. Sense of difficulties in the mental health of occupational therapists (3)Mental health of occupational therapists (1)Mental burden on occupational therapists due to increased contact• Mental health of occupational therapists (1)with patients facing death (3)• Difficulty in changing their minds when working with patients who
Helplessness due to the inability of occupational therapy to help orare dying and those who are not (2)do anything about it (1)• Being in contact with patients who are dying (15)• Helplessness due to the inability of occupational therapy to help or• Mental burden on occupational therapists due to the high number ofdo anything about it (8)patients who die (6)214

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Table 3

Continued.

8. Sense of difficulties related to knowledge, skills, and experience (16)• Things don’t always go according to the manual (5)Overall insufficient knowledge about cancer (6)• Updating knowledge in response to advances in treatment (2)• Lack of knowledge about cancer treatment (1)• Lack of knowledge about cancer as a whole (15)• Lack of knowledge about cancer risk management (1)• Anxiety due to lack of knowledge about cancer treatment (3)• Diverse knowledge for diverse cancers (3)Lack of knowledge about internal disorders (2)• Lack of knowledge of internal diseases (2)• Lack of knowledge about respiratory rehabilitation (1)Lack of knowledge in postoperative management (2)• Lack of knowledge about postoperative management (2)• Lack of knowledge about postoperative risk management (2)Insufficient experience in cancer rehabilitation (6)• Even new, inexperienced OTs must be involved (1)• Differences in experience and knowledge with nurses (1)• Gap between occupational therapy that I have experienced andoccupational therapy for cancer (3)• Lack of experience in cancer rehabilitation (13)• Fewer orders for cancer rehabilitation (4)• Surprising when orders for cancer occupational therapy occurs
rarely (1)Insufficient technical skills of occupational therapists (5)• Ability to correctly communicate the patient’s condition to otherprofessionals (1)• Lack of technical skills (4)• Lack of communication skills(2)• Lack of technical skills to objectively record information in medical
records (3)• All capacities of occupational therapy are needed (1)Insufficient education in cancer rehabilitation (5)• Little training in cancer rehabilitation (5)• Low motivation for learning and lack of knowledge acquisition (1)• Training is mandatory for reimbursement calculation (2)• Inadequate pre-graduation education (5)Lack of knowledge about edema management (3)• Lack of knowledge about edema management (1)• Lack of knowledge about edema (3)• Lack of knowledge about lymphatic massage (3)Lack of knowledge about palliative care (1)• Lack of knowledge about palliative care (1)Lack of knowledge in physical fitness (1)• Lack of knowledge in physical fitness (1)Lack of knowledge in medical equipment (1)• Lack of knowledge in Medical equipment (1)Lack of knowledge in biochemistry (1)• Lack of knowledge in biochemistry (4)Lack of knowledge in radiotherapy (1)• Lack of knowledge in radiotherapy (3)Lack of knowledge in bone metastases (1)• Lack of knowledge in bone metastases (1)Lack of knowledge in pain (1)• Lack of knowledge in pain (1)Lack of knowledge in drugs (4)• Lack of knowledge of the side effects of chemotherapy (2)• Lack of knowledge of the characteristics of pharmacotherapy (1)• Lack of knowledge in drugs (10)• Lack of knowledge about anticancer drugs (3)Lack of psychological support for patients (4)• Lack of knowledge of psychological support (1)• Lack of knowledge of spiritual pain (2)• Understanding of death (3)• Lack of knowledge about patients’ acceptance of disease (1)9. Sense of difficulties related to family support (4)• Coping with uncooperative family members (1)Helping family members to understand how to care and understandthe disease (3)Intervening in strong marital relationships (1)• How to communicate the correct method of care to family members• Strong marital relationships make it difficult for occupational(2)
therapists to get involved• How to teach elderly parents to learn how to care for their children(1)• Helping family members understand the disease (1)Emotional support for family members (1)• How to support mentally unstable families (3)Getting cooperation from uncooperative family members (2)• Coping with a patient with a deteriorating family relationship (2)10. Sense of difficulties related to home support (2)Support for home and treatment (6)Support for discharge from the hospital (8)• Support for those who are not well accepted by the long-term care
• Early discharge in acute care hospitals (1)insurance services (4)• Disagreement among family members about discharge from home
• Patient’s home is not suitable for medical treatment (1)(1)• Home support for patients with lymphedema (1)• Securing an appropriate hospital transfer (4)• Support for patients who are unable to visit the hospital for family• Discharge support for patients living in rented houses (1)reasons (1)• Determining the appropriate time to leave the hospital (6)• Fewer occupational therapists working in the community and• Support for discharging patients to home with insufficient nursing
insufficient support (3)care capacity (7)• Support for patients who are unable to visit hospitals for financial• Support for discharge of patients with limited life expectancy toreasons (1)their homes (1)• Disagreement between family and medical staff about discharge
from home (1)Asian J Occup Ther 18: 209−220, 2022

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Table 3

215

Continued.

11. Sense of difficulties related to the environment (3)Differences in treatment between hospitals and institutions (1)• Differences in treatment between hospitals and institutions (1)Physical environmental factors of hospitals and institutions (6)• In multi-bed rooms, conversations can be overheard by other
patients (3)• Lack of supplies needed for rehabilitation (1)• Being in the same room with a terminally ill patient and arecovering or maintenance patient (3)• Secure a place with privacy (2)• Considerations for when patients do not feel comfortable with eachother (1)• Lack of places to get a change of scenery (2)Human environmental factors (3)• Lack of rehabilitation staff (2)• Lack of occupational therapists with extensive experience in cancer
rehabilitation (1)• Determining the best occupational therapist for the patient (2)12. Sense of difficulties with multidisciplinary cooperation (3)• Difficulties of working alone as an occupational therapist in
Collaboration with doctors (8)collaboration with other professions (2)• Insufficient understanding of rehabilitation by doctors (7)• Insufficient understanding of cancer rehabilitation by other• Insufficient understanding of cancer rehabilitation by doctors (1)professions (4)• Ambiguity in the purpose of physicians’ rehabilitation orders (8)• Insufficient recognition of occupational therapy (1)• Insufficient cooperation among doctors (1)• Expedited nursing care insurance procedures for patients with short• Different doctors have different policies (1)life expectancy (1)• Discretion to the rehabilitation department after ordering (2)• Insufficient cooperation with non-primary physicians (2)Collaboration with nurses (5)• Inadequate exchange of information with the attending physician (9)• Differences in the ease of collaboration among nurses (5)• Insufficient understanding of cancer rehabilitation by nurses (1)Collaboration with multiple professions, including doctors and• Difficulties in working with nurses to achieve goals (2)nurses (7)• Difficulties in collaboration due to nurses’ busy schedules (2)• Timely information sharing with other professions (4)• Collaborating with visiting nurses in supporting patients with
• Difficulties in working with the team (6)lymphedema (4)• Difficulty in managing risk due to lack of rapid information
management (2)slightly, but the patient did not care.” Another participant noted, “I had to start rehabilitation for a patient in adire situation, and I did not know where to set my goal.
I started byfumbling, and I was not able to determine a
specific goal.”
Sense of difficulties in coping with mental healthThis category consists of two subcategories: Emotional support for patient distress, and how to work withpatients who are not active in occupational therapy.
It was noted here that, “The patients may have been
informed, but they did not accept it even though theyknew it. It was like they were in some kind of turmoil
wanting to be cured,” and “Well, they had been vaguely
aware of the fact that their condition was getting worse,and I had some difficulties in terms of how to talk tothem.”
Sense of difficulties in coping with medical conditions
This category consisted of eight subcategories:
Accurate judgment of the patient’s condition, implementation of programs for worsening disease conditions,
coping with inadequate control of pain and numbness,
coping with metastatic bone cancer, difficulties inavoiding the risk of falling while respecting the patient’s
wishes, difficulties specific to cancer, coping with othercoexisting diseases, complications, and side effects, andcoping with patients with little time left to live.

According to some participants, “It is difficult toensure rest and determine what can be done and whatshould not be done, especially for people who havepathological fractures of the long bones or spine, which
can significantly change their ADLs,” and “I had a lotof difficulty with this patient’s rehabilitation because
treatment and pain control were not progressing.”
Sense of difficulties in communication
This category consisted of seven subcategories:
Wording that considers the feelings of patients and theirfamilies, patients who have factors that make communication difficult, communication with uninformed
patients, occupational therapists who do not have timeto spare, communication with families, questions frompatients and families about their condition and treatment, and establishing a relationship with patients.
Some participants said, “I think it is a really subtle
nuance, but it is difficult to choose the right words because I think patients sometimes wonder if it is true.”“For example, when patients ask me if they will
improve in the future, I can tell some of them that they
will improve. However, some patients will gradually getworse in the long run, so I find it difficult in such cases.”
Sense of difficulties in informed consent
This category consisted of five subcategories: Informed consent for occupational therapy, explanation of

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the rehabilitation plan for uninformed patients, insufficient explanations regarding the start of rehabilitation by
the doctor, helping patients and their families understandthat getting better is not the only rehabilitation, andinformed consent when the patient does not understand.
Participants noted that, “The doctor orders rehabilitation. However, when I actually try to do it, I cannot
imagine doing so because the patient is in such a serious
situation. There is such a gap,” and “I do not think I am
doing a good job of communicating the need for rehabilitation.”
Sense of difficulties in the mental health of occupational
therapists
This category consisted of three subcategories:
Mental burden on occupational therapists due to increased contact with patients facing death, the mental
health of occupational therapists, and helplessness dueto the inability of occupational therapy to help or doanything about it.
According to certain participants, “In rehabilitation,
there is a certain amount of time I am in contact withthe person. I see them every day for half an hour or one
hour. I actually talk to them and am involved with them,so I see they are passing away. Therefore, when thatkind of thing happens repeatedly, I feel it is a bit hard.”
Others noted, “I have been doing rehabilitation for orthopedics and neurosurgery, so I have to slightly change
my mind a little bit or slightly prepare myself when I go
to rehabilitate terminal cancer patients.”
Sense of difficulties related to knowledge, skills, and experience
This category consisted of 16 subcategories: Insufficient knowledge about cancer, lack of knowledge
about internal disorders, lack of knowledge about postoperative management, insufficient experience in cancer
rehabilitation, insufficient technical skills of occupational
therapists, insufficient education in cancer rehabilitation,lack of knowledge about edema management, lack ofknowledge about palliative care, lack of knowledge
about physical fitness, lack of knowledge about medical
equipment, lack of knowledge about biochemistry, lackof knowledge about radiotherapy, lack of knowledge
about bone metastases, lack of knowledge about pain,lack of knowledge about drugs, and lack of psychological support for patients.
Some participants said, “First of all, I don’t know
enough about the different cancers.” “I know I needto study, but it’s hard to study because this is not mymain disease.” “When I studied cancer at university, I
didn’t think that cancer patients would be rehabilitated.
I thought it was just a part of internal medicine. Cancer

has become a subject of rehabilitation in our society,and I feel that I am late to the scene. I have to keep myantennae as high as possible.”
Sense of difficulties related to family support
This category consisted of four subcategories:
Helping family members understand how to care forand understand the disease, getting cooperation from
uncooperative family members, intervening in strong
marital relationships, and emotional support for family
members.
It was reported here that, “When a person dies, it
is not just the person who dies but the family and thepeople around them. The range of people involved
is quite wide. Therefore, I think it is only cancer thatmakes the way we relate to and support the bereaved
different.”
Sense of difficulties related to home support
This category consisted of two subcategories:
Support for discharge from the hospital, and support forhome and treatment.
According to participants, “Some families reminisce and regret that they did not take their family members to the hospital at that time,” and “Some patientswere advised to go to a hospice, but it was too far away,
so they came to this hospital.”
Sense of difficulties related to the environment
This category consists of three subcategories: Physical environmental factors of hospitals and institutions,differences in treatment between hospitals and institutions, and human environmental factors.
Various participants reported that, “As an occupational therapist in the hospital environment, I would liketo provide a more personable life for the patient. However, the hospital environment is not really suitable,”and “I am always worried about who is going to be incharge of this patient to get the best results.”
Sense of difficulties with multidisciplinary cooperation
This category consisted of three subcategories:
collaboration with doctors; collaboration with multiple
professions, including doctors and nurses; and collaboration with nurses.
Some participants said, “Sometimes rehabilitation
is prescribed without any specifics, such as what can we
do in this remaining time.” “Well, it’s difficult to answer
because I have not actually seen the patient, but I havereceived a report and the condition changed. I did notactually see the patient, so it was difficult to answer. I
want to respond to the patient’s changes, but I cannot
say anything because I do not know the patient’s current

Asian J Occup Ther 18: 209−220, 2022

state. This is a bit of a problem.”

Discussion
As described in the previous section, 12 themes
emerged regarding the difficulties experienced by
Japanese occupational therapists in cancer rehabilitation.
These 12 themes can be discussed from three perspectives: those related to the practice of occupational
therapy, those related to occupational therapists themselves, and those related to the environment surrounding
occupational therapists (Table 3). In addition to thesethree perspectives, the characteristics of occupational
therapists’ sense of difficulty compared to the nursing
care of cancer patients, for which there are many previous studies, are described below.
Carrying out occupational therapy
The narratives obtained in this study regarding thesense of difficulties related to the occupational therapy
program, goal setting, coping with mental health, copingwith medical conditions, communication, and informed
consent suggest that occupational therapists are trying toprovide occupational therapy unique to cancer patientswith consideration of the patient’s feelings, even while
they are concerned about whether they are providing
adequate occupational therapy.
Miki et al. reported that the majority of occupational therapists feel anxious and doubtful about theirprofessional involvement [13]. The theme of “sense ofdifficulties related to the occupational therapy program”
obtained in this study is consistent with the professional
concerns and doubts that occupational therapists have,as reported by Miki et al.
This difficulty may be related to the fact that occupational therapists in Japan often work with patientsduring the palliative phase. In Japan, many cancer-based
hospitals are acute-phase hospitals, where patients withcerebrovascular and musculoskeletal diseases are often
offered occupational therapy to restore function. It has
been reported that the aim of rehabilitation at the end oflife is to achieve the best possible quality of life [14, 15].
Therefore, occupational therapists involved in cancer
rehabilitation should shift their focus to improving thequality of life of patients who are unlikely to regainfunction.
“Sense of difficulties in setting goals,” and “senseof difficulties in coping with the disease state” suggested
that the goals desired by patients and their families werehigher than their actual abilities, it was difficult to set
clear goals, and it was difficult to cope with worseningof the disease and bone metastases. The reason for thisis that the pressure to change goals and programs as

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patients’ conditions change, and the number of patient
conditions and risks to be managed, may cause a senseof difficulty for occupational therapists. Therefore,
occupational therapists must have the ability and knowledge to assess the patient’s condition appropriately, andmodify the program to suit the situation.
“Sense of difficulties in dealing with mental healthissues” suggested that there were difficulties in dealing
with the patient’s distress, and the patient’s psychological problems affected the performance of occupational
therapy. This is because occupational therapists try tounderstand the patient holistically, not only in terms ofphysical functioning, but also in terms of psychologicalaspects. Lehmann reported that psychological issues are
the most common problems faced by patients duringcancer rehabilitation [16]. Therefore, occupational therapists, who spend most of the time one-on-one with thepatient, can play an important role in providing psychological support to the patient.
In the “Sense of difficulties in communication”
category, although occupational therapists have a willto encourage and provide emotional support to patientsand their families, they need to be careful not to mention
medical conditions or death, regardless of whether they
have been informed. Occupational therapists’ difficulties
are caused by their environment, such as busy work
schedules and family commitments. This may be due tothe conflict between occupational therapists’ willingness
to relieve the patient’s anxiety, and the reality of not
being able to talk honestly about the patient’s condition
during the time spent with them. It has also been reported that nurses have a strong sense of difficulty whencommunicating with patients and their families [7, 8].
Nakazawa et al. reported that the degree of postgraduate
education and clinical experience are related to the senseof difficulty [8]. Therefore, experience and professional
education in cancer rehabilitation may help reduce thesense of difficulty experienced by occupational therapists. Training in communication skills, such as delivering “bad news,” is also important.
In the “Sense of difficulties related to informed consent” category, respondents indicated difficulties when
the physician did not provide a sufficient explanation,
the patient was not informed of the role and necessity ofoccupational therapy, and the patient’s consent was not
obtained. In Yamano’s survey of Japanese occupational
therapists working in the field of physical and geriatricdisabilities, 70% of the respondents noted that the reason
for providing occupational therapy without the subject’s
consent was “because it would benefit the subject” [17].
Grisso stated that a patient’s decision-making capacity
consists of four elements: the ability to express choices,to understand, to recognize, and to think logically [18].

218

SENCE OF DIFFICULTIES IN CANCER REHABILITATIONAs some patients are not fully informed about their disease and prognosis and do not understand occupational
therapy, it is necessary for physicians and occupational
therapists to discuss and explain the disease in advanceto patients and their families. Occupational therapists
should then promote self-determination, build trust, andfacilitate occupational therapy.
Points of view from occupational therapists themselves“Sense of difficulties in the mental health of occupational therapists” indicated that they had more contact
with patients who were dying, and felt unable to help
them. Another factor may be that, although empathy forthe subject is generated through the time spent in one-toone contact, the emotional burden of losing the patient ispresent. Rogers et al. reported that a decreased sense of
personal accomplishment and negative self-evaluationinfluenced burnout in a study among occupational
therapists in the United States and Australia [19]. For
occupational therapists in Japan, feelings of helplessness and deaths of patients are also considered strong
contributors to occupational stress, and it is necessary totake measures to reduce stress, such as setting up a place
to share worries.
It was indicated that “Sense of difficulties related toknowledge, skills, and experience” was related to lackof knowledge, experience, skills in cancer rehabilitation,and insufficient education. In Japan’s disease-specificrehabilitation system, cancer rehabilitation was institutionalized in 2010. However, cancer rehabilitation
was being conducted before it was institutionalized.
Despite this, the description of occupational therapy forcancer was not included as a separate chapter in typicalJapanese textbooks on physical disabilities until 2016;
before that, only a few pages were included. Therefore,
even experienced occupational therapists have received
little education regarding cancer. In addition, postgraduate education is only a one- to several-day course.
Since Rogers et al. reported that the number of years ofeducation is related to motivation [19], it is predictedthat enhanced pre- and postgraduate education is likely
to reduce the sense of difficulty.
Points of view from occupational therapists’ environments
The results indicated that “Sense of difficulties
related to family support,” “Sense of difficulties related
to home support,” and “Sense of difficulties related tothe environment” were related to difficulties in caring
for older adults at home due to aging and nuclear families, problems specific to acute-care hospitals that must
shorten the average length of stay, uneven distributionof resources related to home support and palliative care,inadequate financial support, and inadequate recuperation and treatment environments. The third phase of
the Japanese National Plan for the promotion of cancer
control aims to construct a society in which people canlive with dignity and peace of mind [2]. The family is
the key person who supports the patient’s life at home,
and an improved system of support for the family isnecessary to achieve this goal.
In the “Sense of difficulties with multidisciplinary
cooperation” section, the difficulty of working with
doctors, nurses, and other medical professionals was
mentioned, which suggests the difficulty of team medicine. In 2010, the Ministry of Health, Labor, and Welfare (MHLW) proposed that to achieve higher quality
medical care for patients and their families, it is necessary to change the concept of integration through team
medicine, while improving the expertise of individual
medical staff [20]. Jünger et al. reported the presence of
close communication, team philosophy, good interpersonal relationships, high team commitment, autonomy,
and the ability to cope with death as essential elementsof multidisciplinary cooperation in palliative care [21].
Compared to other professions, occupational therapists
are able to take their time and engage with patients on
a one-on-one basis, which enables them to comprehensively understand patients not only physically, but also
psychologically and socially, and to share the information obtained with other professionals. In other words,
the benefits of occupational therapists’ involvement in
the treatment of cancer patients should be demonstrated
to other professions to increase the possibility of supporting their personal lives. In addition, the involvementof occupational therapists in medical care, nursing care,welfare, and employment support, particularly in basic
cancer hospitals, will enable cancer patients to live incommunities with dignity.
Characteristics of sense of difficulties experienced byoccupational therapists compared to nurses
Sasahara et al. reported that 78 items were identified as difficulties experienced by nurses working in a
general ward and caring for terminally ill cancer patients[7]. Although it is difficult to make a simple comparison
because the methods and objectives of the studies are
not the same, this study also identified a large number ofdifficulties, suggesting that both occupational therapists
and nurses have a great sense of difficulty when dealing
with cancer patients.
Nakazawa et al. indicated that the difficulties facedby nurses decreased slightly in 2015 compared with the2008 survey, and they speculated that this might be dueto the increase in the number of workshops on palliative
care [8]. In contrast, while post-graduate education onAsian J Occup Ther 18: 209−220, 2022

cancer has also been held for occupational therapists, theduration is only one to several days. In addition, there
is often more than one nurse in charge of each patient.
Moreover, there is a system of certified nurse specialists
in oncology nursing and a system of certified nurses in
the fields of palliative care, cancer chemotherapy, cancer
pain nursing, breast cancer nursing, and cancer radiotherapy nursing, which are already qualified and haveleadership roles in their institutions [22]. In contrast,
occupational therapists in Japan often deal with a small
number of patients with various cancer types, stages,
and treatment methods, and one occupational therapist
is usually responsible for one patient. The number ofoccupational therapists specializing in oncology is still
small [23], and there are few people in leadership rolesin their institutions, which may contribute to the sense ofdifficulties faced by occupational therapists. Therefore,
we believe that it is crucial to alleviate each of the difficulties identified in this study based on previous nursing
and occupational therapy practices in other countries,
which will lead to high-quality occupational therapy forcancer.
Limitations
This study is a qualitative analysis of the narratives
obtained from 18 occupational therapists in Prefecture
A. In the analysis, we tried to draw as many valid inferences as possible, but it was difficult to completely
escape the subjectivity of the researcher through thismethod. In addition, this study design did not allow for
the separation of occupational therapy difficulties related
to cancer and non-cancer diseases. Therefore, it cannot
be denied that the difficulties of occupational therapists
obtained in this study may include not only those specific to cancer, but also those that apply to occupational
therapy in general, or those applying to other terminal
diseases as well.

Conclusions
The results of this study show that Japanese occupational therapists face many difficulties in providing
occupational therapy to cancer patients. To alleviate
this difficulty, it is crucial to follow the precedent set bynurses and other countries, including the United States,
and to train more occupational therapists specializing incancer, especially through more extensive post-graduate
programs. In addition, occupational therapists should
contribute as members of the medical team, taking advantage of the fact that they can easily obtain psychosocial and physical information. In this way, collaboration
with the community and other professionals will help
resolve the sense of difficulties that occupational thera-

Asano T et al.

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pists cannot solve alone.

Conflicts of Interest
The authors have no conflicts of interest to declare.

Acknowledgements
We would like to thank all the occupational therapists who agreed with the aims of this study and cooperated.

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