■ORIGINAL ARTICLE

Brake Operation and Palmar Perspiration Reflect
Older Adult Drivers’ Ability to Predict Hazards:
Driving Simulation Research
Jun Iwanami1, Masayoshi Kobayashi1, Akira Sagari1,
Tsutomu Sasaki2, Hideya Momose3, Toshio Ohhashi4
1

Graduate School of Medicine, Shinshu University, Nagano, Japan
Hokkaido Chitose College of Rehabilitation, Hokkaido, Japan
3
SKINOS Co., Ltd., Nagano, Japan
4
Department of Innovation of Medical Health Sciences Research, Shinshu University School of Medicine, Nagano, Japan
2

Abstract: Objective: Motor accidents caused by older drivers have been increasing and may result from a decline incognitive functioning and delay in hazard perception. This study examined how brake operation and palmar perspiration indicate hazard predictive ability of older drivers in a driving simulation.
Method: We compared brake operation performance, palmar sweating response, and skin potential reflex responses inhealthy older adults (n = 43) and healthy young adults (n = 36) during hazard and hazard prediction scenes in a driving
simulator.
Results: In the hazard scene, both groups displayed rapid brake operation and skin potential reflex responses. In thehazard prediction scene, all young adults braked consistent with simulation footage, but 46.5% of older adults failed tobrake. Palmar sweating response was greater ( p < 0.01) in older adults who braked compared to older adults who did
not. In those who failed to break, palmar sweating response was lower than the overall average observed in the older
adult group, suggesting that non-operating group members lacked a sense of tension.
Conclusion: Cognitive processes of hazard perception and hazard prediction may facilitate the observed increase inpalmar sweating response. Brake operation monitoring and palmar sweating response measurement appear to be usefulfor evaluating hazard perception ability in a driving simulator.
Keywords: simulated driving, older drivers, hazard perception, brake operation, palmar perspiration(Asian J Occup Ther 16: 1−9, 2020)

Introduction
In Japan, an increasingly aging population has beenaccompanied by an increase in automobile accidents. In
2016, drivers aged 75 and older caused 13% of all fatal
accidents [1]. Such accidents are associated with agerelated cognitive decline [2, 3]; thus, cognitive evaluations are now mandatory to renew the licenses of drivers
over 75. According to the National Police Agency,
Received: 26 August 2018, Accepted: 27 October 2019
Corresponding to: Masayoshi Kobayashi, Ph.D., Graduate School of
Medicine, School of Health Science, Shinshu University, 3-1-1, Asahi,
Matsumoto 390-8621, Japane-mail: mkobaya@shinshu-u.ac.jp©2020 Japanese Association of Occupational Therapists

enforcement of this new law resulted in 1,120,000 individuals undergoing cognitive function testing between
March and September 2017. Examination resulted in
300,000 aging drivers to be diagnosed with possible
dementia; 697 (0.23%) had their licenses suspended or
revoked. This implies that it is difficult to determine
driving ability via a written cognitive function test administered during license renewal.
Pre-driving (i.e., driving simulation) and practical
driving (i.e., road driving) tests can be incorporated
into comprehensive evaluations aiming to help disabledindividuals resume driving. The Trail Making Test
(TMT)— assessing attention, visual search, information
processing speed, and executive function—is used forneurophysiological aspects of pre-driving evaluations[4−6] and has been proven effective [7]. The Mini-Men-

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BRAKE OPERATION AND PALMAR PERSPIRATION REFLECT DRIVERS' HAZARD PREDICTION

tal State Examination (MMSE) also measures cognitive
function; it may be administered when evaluating anolder driver. A study using standardized road driving
evaluations, neurophysiological examinations, and medical tests to assess Alzheimer’s patients found that the
MMSE usefully predicted older adults’ driving ability[8]. However, others have suggested that cognitive
function tests, such as the MMSE, cannot adequately
determine the driving ability of older adults with earlystage dementia [9]. Pre-driving evaluations of this nature—even those that include neurophysiological examinations—illustrate that defining one’s driving ability is difficult, and costs and accident risks limit the applicabilityof driving evaluations [10]. Additionally, among older
adults, cessation of driving has been associated witha worsening of depressive symptoms [11, 12] and theshrinking of one’s social network [13]. Therefore, newresearch is needed that examines diagnostic methods
under which older adults and individuals with cranialtrauma may resume or continue driving.
Hazard perception (HP), the process of responding
to dangerous conditions with traffic accident potential[14], is a critical ability for safe automobile operation;
it is “the ability to read the road and anticipate forthcoming events” [15, 16]. Further, research indicates that
HP is related to processes such as “anticipation” and“surprise” [14, 17]. HP paradigms have been used in
evaluations wherein several minutes of driving footage
are played for participants who must identify hazardous
events as they occur [18]. However, these methods do
not assess participants’ real-time behavior in response tohazards. Consequently, it is imperative that evaluationsof automobile driving ability include tests that examine
the entire chain of processes from HP to vehicle operation.
The palmar sweating response (PSR) and electrodermal activity (EDA) occur when humans are surprisedor perceive hazards. PSR is an indicator of “mental
sweating” or “emotional sweating” [19]. It can closely
follow emotional changes like tension and surprise [20−22]. The PSR can also be elicited by situations in which
one “steels oneself” in response to unfamiliar situations
or by higher-order neurological activity, like mental
math [21, 22]. It reflects activity of the dermal sympathetic nerves, and while it is subject to modification by
the cerebral cortex, the central mechanism is closely
related to the limbic system [23, 24]. The amygdala, anterior cingulate gyrus [25], and insula [26] are involvedin this response. In contrast, EDA reflects activity of theeccrine sweat glands and can be broadly differentiatedinto skin potential activity (SPA) and skin conductanceactivity (SCA) based on the methods used to measure
it [27−29]. SPA is often measured via the skin potentialreflex (SPR), whereas SCA is measured via galvanic
skin response (GSR) or skin conductance response(SCR).
One study measured participants’ GSR during driving and found that it reflected their level of emotional
tension during driving tasks [30]. Further, research measuring drivers’ SCR found a strong correlation (r = 0.95)
between driving SCR and brake pressure, with SCR
occurring 0.2 seconds prior to accelerator release and 1.9
seconds prior to braking [31]. In a study showing video
clips of driving, police drivers rapidly identified hazards,
and their SCRs were significantly greater than those ofnovice drivers [20]. Research that involved playing HP
video clips to three experimental groups of drivers—
training drivers, novice drivers, and experienced drivers—showed that the SCR of experienced drivers was
twice that of novice drivers and three times that of training drivers, suggesting that HP is a skill learned throughdriving experience [32]. The above results indicate that
PSR and EDA are experimental measures that can appropriately evaluate drivers’ HP ability.
We developed a computer-based driving simulator
apparatus [33] to assess drivers’ HP abilities. Actual
automobile parts were used for the steering wheel,
accelerator, and brake pedal, which were connected toa spring-based system to provide appropriate resistanceand feedback. Steering wheel, accelerator, and brake
pedal responses were measured using a potentiometer
connected to a computer via an analog-to-digital (A/D)
converter. These responses were recorded alongside theoutput signals of a perspiration meter (SKINOS SKN2000) and a skin potentiometer (SKINOS SPN-01;
Fig. 1).
Pre-recorded digital driving footage was played on
an LCD monitor. Participants were instructed to perform
appropriate mock driving operations using the testing
apparatus. The footage shown to participants had anapproximate field of view of 90° and was a five-minutelong, 1 km course through narrow residential streets. An
automatic car was used in the recording. The maximum
recorded speed was 40 kph with an average speed of 12kph. The footage contained scenes requiring participants
to predict hazards, such as “jogger approaches from the
opposite direction” and sudden hazard scenes, such as“pedestrian runs out from a side street.” A green-arrowblinker synced with the footage, indicating the direction
participants would need to turn at intersections (Fig.
1-a).
This driving simulator employed only real-world
footage to maintain the reality of visually perceived
information. However, the steering wheel, accelerator,and brake pedal were not linked to the footage itself.
Therefore, even if the brake pedal were to be depressed,

Iwanami J et al.

Asian J Occup Ther 16: 1−9, 2020

a.

1

3

b.

Figure1. Driving
Fig. 1. Driving
Simulation
Test. Simulation Test. (a) The subject was asked to operate the steering wheel,(a) The subject was asked to operate the steering wheel, accelerator, and brake according to the scene displayed on the screen.
(b)accelerator,
PSR was measured
placinga sweating to
meter
on displayed
the palm of theleft thumb.
SPR wasby bipolar
and bybrakeaccordingtheprobe
scene
onsubject’s
the screen.
(b) PSR
wasmeasured
measuredby
induction, in which a skin electrometer electrode was applied to the subject’s left forearm and left thumb ball, and a referenceelectrode was placed between the electrodes.
placing a sweating meter probe on the palm of the subject's left thumb. SPR was measured bybipolar induction, in which a skin electrometer electrode was applied to the subject's left forearmthe car in the footage would not slow. Participants asof scenes. The “hazard prediction scene” was where
sumed the role of the vehicle’s driver and operated thethe road narrowed with poor visibility, near a fence andand left thumb ball, and a reference electrode was placed between the electrodes.
steering wheel, accelerator, and brake consistent withhedge, that required depressing the brake and slowing
the movements seen on screen. PSR, SPR, and brake
before making a left turn at a T-junction. The sudden
operation responses matched to hazard scenes in thisemergence of a pedestrian from a side street to the righttype of driving simulation test are largely similar acrosswhile the driver was proceeding straight down an alleyparticipants [33]. This study aimed to use a driving
way was termed the “hazard scene”. For five seconds
simulation test to compare the PSR, SPR, and brakefrom the start of both scenes, we checked for the presoperation performance of older and young adult drivers
ence or absence of brake operation and summarized theduring hazard and hazard prediction scenes.
results in a frequency distribution table. Then we compared the PSRs of the group that activated brakes withthe group that did not and examined factors that affected
Material and Methods
the presence or absence of brake operation. Finally, we
Participants
compared the latencies of brake operation and SPR reOlder adults above the age of 60 (n = 43; 18 men,sponses of the two driver groups during the hazard and25 women; age range 60−85; Mage = 69.8 years, SD = 5.7)
hazard prediction scene.
and young adults (n = 36; 8 men, 28 women; age range
19−36; Mage = 21.3, SD = 2.8) provided written informed
Procedure
consent before participating in this experiment. The
The temperature of the experiment was 23−26°C.
older adult group comprised healthy individuals attendPSR elicited by the driving simulation test was measured
ing health classes in the Matsumoto region. The olderusing a sweating meter probe affixed to the palmar side
adult group had an MMSE of 24 or higher with noof the participant’s left thumb, where the moisture conobserved decline in cognitive function. The older adults
tent of 1 cm2 of skin was measured via the ventilation
drove daily with 10 plus years of experience each. The
capsule method. SPR was measured with bipolar leads
young adult group comprised primarily college students
using a skin potentiometer with electrodes affixed to theand all had a driver’s license, but their driving expeparticipant’s left forearm, the ball of the left thumb, andrience was within a few years except for one. No one
a reference electrode placed in between (Fig. 1-b).
drove daily.
Before the driving simulation test, each participant
practiced mock driving in the simulator using footage
Experimental Design
prepared specifically for practice use. After confirming
We defined events in the simulation footage of drivthat the participant could correctly operate the steeringing through narrow residential streets as specific types
wheel, accelerator, and brake pedal, we played the test

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BRAKE OPERATION AND PALMAR PERSPIRATION REFLECT DRIVERS' HAZARD PREDICTION

footage at a sound pressure of 50−60 dB. The PSR
and SPR responses, as well as the analog signals fromthe steering wheel, accelerator, and brake pedal, wererecorded at a sampling frequency of 100 ms after A/D
conversion. This research complied with the tenets of
the Declaration of Helsinki and was conducted with theapproval of the ethics board of the Shinshu University
School of Medicine (approval code 2073).
Data Analyses
Brake operation was tracked for five seconds immediately following the appearance of either the hazard or
hazard prediction scene on the screen. Participants who
successfully operated their brakes were placed in the“operation group” and those who did not were placedin the “non-operation group.” For the operation group,
the time from the start of the hazard or hazard prediction
scene to the appearance of a response waveform wastermed brake response latency (Fig. 2-c). PSR volume
was evaluated as the mean reaction volume over thefive seconds immediately following the beginning of
the hazard or hazard prediction scene (Fig. 2-a). SPR
response latency was evaluated as the time between
the start of the hazard or hazard prediction scene to theappearance of a spike-like negative wave (Fig. 2-b). The
data of participants who did not show a clear negative
spike in their SPR waveforms were regarded as missing
and were excluded from analyses.
We confirmed the independence of the frequency
distributions of the operation and non-operation groups
using a chi-square test. Intergroup comparison ofbraking, PSR, and SPR response was evaluated with astudent’s t-test. Multivariate logistic regression analysis
with forced entry was used to determine the predictorsof brake operation. The Hosmer–Lemeshow test wasused to examine the goodness-of-fit of this model, andthe significance threshold was set at p > 0.05, showing
an acceptable fit. All statistical analyses were performed
with IBM SPSS Statistics for Windows release 25 (IBMJapan Ltd., Tokyo, Japan). All tests had a significancelevel of p < 0.05.

Results
Response Waveforms Obtained During Driving Simulation Test
Figure 3 shows examples of response waveforms
obtained. In scenes with predictable hazards, and scenes
where the participant had to suddenly react to avoid
hazards, PSR and SPR nearly synchronized responses ofsteering wheel and brake pedal operation were observed.
In stop scenes, during which the brake pedal was continuously depressed, a decrease in PSR and SPR response

Fig. 2. Measurement Method of PSR Volume, SPR Latency,
and Brake Latency.
PSR = palmar sweating response; SPR = skin potential reflex; Brake = brake operation.

was seen. SPR also tended to occur a few seconds fasterthan PSR.
Brake Operation and PSR Volume
The presence or absence of brake operation in thehazard and hazard prediction scenes is summarized inTable 1. In the hazard prediction scene, 23 participantsfrom the older adult group were placed in the operationgroup and 20 in the non-operation group. In contrast,
all participants from the young adult group were placedin the operation group. The independence of these frequency distributions was confirmed by a chi-square test
( p < 0.001). In the hazard scene, all participants operated their brakes.
Table 2 displays the PSR reaction volumes of theolder and young adult groups in the hazard and hazard
prediction scenes. The following PSR volumes wereobserved [mg/min/cm2]—hazard prediction scene: older
adults M = 0.38 (SD = 0.26), young adults M = 0.20 (SD= 0.22); hazard scene: older adults M = 0.40 (SD = 0.24),
young adults M = 0.25 (SD = 0.28). In both scenes, theamount of PSR was significantly higher in the older
adult group. In the young adult group, the amount of
PSR was significantly higher in the hazard scene than in
the hazard prediction scene, but the PSR volume of theelderly adult group was not significantly different between the hazard prediction scene and the hazard scene.
We compared the PSR volumes of the operation

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Asian J Occup Ther 16: 1−9, 2020

5

Fig. 3. Changes in PSR, SPR, and Reaction Volume of Steering Wheel, Accelerator, and Brake During Driving Simulation Test.
[A] Jogger approaches from the opposite direction; [B] Vehicle approaches from the opposite direction; [C] Participant’s vehicle
overtakes a bicycle; [D] Participant’s vehicle turns left at T-junction (hazard prediction scene); [E] Pedestrian runs out from a sidestreet (hazard scene).

Table 1 Participant’s Brake Operation in Hazard Prediction Scene and Hazard Scene.

Hazard Prediction Scene

Hazard SceneGroup

Operation Groupn(%)

Non-Operation Groupn(%)

Older Adultn = 4323(53.5)

20(46.5)

Young Adultn = 36

36
(100)

0
(0)

Older adultn = 43

43
(100)

0
(0)

Young adultn = 36

36
(100)

0
(0)

χ2

p

22.4

0.000*−−

Note. Comparison of Operation Group and Non-Operation Group was conducted using the χ 2 test.
*p < .01.

(n = 23) and non-operation (n = 20) subgroups of theolder adult group in the hazard prediction scene. PSR
volumes (mg/min/cm2) were operation group M = 0.48
(SD = 0.19); non-operation group M = 0.31 (SD = 0.16).
The PSR volume of the operation group was significantly larger ( p = 0.004).

Multivariate logistic regression analysis with forced
entry was conducted to investigate the factors related tobrake operation by the older adults in the hazard prediction scene. Brake operation was used as the dependent
variable. The independent variables included age,gender, and PSR. There was a statistically significant

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BRAKE OPERATION AND PALMAR PERSPIRATION REFLECT DRIVERS' HAZARD PREDICTION

Table 2 Comparison of Palmar Sweating Response Volume of Older and Young Adult Groups.

Hazard prediction scene
Hazard scenetpOlder Adult Groupn = 43M (SD)

Young Adult Groupn = 36
M (SD)

0.38 (0.26)
0.40 (0.24)
−1.53
0.135

0.20 (0.22)
0.25 (0.28)−2.14
0.039*

t

p

3.34
2.60

0.001**
0.011*

Note. Comparison of Older Adult Group and Young Adult Group was conducted using the Student’s
t test and comparison of Hazard prediction scene and Hazard scene was conducted using thepaired t test.
*p < .05. **p < .01.

Table 3 Multivariate Logistic Regression Analysis for Brake Operation of Older Adult Group in Hazard Prediction Scene.
VariableOR

95% CIp

Age
Gender
PSR

0.93
0.61
484.2

0.82–1.05
0.12–3.23
2.82–83066.59

0.247
0.564
0.019*

Note. N = 43. PSR = palmar sweating response. OR = Odds ratio. CL= Confidence interval.
*p < .05.

association between brake operation and PSR (OR =484.2, 95% CI [2.82, 83066.6], p = 0.02; Table 3).
Brake Response Latency
We compared the brake response latencies of participants who were observed to brake in the hazard andhazard prediction scenes (Table 4). In the hazard prediction scene, brake responses in the older adult groupdemonstrated a latency of M = 3.20 seconds (SD = 1.51)
and in the young adult group M = 1.58 second (SD =0.79); the brake latency of the young group was significantly shorter ( p < 0.001). Furthermore, in the hazard
scene, the older adult group demonstrated a latency of M
= 1.26 (SD = 0.57) and the young adult group M = 0.83
(SD = 0.34); the brake latency of the young group was
significantly shorter ( p < 0.001). Both the older adultgroup ( p < 0.001) and the young adult group ( p < 0.001)
showed shorter brake response latencies in the hazard
scene versus the hazard prediction scene.
SPR Response Latency
We compared the SPR response latencies of theseparticipants (Table 4). The SPR response latencies in thehazard prediction scene for the older adult group was M= 3.22 seconds (SD = 2.22) and the young adult group
was M = 4.49 seconds (SD = 2.58); the SPR response
latency of the older adult group was significantly shorter( p < 0.05). In the hazard scene, the older adult group

had a latency of M = 2.23 seconds (SD = 0.87) while theyoung adult group was M = 1.93 seconds (SD = 1.18).
Both the older ( p < 0.001) and young adults ( p < 0.001)
showed shorter latencies in the hazard scene than in thehazard prediction scene.

Discussion
In the hazard scene, which involved visually
identifying a pedestrian running into the path of thevehicle and the sudden movement necessary to avoid
this pedestrian, all participants successfully operated
their brakes. Their brake and SPR response latencies
were significantly shorter than in the hazard prediction
scene. These reactions are prompted by different mechanisms than the cognitive processes underlying hazard
prediction and may be regarded as automatic responses
to HP. However, in the hazard prediction scene, which
involved slowing before making a left turn into a narrow
alleyway, all young adults operated their brakes consistent with simulation footage, while nearly half (46.5%)of older adults failed to do so.
In the hazard prediction scene, the poor view into
the alleyway where the participant was asked to turnnecessitated slow, careful driving. We believe that thelack of brake operation in the hazard prediction scene isrelated to a decrease in predictive ability, possibly the
result of overlooking the hazard due to inattentiveness or
slowed visual confirmation. It is possible that the older
adult group contained participants who did not predictthe possibility of a hazard.
While PSR is thought to decline as one ages [34,35], Table 2 illustrates that the older adult group had
higher PSR volumes in both scenes. Increases in PSR
magnitude in this group reflect elevated levels of concentration and tension. We also believe that the significant difference in PSR volume between the operationand non-operation groups represents a difference inhazard prediction abilities. The PSR volume of the operation group surpassed the mean value for the older adultIwanami J et al.

Asian J Occup Ther 16: 1−9, 2020

7

Table 4 Brake and Skin Potential Reflex Response Latencies.

Hazard Prediction Scene
A

Brake

Hazard Scenetp
Hazard Prediction Scene

B

SPR

Hazard Scenetp

Older Adult GroupM (SD)

Young Adult GroupM (SD)

3.20 (1.51)
n = 23
1.26 (0.57)
n = 437.54
0.000**

1.58 (0.79)
n = 360.83 (0.34)
n = 365.25
0.000**

3.22 (2.22)
n = 432.23 (0.87)
n = 432.72
0.008**

4.49 (2.58)
n = 36
1.93 (1.18)
n = 365.40
0.000**

t

p

5.39

0.000**

3.90

0.000**−2.34

0.022*

1.31

0.196

Notes. Comparison of Older adult group and Young adult group was conducted using the Student’s t test and comparisonof Hazard prediction scene and Hazard scene was conducted using the paired t test. SPR = Skin potential reflex.
*p < .05. **p < .01.

group, indicating that the cognitive processes of hazard
prediction may have elevated PSR in these individuals.
Furthermore, in the non-operation group, the PSR
volume was lower than the mean value for the entire
older adult group, which suggests the absence of a senseof tension in non-operation participants. The results ofthe multivariate logistic regression analysis indicatedthat brake operation in the hazard prediction scene was
not related to the age or gender of participants but to the
PSR caused by the hazard prediction scene.
In literature where PSR is an index, reports involving videos of a truck coming toward participants showedthat PSR and sense of tension vary with the distance
between their own car and the truck. Specifically, thecloser the truck is to the participant, the higher thesevalues become [36]. Previous research using similar
driving simulation tests has reported that while a clear
increase in PSR is observed in both hazard and hazard
prediction scenes, the timing of brake operation and
PSR and/or SPR responses in older adults with impaired
cognitive function does not correspond with the average
responses seen in healthy older adults [33].
In both scenes, the young adult group operated theirbrakes significantly quicker (Table 4). Studies on thebrake operation practices of older adult drivers showedthat they tend to leave their foot on the accelerator
longer [37] and tend to delay “switching” the foot fromthe accelerator to the brake pedal [38]. In addition, it isgenerally accepted that young adults have better visual
search ability and faster cognitive processing than older
adults [39]. The rapid brake operation in the young adultgroup in this study align with these findings, and it suggests age-based differences.

We believe measurement of PSR alongside monitoring of brake operation is useful in evaluating the HP
ability of older adult drivers using a driving simulator,
particularly when evaluating the presence or absence of
hazard prediction ability.

Limitations and Future Research
We could not recruit sufficient participants after
controlling for gender ratio. It is possible that the difference in gender and driving experience influenced
the driving simulation test outcome. Therefore, futurestudies should examine the influence of participants’age, sex, and driving experience on driving simulation
test performance.
The driving simulator used in this experimentemployed footage recorded with a consumer model
digital camera and had a limited field of view. Since thesimulator steering wheel, accelerator, and brake pedal
were not linked to the footage, we could not gather
detailed information about the appropriateness of theparticipants’ driving operations. In addition, because
standards for PSR, SPR, steering wheel, accelerator, andbrake responses have not been predetermined, we would
need to collect a large number of samples and establish
a range of standard responses to determine which responses would be considered appropriate.
The simulator’s capacity to evaluate the HP abilityof the driver using biological indicators like PSR and
SPR is a one strength though we only used two scenes offootage—one as a hazard prediction scene and the otheras a hazard scene. Further research must distinguishwhich measurements and evaluations are appropriate for8

BRAKE OPERATION AND PALMAR PERSPIRATION REFLECT DRIVERS' HAZARD PREDICTION

various scene and formulate testing protocols for driving
simulations. In addition, it is necessary to examine indetail in the future how much the PSR, SPR and brake
responses observed in this driving simulation test reflect
the response when actually driving on the road. Further
research is needed to clarify the causal relationshipbetween PSR and SPR responses and actual delays anderrors in driving.

Conflicts of Interest
The authors declare no conflict of interest.

Funding statement
This research was subsidized by JSPS Grant-in-Aid
for Science and Technology JP23300245.

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■ORIGINAL ARTICLE

Recognition and Intervention of Rehabilitation
Professionals Handling the Health Conditionsof Syrian Refugees with Disabilities in Jordan
Seiji Yamamoto1, Takuma Amari2, Hiroya Matsuo3
1

Kobe University Graduate School of Health Sciences, Department of Public HealthJapanese Association of Occupational Therapists
3
Kobe University Graduate School of Health Sciences
2

Abstract: In Jordan, situated to the south of Syria, some 671,919 Syrians are registered as refugees with the UNHCR.
Twenty-eight percent of the refugees have some kind of disorder. However, there are no studies regarding the Recognition and Intervention of Rehabilitation Professionals Handling the Health Conditions of Syrian Refugees with Disabilities (Person with Disabilities: PWDs) in Jordan. Therefore, the purpose of this study was to understand the challenges
experienced by rehabilitation professionals who were providing rehabilitation services to Syrian refugee with disabilities through semi-structured interviews. The subjects of the study were Fifteen participants. Constant comparative analyses method was performed to assess them. As a result, the recognition and intervention of rehabilitation professionals
who work with PWDs in Jordan were categorized under four main themes:【Deterioration of PWDs’ health conditions】,,【Difficulties in continuously providing rehabilitation to PWDs in urban areas】,【Lack of rehabilitation programs】
and【Forthcoming challenges facing rehabilitation programs by community-based organizations】. The study identified
that rehabilitation professionals provided outpatient rehabilitation, home-visit rehabilitation and provision orthosis to
PWDs. They also recognized the difficulties PWDs faced in accessing health care due to poverty, the spread of disuse
syndrome, and the lack of caregivers in PWDs’ families. However, the prevention of disuse syndrome, the provision ofnursing care methods, and the intervention of Activities of Daily Living (ADL) were not mentioned as future challenges. Therefore, it is essential that rehabilitation professionals conduct prevention of disuse syndrome, provide intervention for ADL.
Keywords: Syrian refugees with disabilities, intervention of rehabilitation professionals, disuse syndrome(Asian J Occup Ther 16: 11−18, 2020)

Introduction
The Syrian conflict, which has raged since 2011,
has produced 6,100,000 internally displaced people
and 5,582,018 refugees who have fled the country,
and is said to be the largest humanitarian crisis of thiscentury [1]. Many Syrian refugees have evacuated to
the neighboring countries of Jordan, Turkey, Lebanon,
Iraq and Egypt. Some 671,919 Syrians are registeredas refugees with the UN Refugee Agency (UNHCR)
Received: 12 April 2019, Accepted: 24 November 2019
Corresponding to: Seiji Yamamoto, Kobe University Graduate Schoolof Health Sciences, 7-10-2, Tomogaoka, Suma-ku, Kobe 654-0142
Hyogo, Japane-mail: talktoseiji@hotmail.com©2020 Japanese Association of Occupational Therapists

in Jordan, located to the south of Syria. According
to a survey by Handicap International, 22 percent of
Syrian refugees have some impairment and 6 percent
have severe impairment [3]. The UNHCR, international
agencies, community-based organizations (CBOs) andthe Jordanian government are carrying out support
programs for Syrian refugees with disabilities in urban
areas. However, in terms of the increase in refugees dueto the ongoing conflict in Syria, support for Syrian refugees with disabilities is insufficient [4, 5]. Meanwhile,
several studies reported that low social status, poverty,
and discrimination influence the health conditions andthe social participation of persons with disabilities indeveloping countries [6, 7].
We have engaged in Grant Aid for Japanese NGO’s
Projects of Official Development Assistance (ODA) inministry of foreign affairs of Japan as expert in support

12

THE HEALTH CONDITIONS OF SYRIAN REFUGEE WITH DISABILITIES IN JORDAN

program for Syrian refugee with disabilities living
urban area of Jordan since 2015. The project has been
implemented in cooperation and partnership with CBOs
approved by the Ministry of Social Development in
Jordan.
The Jordanian government has accepted many refugees due to the Syrian conflict, however, recommends
that international agencies and CBOs support not only
Syrian refugees and but also Jordanians for assistanceprogram [8]. furthermore, there are many reports ofproblems with employment opportunities and povertyof Syrian refugee in urban area [9, 10]. Meanwhile, due
to the prolonged Syrian conflict, there was a shortage offunds for each CBOs handling the health conditions of
Syrian refugees with disabilities in Amman. As of 2017,
some CBOs have withdrawn their support activities to
Syrian refugees with disabilities in urban area. Therefore, there is a tendency to reduce support for Syrian
refugee with disabilities in urban area from CBOs incooperation with ODA. Under these circumstances, it ispresumed that Syrian refugees with disabilities in urban
area face difficulties on their life.
The authors indicate that Syrian refugees withdisabilities exhibited disuse syndrome related to theirhealth conditions, and faced restrictions in terms ofsocial participation through insufficient health literacy,
lack of health care services, their vulnerable positions
as refugees, and limitations on activities due to their
physical disabilities. Therefore, it is essential that rehabilitation professionals support social participation by
Syrian refugees with disabilities [11].
However, there is a lack of reports demonstrating
support programs for Syrian refugees with disabilities
in Jordan. Therefore, we conducted the present study
to examine the current state of intervention for Syrian
refugees with disabilities in Jordan and the recognitionof rehabilitation professionals handling the health of
Syrian refugees with disabilities through semi-structured
interviews. The purpose of the present study was toclarify the challenges of intervention by rehabilitation
professionals, including occupational therapists, onbehalf of Syrian refugees with disabilities.

Subjects and Methods
1. Study design
Constant comparative analyses method was usedin this study. The method allowed us to obtain comprehensive and diverse data in a short period of time, andallowed us to investigate recognition and interventionof rehabilitation professionals handling the healthconditions of Syrian refugee with disabilities in Jordan.
Furthermore, there are few CBOs who support Syrian

refugees with disabilities in urban area, and rehabilitation professionals who belong to the CBOs. However,very little empirical data are available from previous
research related to this study.
Therefore, a qualitative research design was used
to clarify challenges through recognition of them in thisstudy.
2. Setting
Amman city is located in the Hashemite Kingdomof Jordan as capital. 196,068 Syrian refugees lived in
the city [2]. As of 2017, three CBOs (A, B, C) were
providing rehabilitation assistance to Syrian refugees
with disabilities in the city. Approximately forty rehabilitation professionals belonged to those CBOs.
3. Participants
The subjects of the study were rehabilitation professionals who had engaged in rehabilitation programs.
We requested each CBOs to recruit participant for our
research. and then, fifteen participants were chosen randomly for this study from a list of rehabilitation professionals in CBOs. During the recruitment, we excluded
rehabilitation professional who do not have a Jordanian
work permit or who support rebel. We explained thatthe study would comprise recorded interviews, followedby analysis of the interview data. We received letters ofconsent and acceptance from the 15 participants, andconducted study interviews with them.
4. Questionnaire and Interview
This study involved the use of a questionnaire and arecorded semi-structured interview in Arabic. The interview was conducted with each participant individually
between April 2016 and August 2017. The questionnaire
inquired about the participant’s name, sex, age, official
position, duration of support for Syrian refugees withdisabilities in his/her organization, and length of work
experience. The semi-structured interview was conducted with an interview guide.
The interview covered the current situation of
Syrian refugees with disabilities (“How are the healthconditions of Syrian refugees with disabilities, and inwhat situations do they face difficulty?”); the details of
the participant’s support for Syrian refugees with disabilities in urban areas (“What kind of support do you
provide for Syrian refugees with disabilities?”); Difficult
points of the current support program (“Do you face any
difficulties in your program?”); and the recognition ofnecessary activities for assistance for Syrian refugees
with disabilities in the future (“What kind of activities
are needed for Syrian refugees with disabilities in urban
areas?”). The interviews were recorded by IC recorderYamamoto S et al.

Asian J Occup Ther 16: 11−18, 2020

13

Table 1 Interview guide to rehabilitation professionals of community based organizations.
TopicsQuestion

1. Current situation of Syrian refugees with disabilities“How are the health conditions of Syrian refugees in whatsituations do they face difficulty?”

2. Details of support for Syrian refugees with disabilities“What kind of support do you provide for Syrian refugees
with disabilities?”

3. Difficult points of the current program“Do you face any difficulties in your program?”

4. Recognition of necessary activities for assistance for
Syrian refugees with disabilities in the future“What kind of activities are needed for Syrian refugees
with disabilities in urban areas?”

Table 2 Profile characteristics of participants (April 2016 and August 2017).
No

Professional

GenderAge

Clinical experience(years)Support experience(years)Interview time(min)

Affiliationof CBOs

Contents of Intervention

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

PT
PT
PT
PT
PT
PT
PT
PT
PT
PT
PT
PT
PT
PT
OT

male
male
femalemale
male
female
male
male
male
male
male
femalefemalefemalefemalefortiesthirties
thirties
thirties
thirties
thirties
twenties
twenties
twenties
twenties
twenties
twenties
twenties
twenties
twenties

22
8
7
7
8
6
4
5
4
4
6
4
4
3
3

4
3.4
3.1
2.9
2.5
3.1
1.1
3.4
2.1
1.9
2.2
3.5
2
2.3
2.1

22
19
30
23
26
27
21
22
24
19
22
27
23
20
19

A
A
A
A
A
B
B
B
B
C
C
C
C
C
C

Outpatient Rehabilitation
Outpatient Rehabilitation
Outpatient Rehabilitation
Home-Visit Rehabilitation
Home-Visit Rehabilitation
Outpatient Rehabilitation
Outpatient Rehabilitation
Outpatient Rehabilitation
Home-Visit Rehabilitation
Outpatient Rehabilitation
Outpatient Rehabilitation
Outpatient Rehabilitation
Home-Visit Rehabilitation
Home-Visit Rehabilitation
Outpatient Rehabilitation

PT: Physical Therapist OT: Occupational Therapist(Table 1).
5. Data Analyses
The proceedings of the semi-structured interview
were transcribed verbatim, and constant comparative
analyses were used to analyze the data. The analyses
were conducted by three researchers familiar with theinternational health field. The researchers listened tothe interview data and transcribed the contents. To
avoid language bias, we conducted back-translation.
The verbatim transcriptions were then coded to identify
elements of each participant’s comments. The codes
were sorted into sub-categories and categories basedon the similarities and differences in the responses, andthe relevance of each category was analyzed. During
the analyses of the qualitative data, specialists (SY, TA
and HM) with immense experience in the field of international health including refugee with disabilities issue
were discussed to ensure the reliability and validity ofthis study.

6. Ethical Considerations
The study carried out the research with the approval(Number 757) of the Kobe University Ethical Committee.

Results
1. Characteristics of Participants
There were 15 participants: nine male and six
female. The total interview time was 344 minutes. The
median interview time per participant was 22.9 minutes.
The mean age of the participants was 29.7 ± 3.2 years.
Fourteen participants were physical therapists, and one
was an occupational therapist. Their duration of clinicalexperience was 5 ± 4.6 years, and their length of support
experience for Syrian refugees with disabilities in community-based organizations was 2.5 ± 0.7 years (Table
2).

14

THE HEALTH CONDITIONS OF SYRIAN REFUGEE WITH DISABILITIES IN JORDAN

Table 3 Recognition and intervention of rehabilitation professionals who work with Syrian refugees with disabilities in Jordan.
Sub-Category [14]Category [4]Lack of medical and rehabilitation services for Syrian refugees with disabilities
Spread of disuse syndrome
Inability to pay for treatment due to poverty
Lack of caregivers in families

Deterioration of PWDs’ health conditions

Implementation of outpatient rehabilitation
Implementation of home-visit rehabilitation
Supply of orthosis and assistive products

Lack of rehabilitation programs

Lack of budget for support programs for Syrian refugees with disabilities
Lack of transportation for home-visit rehabilitation
Lack of knowledge among Syrian refugees with disabilities and their family
members about rehabilitation
Lack of information about Syrian refugees with disabilities in urban areas

Difficulties in continuously providing rehabilitation
to PWDs in urban areas

Development of human resources to work in rehabilitation
Acquisition of operation funds
Necessity of cooperation with international organizations

Forthcoming challenges facing rehabilitation
programs by community-based organizations

2. Current situation of Syrian refugees with disabilities
and assistance programs for them
A total of 627 codes relating to the current situationof Syrian refugees with disabilities and assistance programs for them were extracted from the transcriptions.
Sub-categories and categories were defined within thecodes along with the “Recognition and interventionof rehabilitation professionals who work with Syrians
refugees with disabilities in Jordan” (Table 3). Then, thecategories, subcategories, codes and personal narratives
were described as 【Category】, [Subcategory], and『Personal narrative』, respectively.
The category 【Deterioration of PWDs’ healthconditions】 comprised four sub-categories: [Lack of
medical and rehabilitation services for Syrian refugees
with disabilities], [Spread of disuse syndrome], [Inability
to afford treatment costs due to poverty], and [Lackof caregivers in families]. One therapist discussed the[Lack of medical and rehabilitation services for Syrian
refugees with disabilities] as follows:『In some patients,
their health condition often became worse, because
they didn’t receive medical treatment or rehabilitation
services in Jordan after evacuating from Syria』. One
therapist discussed [Spread of disuse syndrome] asfollows: 『Many patients suffer from contracture anddisuse muscle atrophy, because they don’t know about
disuse syndrome and are unaware of the need to prevent
it…』. One therapist discussed [Inability to pay for treatment due to poverty] as follows:『Almost all refugees
with disabilities are poor, as is the case with healthy
refugees. So they don’t have money to pay for treatment.
And if they need to take care of a family member, it isdifficult for them to work』. One therapist discussed[Lack of caregivers in families] as follows:『One of mypatients has no caregiver, because he evacuated from
Syria without his family. Another patient can’t visit our
rehabilitation center. His family members are working
every day, so they can’t bring him here (to the rehabilitation center)』.
The category 【Lack of rehabilitation programs】
comprised three sub-categories: [Implementation of
outpatient rehabilitation], [Implementation of home-visit
rehabilitation], and [Supply of orthosis and assistive
products]. One therapist discussed [Implementation of
outpatient rehabilitation] as follows:『Our unit supports
Syrian refugees with disabilities in an urban area at our
rehabilitation center. Once or twice a week, patients
visit our center. However, there aren’t enough therapists
registered because we don’t have enough money to pay
their wages, so we can’t handle many patients. However,
we provide rehabilitation services, for example, standing training, walking training and so on』. One therapist
discussed [Implementation of home-visit rehabilitation]
as follows:『Some patients can’t visit our center forrehabilitation, because their impairment is so severe,and it is difficult for their family members to bringthem. Therefore, we visit to their house and perform
rehabilitation there, for example, a various movement
exercises, muscle training, and PNF for dysfunctions on
the bed.』One therapist discussed [Supply of orthosis
and assistive products] as follows:『Among the wounded
refugees, there are many amputees. They need orthosis
and assistive products. So we provide them for somepatients. However, lack of funds means we can’t provide
prosthetics to all person with disabilities.』
The category【Difficulties in continuously providing rehabilitation to PWDs in urban areas】comprisedYamamoto S et al.

Asian J Occup Ther 16: 11−18, 2020

four sub-categories: [Lack of budget for support
programs for Syrian refugees with disabilities], [Lackof transportation for home-visit rehabilitation], [Lackof knowledge among Syrian refugees with disabilities
and their family members regarding rehabilitation],and [Lack of information about Syrian refugees withdisabilities in urban areas]. One therapist discussed [Lackof budget for support programs for Syrian refugees withdisabilities] as follows:『As you know, the conflict has
been continuing for six years. At the beginning of theconflict, many people were interested in this support.
But recently…it’s been difficult to secure funds for our
programs. So we can’t provide enough support for
Syrian refugees with disabilities. For example, there
aren’t enough health professionals, rehabilitation equipment or assistive products』. One therapist discussed[Lack of transportation for home-visit rehabilitation]
as follows: 『We don’t have transportation for home
visits. Sometimes we visit to patients’ homes at our own
expense. And the family of the patient can’t afford thetransportation cost for visiting the rehabilitation center,so it is difficult for us to continue providing them withrehabilitation』. One therapist discussed [Lack of knowledge among Syrian refugees with disabilities and theirfamily members regarding rehabilitation] as follows:『They don’t understand the necessity of rehabilitation.
Generally speaking, their doctors often do not give theman adequate explanation of rehabilitation. So sometimes they are reluctant to receive rehabilitation』. One
therapist discussed [Lack of information about Syrian
refugees with disabilities in urban areas] as follows:『In urban areas, it is difficult to figure out where they
live, unlike in refugee camps. Since many families are
isolated in the region, it is hard for us to grasp theirinformation』.
The category【Forthcoming challenges facing rehabilitation programs by community-based organizations】
comprised three sub-categories: [Development of humanresources to work in rehabilitation], [Acquisition ofoperation funds], and [Necessity of cooperation withinternational organizations]. One therapist discussed[Development of human resources to work in rehabilitation] as follows:『We must provide rehabilitation forvarious diseases. There are amputations, spinal cord
injuries, peripheral nerve injuries and so on. Therefore,
we also want to gain knowledge ourselves, and we must
develop more human resources for our program』. One
therapist discussed [Acquisition of operation funds] asfollows:『Many donors who supported us thus far havealready left our program. So, securing funds is a highpriority for us』. One therapist discussed [Necessity ofcooperation with international organizations] as follows:『Unlike refugee camps, partnerships with international

15

organizations are scarce in urban areas. It is important
to cooperate with international organizations, not only
for our support in the future』.

Discussion
The study identified that rehabilitation professionals
of community-based organizations (CBO) recognizeddeterioration in the health conditions of Syrian refugeewith disabilities (PWDs: Person with Disabilities) inurban areas. They carried out programs of outpatient
rehabilitation and home-visit rehabilitation for Syrian
refugees with disabilities to alleviate their dysfunction.
Furthermore, they faced difficulties relating to the poverty of PWDs, lack of management funds, lack of information about Syrian refugees with disabilities in urban
areas, and lack of health literacy among PWDs and theirfamily members.
In general, refugees face restrictions in terms ofsocial participation (e.g., socio-economic deprivationor lack of access to fundamental human rights) in their
new communities [12]. Syrian refugees are also in a vulnerable socio-economic position in Jordan. Therefore,
they need various support, basic needs, education, foodsecurity, health, shelter, water, sanitation, and hygiene
through humanitarian aid [13]. According to a previous
study, disasters and conflict can result in increased incidence of impairment and subsequent disability. However, their dysfunction and restriction in terms of social
participation prevent PWDs from accessing mainstream
humanitarian assistance programs [14].
1. Deterioration of PWDs’ health conditions
Regarding the situation of Syrian refugees withdisabilities in urban areas, rehabilitation professionals
recognized that the deterioration of their health conditions correlated with difficulty accessing health caredue to poverty, lack of caregivers, and spread of disuse
syndrome. We previously reported that lack of healthcare and insufficient health literacy may contribute to
the deterioration of their health conditions and the highrisk of disuse syndrome [11]. Furthermore, previous
studies clearly indicate the cycle by which poverty anddisability are mutually reinforcing [15]. Therefore,
it was estimated that the deterioration of their healthconditions was related not only to their dysfunction but
also to poverty, lack of caregivers, disuse syndrome, andtheir vulnerable position in Jordan.
2. Lack of rehabilitation programs
Regarding support programs for Syrian refugees
with disabilities by rehabilitation professionals of community-based organizations, most of the rehabilitation

16

THE HEALTH CONDITIONS OF SYRIAN REFUGEE WITH DISABILITIES IN JORDAN

professionals engaging in these support programs were
physical therapists. The reason is that a training schoolfor physical therapy and occupational therapy has been
established in Jordan; however, there are fewer qualified
occupational therapists than physiotherapists, and manyoccupational therapists go and work abroad after acquiring qualification [16, 17]. In the present intervention by
CBO, rehabilitation professionals have provided orthosis, outpatient rehabilitation and home-visit rehabilitation for improvement of dysfunction and transfer motion
for Syrian refugees with disabilities in Amman. Thosecontents have been classified under “rehabilitation” and“assistance devices” in the CBR matrix of the World
Health Organization [18]. There are no contents under“medical services,” “promotion” and “prevention.” The
WHO recommends rehabilitation not only for impairment but also for intervention relating to restrictions in
activities and participation [19]. However, it was shownthat a lot of the current assistances for Syrian refugees
with disabilities were interventions intended to improve
dysfunction. There was also a lack of intervention in
activity limitations including self-care, prevention ofdisuse syndrome, education for nursing care, and participation restrictions.
3. Difficulties in continuously providing rehabilitation to
PWDs in urban areas
Rehabilitation professionals of community-basedorganizations recognized personnel expenses andmovement expenses for visiting rehabilitation due to thelack of funds for management, and lack of information
on Syrian refugees with disabilities in urban areas dueto the fluid situation of the Syrian conflict as difficult
points. Furthermore, rehabilitation professionals identified insufficient access to necessary health care services
due to poverty and lack of health literacy among Syrian
refugees with disabilities and their family members as
problems.
4. Forthcoming challenges facing rehabilitation programs by community-based organizations
According to a report on the economic situationof support for Syrian refugees, a chronic shortage ofmanagement funds for support programs for Syrian refugees has been reported [20]. In this way, rehabilitation
professionals faced economic difficulty in providing
continuous support for Syrian refugees with disabilities.
Therefore, rehabilitation professionals recognized that
securing management funds, and collaborating withinternational support organizations were necessary. Persons with disabilities in urban areas presented a variety
of diseases, disorders and conditions due to war injuries,
congenital disorders and non-communicable diseases[21]. Therefore, rehabilitation professionals regarded
the development of human resources for intervention invarious diseases as a future challenge. However, they
did not recognize the prevention of disuse syndrome, theprovision of nursing care methods for family members,
or intervention in self-care as future challenges. In
general, persons with disabilities are at significant riskof disuse syndrome. It is important that comprehensive
health promotion be included in the rehabilitation program [22]. In addition, recently we reported that Syrian
refugees with disabilities in urban areas of Jordan havea high risk of disuse syndrome, and disuse syndrome isassociated with restrictions on activities and participation [11]. Furthermore, rehabilitation professionals in
Jordan tend to focus on approaches to the dysfunctionof persons with disabilities [23]. Therefore, those results
suggested that intervention in the case of disuse syndrome or restrictions on activities or participation are
really needed in support programs for Syrian refugeewith disabilities in urban areas of Jordan.
In general, occupational therapy plays an importantrole in intervention in the case of restrictions on activities including self-care and participation [24]. Effective
intervention using occupational therapy have also beenreported for disuse syndrome [25]. Therefore, it can besuggested that occupational therapists need to guide preventive measures of disuse syndrome, and intervention
in the case of restrictions on activities and participation
among PWDs. Our study was limited by the small sizeof the sample, because there are few rehabilitation
professionals undertaking support for Syrian refugees
with disabilities living in urban areas. However, this was
the first time for a study to be conducted on the current
situation of support programs for Syrian refugees withdisabilities by rehabilitation professionals in community-based organizations in Jordan.

Limitation
Our study had four major limitations: the samplingbias for participants in a limited area, The small sample
size, The limited geographic area, and the lack of statistical analysis. because there are few rehabilitation
professionals engaged in support for Syrian refugee withdisabilities living urban area in Jordan. However, thisstudy was the first survey to identify current state of intervention for Syrian refugees with disabilities in Jordan
and the recognition of rehabilitation professionals handling the health of Syrian refugees with disabilities, andthe challenges that they face in providing rehabilitation
services. however, in our results, there was only one
occupational therapy professional and no nursing or
psychologist. Therefore, in occupational therapy pointYamamoto S et al.

Asian J Occup Ther 16: 11−18, 2020of view how lack of occupations, routines, habits, crafting, and group-work can promote health and well-being,these knowledges are missing from this rehabilitation
professionals. those can evade disuse syndrome. Further
research is necessary to explore these issues.
Furthermore, participants in this study were rehabilitation professionals in the capital Amman. Syrian
refugee with disabilities also lives in other large cities[2]. In the future, it is necessary to investigate rehabilitation professionals who are engaged in support activities
in large cities other than the capital Amman.
As of 2019, The conflict in the Syrian Arab Republic has been ongoing. Furthermore, it is estimatedthat the situation of Syrian refugee with disabilities inurban areas of Jordan change in the future due to social
conditions. Therefore, additional research is needed toconfirm the situation of Syrian refugee with disabilities
and intervention of rehabilitation professionals handlingthe health of Syrian refugees with disabilities in Jordan.

Conclusions
Our current study concluded that rehabilitation
professionals of community-based organizations inurban areas of Jordan provided outpatient rehabilitation,home-visit rehabilitation and provision orthosis to
Syrian refugees with disabilities in urban areas. They
also recognized difficulties in access to health care dueto the poverty of Syrian refugees with disabilities, thespread of disuse syndrome, and the lack of caregivers
in PWDs’ families. Furthermore, they faced a lack offunds for their programs, and difficulty grasping information of Syrian refugees with disabilities in their field.
Therefore, they regarded securing management funds,
collaboration with international support organizations
and development of human resources as challenges.
However, the prevention of disuse syndrome, the provision of nursing care methods, and intervention in thecase of restrictions on activities and participation were
not mentioned as future challenges.
It is essential that rehabilitation professionals
including occupational therapists engage in preventing
disuse syndrome, and provide intervention in the caseof restrictions on activities and participation for Syrian
refugees with disabilities in urban areas of Jordan. therefore, there is a need to study the disuse syndrome andhealth status of Syrian refugee with disabilities in urban
area. furthermore, it was suggested that rehabilitation
professional should consider effective countermeasures
for support programs.

17

Conflicts of Interest
We declare no conflicts of interest.

Acknowledgement
This work was supported by JSPS KAKENHI
Grant-in-Aid for Research Activity Start-up (Grant
Number 18H07716).

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■ORIGINAL ARTICLE

Factors Affecting Changes in Social Activities
of People with Stroke Living in The Community:
Follow-Up 1 to 3 Years after Being Discharged Home
Hitoshi Mutai1, Ayumi Wakabayashi2, Akihito Suzuki2, Tomomi Furukawa3
1

School of Health Sciences, Shinshu University School of Medicine
Azumino Red Cross Hospital
3
Nagano University of Health and Medicine
2

Abstract: Purpose: This follow- up study by questionnaire aimed to identify factors associated with social activity
levels of stroke patients by investigating their activities between 1 and 3 years after discharge.
Materials and Methods: Participants included 191 people with stroke who were living in their home. Their social
activity levels at 1 and 3 years post-discharge were investigated using the Frenchay Activities Index (FAI: an index forevaluating social activities such as housework, leisure, and work). Factors associated with inactivity at 3 years postdischarge, and with a decline in activity levels from 1 to 3 years post-discharge were analyzed by logistic regression
analysis.
Results: The median FAI was 23 points after 1 year; however, it declined significantly to 19 points after 3 years.
Cognitive dysfunction [odds ratio (OR) = 11.61, p < .001] and dependency in activities of daily living (ADLs) [OR =8.46, p < .001] were identified as factors associated with inactivity after 3 years. Moreover, dependence in ADLs (OR =0.10, p = .027) was identified as a factor associated with a decline in activity level from 1 to 3 years post-discharge.
Conclusions: Patients with stroke living at home tend to be inactive in the long term; this could be attributed to cognitive dysfunction and ADL dependency. Therefore, occupational therapists need to pay more attention to the social activities of patients with stroke in the community; providing activities tailored to the patient’s abilities is vital. Furthermore,interventions are needed to prevent long-term decline in social activities in patients with stroke living at home, whoshow independence in ADL.
Keywords: stroke, social activity, predictors, long-term outcome, rehabilitation(Asian J Occup Ther 16: 19−27, 2020)

Introduction
The incidence of stroke increases with age; whilemortality rates have been declining owing to advancesin acute treatment, long-term care is required at homeowing to persistent paresis and cognitive dysfunction [1].
The number of patients requiring long-term care at homeis also rising in proportion to the population age [2].
Therefore, it is essential to identify methods to improve
the lives of people with stroke living at home.
Received: 31 July 2019, Accepted: 25 February 2020
Corresponding to: Hitoshi Mutai, School of Health Sciences, Shinshu
University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 3908621, Japane-mail: hitmutai@shinshu-u.ac.jp©2020 Japanese Association of Occupational Therapists

The aging population in developed countries andJapan in particular, has been increasing in recent years.
The Ministry of Health, Labor, and Welfare introduced acommunity-based integrated care system to support the
rapidly increasing number of elderly people in provincial regions [3, 4]. The goal of the system is to develop
a local framework to provide comprehensive support
services enabling elderly people in the community tocontinue living accustomed lifestyles as far as practicable until the end of life [4]. Moreover, for rehabilitationof elderly people in the community, the system aims
to promote “activities” and “participation,” as definedby the International Classification of Functioning,
Disability, and Health [5]. Support and rehabilitation
frameworks must similarly be developed for people withstroke; however, the current status of social activities
directly associated with accustomed lifestyles, activities,

20

SOCIAL ACTIVITIES OF PEOPLE WITH STROKE

and participation, such as housework, leisure, and work
remains unclear in people with stroke living in provincial regions of Japan; relevant studies with long-term
follow-up are scarce.
Several longitudinal studies of social activities havebeen conducted in Europe and North America [6–11].
Most evaluated patients from 1 to 3 years after stroke
onset; others have identified various factors associatedwith social activities, including stroke severity, complications, cognitive dysfunction, and activities of dailyliving (ADLs). On univariate analysis, leg function 1
year after stroke onset was associated with a decline insocial activities [9]. However, as social activities arestrongly influenced by cultures, results from studies
conducted in Europe and North America may not be
generalized to Japan, and similar studies should therefore be conducted in this setting.
It is essential to investigate the social activities ofpatients with stroke, who account for most individuals
requiring long-term care in Japan; the Japanese population is aging at unprecedented rates compared to others.
This will facilitate rehabilitation with a focus on future
support frameworks and on the promotion of activities
and participation, especially for those living in local
communities. Therefore, we investigated the social
activities of people with stroke living at home at 1 and 3
years after hospital discharge, and performed a multivariate analysis to identify related factors and changes insocial activity levels at these time points.

Materials and Methods
ParticipantsThis follow-up study included 191 stroke people
living at home. They were selected from 338 consecutive stroke patients discharged home between October
2012 and October 2014; all responded to a questionnaire
after 1 year. Our hospital is a general hospital in aprovincial city, and treats several patients with stroke
who are brought in by ambulances and subsequently
admitted to a ward in the Department of Neurology or
Neurosurgery, where they undergo acute-stage therapy
with comprehensive rehabilitation based on full-riskmanagement. Patients without serious complications
receive physical and occupational therapies. Physicaltherapy includes physical exercise and training in basic
activities. Occupational therapy involves training for
ADL and cognitive function. Patients with aphasia and/or dysphagia receive speech therapy. Approximately
50% of patients are discharged home from the acuteward, and 20% of patients with moderate-to-severe
motor-induced paralysis and cognitive impairment aretransferred to a rehabilitation ward in the same hospitalfor long-term rehabilitation. Approximately 80% of
patients in the rehabilitation ward are discharged home,
and the remaining are transferred to another hospital ora nursing home.
Patients with ischemic or hemorrhagic strokes
diagnosed by clinical and radiographic findings were
included, while those with serious impairments ofconsciousness, unstable medical complications, or otherdiseases that could impede active rehabilitation were
excluded from the study.
Assessment
Subjects were followed-up at 1 and 3 years after
hospital discharge. Questionnaires were mailed forthe subjects to fill out, and were returned by either thepatients or their representatives, if they were unable
to reply themselves. We sent a postcard three weeks
after the questionnaire was sent, that served as both,a thank-you letter and a reminder. Follow-up surveys
were conducted, which included assessment of social
activities using the Frenchay Activities Index (FAI).
Fifteen different items related to social activities were
evaluated; each item was scored from 0 to 3 (total
score, 0–45 points) [12, 13]. The items were categorized as follows: domestic (preparing meals, washingup, washing clothes, and light or heavy housework),outdoor (local shopping, walking outdoors, driving/
train travel, gardening, and house/car maintenance), andleisure/work (social outings, pursuing hobbies, outings/
car rides, reading books, and gainful work). Activity
levels were classified according to the score as follows:inactive (0–15), moderately active (16–30), and highly
active (31–45). A subscale score of 0–5 was defined asinactive, 6–10 as moderately active, and 11–15 as highly
active; scores for individual items were classified as inactive (0–1), moderately active (2), and highly active (3).
Basic ADLs were assessed using the Barthel Index (BI)[14]. The BI assesses 10 items related to basic ADLs,
with a score ranging from 0 to 100 points; subjects with
100 points are classified as being more independent, andthose with scores ≤ 95 points are classified as having
dependence in ADLs. We used self-reported BIs [15,16]. Mental function was assessed using the Hospital
Anxiety and Depression Scale (HADS). The HADS is aself-administered questionnaire with subscales measuring anxiety (HADS-A) and depression (HADS-D). Each
subscale includes seven questions; each is scored from 0
to 3 (total score, 0–21 points). Subjects with high scores
generally exhibit more severe symptoms of anxiety or
depression [17]. A score of ≥ 11 points on either scale
was considered to indicate the presence of symptoms.
We also investigated the cohabitation (living alone orwith family) and social service usage (long-term care

Mutai H et al.

Asian J Occup Ther 16: 19−27, 2020

insurance) status.
Subject Characteristics
Patient characteristics at hospital discharge wereobtained from the medical records of our hospital. We
investigated the following parameters: age, sex, stroke
type (lacunar, others, or ischemic of non-lacunar andhemorrhagic type), stroke event (first or recurrent),
medical complications (hypertension, ischemic heartdisease, diabetes mellitus, or atrial fibrillation), Stroke
Impairment Assessment Set (SIAS), and Functional
Independence Measure (FIM). The SIAS evaluates
stroke severity, with a score ranging from 0 to 75. A
lower score indicates less severe stroke [18]. Paresis wasassessed using the paresis-related items of the SIAS.
The maximum scores for the arms and legs were 10 and
15 points, respectively, with a score of ≤ 9 for the armsand ≤ 14 points for the legs indicative of paresis. FIM is
one of the most commonly used methods for evaluating
function in patients with stroke, and enables functional
assessment using the twin perspectives of motor andcognitive functions. The motor FIM score ranges from0 to 91 points, while the cognitive FIM score ranges
from 0 to 35; higher scores indicate better function[19, 20]. The Mini-Mental State Examination (MMSE)
is the most widely used assessment tool for cognitive
function; however, it is difficult to use with aphasic
patients. Therefore, we used the cognitive FIM to assess
cognitive function, with a score of ≤ 29 points indicating
cognitive dysfunction. The MMSE and cognitive FIM
scores were correlated [21].
Statistical Analyses
Kruskal-Wallis and χ2 tests were used to compare
subject characteristics at hospital discharge and at 1
and 3 years post-discharge. These tests were also used
to compare the follow-up data of the subjects at home
who responded 1 year after discharge, those at home
who responded 1 and 3 years after discharge, and thoseat home who responded 3 years after discharge. Posthoc analyses were performed using the Dunn’s method;the Bonferroni correction was used for multiple comparisons. Proportions of subjects who were inactive according to the FAI at 1 and 3 years post-discharge, werecompared using the χ2 test; the median FAI at 1 and 3
years post-discharge was compared using the Wilcoxon
signed-rank test.
To identify factors associated with inactivity according to the FAI at 3 years post-discharge, binomial
logistic regression analysis of the FAI was performed
at 3 years post-discharge. Binomial logistic regression
analysis was conducted to identify factors associatedwith a decline in the activity level from 1 year to 3 years

21

1 year post-discharge
191

Home
166

Hospital
5

3 years
121

Uncollected
45

Home
101

Hospital
1

Nursing
home
6

Death
14

Nursing
home
9

Death
10

Fig. 1. Flow diagram of the data collection over the course of
the study.

post-discharge. A decline in the activity level was defined as a decrease from moderate to low or from high tomoderate/low levels. Explanatory variables used during
analysis included sex, stroke type, stroke event, cognitive impairment (cognitive FIM at discharge), paresis(the paresis-related items of the SIAS at discharge), age
at 1 year post-discharge, family dynamics (living alone/other), ADLs (independent/requiring assistance), anddepression (yes [HADS-D score of ≥ 11]/no).
For all analyses, statistical significance was set at< 5%. Statistical analyses were conducted using the
IBM SPSS Statistics version 25 (IBM Corp., ArmonkNY) software package.
Ethics
The appropriate ethics review boards approved thisstudy on October 2, 2012 (approval No. 2122). Written
informed consent was obtained from all subjects or their)LJXUH
relatives if the patient
was unable to provide consent.

Results
Among 191 subjects discharged home, 166 were
living at home, 5 had been admitted to the hospital,
6 had entered nursing homes, and 14 died at 1-year
post-discharge. Overall, 121 subjects responded to thesurvey at 3 years post-discharge, of whom 101 were
living at home, 1 had been admitted to hospital, 9 hadentered nursing homes, and 10 had died (Fig. 1).
A comparison of patient characteristics at discharge

22

SOCIAL ACTIVITIES OF PEOPLE WITH STROKE

Table 1 Comparison of Characteristics at Discharge between the groups during and at 1 and 3 Years After Discharge.
Characteristics
Age
Sex
Stroke type
Stroke event
Medical complication

SIAS
Motor paresis
FIM
Cognitive dysfunction

FemaleLacunarFirst
Hypertension
Ischemic heart disease
Diabetes mellitus
Atrial fibrillation
U/E
L/E
Total
Motor
Cognitive
Cognitive FIM < 30

At discharge(n = 191)

1 year(n = 166)

3 years(n = 101)p

76 (69–84)
75 (39.3)
66 (34.6)
139 (72.8)
94 (49.2)
14 (7.3)
25 (13.1)
15 (7.9)72 (62–75)
74 (38.7)
80 (41.9)
105 (79–118)
75 (56–85)
31 (23–35)
81 (42.6)

74 (68.25–82)
65 (39.2)
58 (34.9)
122 (75.8)
80 (48.2)
9 (5.4)21 (12.7)
12 (7.2)
73 (65.25–75)
57 (34.3)
64 (38.6)
108 (88.75–118)
77 (61–87)
32 (25–35)
60 (36.4)

73 (69–81)
37 (36.6)
32 (31.7)
83 (82.2)
52 (51.5)
2 (2.0)12 (11.9)9 (8.9)73 (70–75)
26 (25.7)
33 (32.7)
112.5 (101–121)
79.5 (69–87)
33 (28–35)
27 (27.0)

.223
.895
.801
.202
.872
.160
.957
.885
.073
.081
.274
.024*
.034*
.016*
.032*

* p < 0.05. Values are presented as median (Q1–Q3) for continuous data and n (%) for nominal data.
SIAS: Stroke Impairment Assessment Set; FIM: Functional Independence Measure; U/E: upper extremity; L/E: lower extremity.

Table 2 Comparison of Follow-up Assessment at 1 and 3 Years.

Cohabitation status
Social service
HADS
Anxiety score
Anxiety symptoms
Depression score
Depression symptoms
BI
ADL Dependence
FAI

Alone
Use
HADS-A ≥ 11
HADS-D ≥ 11
BI < 95
Total

1 year(n = 166)

1 yeara(n = 101)

3 years(n = 101)p

13 (7.8)
72 (43.4)

5 (5.0)35 (34.7)8 (7.9)38 (37.6)

.622
.336

6 (3–8)25 (15.1)
7 (4–11)45 (27.1)
90 (65–100)
84 (50.6)
16 (3–29)

5 (2–8)8 (7.9)6 (3–9)15 (14.9)
100 (80–100)
41 (40.6)
23 (5–33)

4 (2–7)9 (8.9)6 (4–9)18 (17.8)
100 (80–100)
40 (39.6)
19 (4–31)

.146
.312
.119
.042
.113
.159
.149

Values are presented as median (Q1–Q3) for continuous data and n (%) for nominal data.
HADS: Hospital Anxiety and Depression Scale; BI: Barthel Index; FAI: Frenchay Activities Index.
aPatients who responded both at 1 year and 3 years post-discharge.

with those of respondents living at home at 1 and 3
years post-discharge revealed significant differences in
FIM (total, motor, and cognitive) scores and cognitive
dysfunction; post-hoc analysis revealed significant
differences between subjects at discharge and those
who responded at 3 years post-discharge (Table 1). A
comparison of follow-up assessments of respondents
living at home 1 and 3 years post-discharge showed asignificant difference in the incidence of symptoms ofdepression. Post-hoc analysis also revealed a significant
difference between respondents living at home at 1-year
post-discharge and those living at home 3 years postdischarge (Table 2).
Figure 2 shows the proportions of patients living
at home at 1 and 3 years post-discharge, who were
inactive according to the FAI. Activities in which a low
proportion of patients were classified as inactive were

outings/car rides (1 year and 3 years, 34.0% and 38.8%,
respectively), walking outdoors (41.2% and 43.9%),
and local shopping (47.4% and 49.0%). Conversely,
activities in which a high proportion of patients wereclassified as inactive included driving/train travel (80.4%
and 84.7%) and gainful work (84.5% and 85.7%). A
comparison of the proportions of patients who wereclassified as inactive in each activity at 1 and 3 years
post-discharge did not yield any significant differences.
However, a comparison of the median values at 1 and3 years post-discharge revealed significant decreases intotal score after 3 years (23 vs. 19, p = .005), leisure/work (5 vs. 4, p = .006), and reading books (2 vs. 1, p =.024).
Table 3 shows the results of the binomial logistic
analysis of factors associated with inactivity according
to the FAI 3 years post-discharge using patient char-Mutai H et al.

Asian J Occup Ther 16: 19−27, 202023

Total 1*
3
Domestic 1*
3
Outdoor 1*
3
Leisure/work 1*
3
Outings/car rides 1*
3
Walking outdoors 1*
3
Local shopping 1*

3
Washing up 1*

FAI

3
Light housework 1*
3
Heavy housework 1*
3
Pursuing hobby 1*
3
Reading books 1*
3
Preparing meals 1*
3
Washing clothes 1*
3Social outings 1*
3
Gardening 1*
3
House/car maintenance 1*
3
Driving/train travel 1*
3
Gainful work 1*
3
0%
n=101

20%

40%

Inactive

60%

80%

Moderately

Highly100%

Fig. 2. Proportions of activity levels for each FAI item 1 and 3 years post-discharge.
1*, patients at home who responded at 1 and 3 years after discharge; 3, all patients who responded at 3 years post-discharge.

acteristics and survey results 1 year post-discharge as
ciated with the total score. Male sex (OR = 8.48, 95%
Figure 2.
explanatory variables. Cognitive dysfunction [odds ratio
CI 2.41–29.41, p = .001), cognitive dysfunction (OR =(OR) = 11.61, 95% confidence interval (CI) 3.13–43.09,
7.70, 95% CI = 1.97–30.09, p = .003), and dependence
p < .001] and dependence in ADLs (OR = 8.46, 95% CI
in ADLs (OR = 4.41 95% CI 1.46–13.26, p = .008)
2.86–25.00, p < .001) were identified as factors assowere identified as factors associated with the domestic

24

SOCIAL ACTIVITIES OF PEOPLE WITH STROKE

Table 3 Factors Associated With Inactivity According to FAI at 3 Years.

Total
Domestic
OutdoorLeisure/work

Predictor

OR

95% CIp

R2

Cognitive dysfunction
Dependence in ADL
Men
Cognitive dysfunction
Dependence in ADL
Cognitive dysfunction
Dependence in ADL
Dependence in ADL
Depression

11.61
8.46
8.48
7.70
4.41
14.92
7.99
6.35
12.27

3.13–43.09
2.86–25.00
2.41–29.41
1.97–30.09
1.46–13.26
6.16–70.34
2.57–24.83
2.30–17.59
1.45–103.64< .001< .001
.001
.003
.008
< .001< .001< .001
.021

.513
.426
.540
.324

FAI: Frenchay Activities Index; ADL: activities of daily living; OR: odds ratio; CI: confidence interval

subscale score; cognitive dysfunction (OR = 14.92, 95%
CI 6.16–70.34, p < .001) and dependence in ADLs (OR= 7.99, 95% CI 2.57–24.83, p < .001) were associatedwith the outdoor subscale score; dependence in ADLs
(OR = 6.35, 95% CI 2.30–17.59, p < .001) and depression (OR = 12.27, 95% CI 1.45–103.64, p = .021) wereassociated with the leisure/work subscale score.
Binomial logistic regression analysis of factors
associated with a decline in the activity level basedon the FAI from 1 to 3 years post-discharge, identified
dependence in ADLs as a factor significantly associatedwith a decline in the total FAI (OR = 0.10, 95% CI 0.01–
0.76, p = .027), outdoor subscale score (OR = 0.10, 95%
CI 0.01–0.83, p = .033), and leisure/work subscale score(OR = 0.09, 95% CI 0.01–0.50, p = .009). No factors
were associated with the domestic subscale score.

Discussion
We investigated the social activity level among patients with stroke 1 and 3 years after discharge following
rehabilitation. In the assessment of social activities using
the FAI, the median scores were 23 and 19 points at 1
and 3 years post-discharge, respectively. The factors associated with social inactivity at 3 years post-discharge
were cognitive function decline and ADL dependence.
The factor associated with decreased social activities
from 1 to 3 years post-discharge was independence in
ADLs.
Social Activity Level
A number of previous studies have used the FAI toassess social activities after periods of time ranging from
1 to 3 years following discharge, and have found minimal differences in scores between these time points. For
instance, Patel et al. [8] reported a mean score of 15.4
points at 1 year and 15.8 points at 3 years, and Jansen
et al. [9] found that the mean score did not change at 1
year and was 19.5 points at 3 years post-discharge. Our
results were similar or somewhat higher than the previ-

ously reported values at 1 and 3 years post-discharge,
with a significant decline from 23 points to 19 points.
Moreover, our results were substantially lower than themean score of 26.4 points reported in a study of FAIs
among healthy older individuals in Japan [13].
Although the overall activity level was low in ourstudy, the patients were relatively more engaged in
outdoor activities, such as outings/car rides, walking
outdoors, and local shopping. The patients in our study
received instructions on walking exercises by rehabilitation staff at the time of discharge; this had possibly
established a habit of going for walks in their local
neighborhoods, parks, and other areas with the goal of
improving and maintaining motor function. Shoppingand outings/car rides to nearby destinations are difficult
or even impossible to be performed alone; performed
with other family members provided opportunities forthe patients to go out. Conversely, our patients’ engagement in driving/train travel or gainful work was extremely limited. Driving among patients with stroke has
become a prevalent social issue in Japan, and considering the damages in the event an accident happens, thecriteria for resuming driving have become more rigid.
Moreover, the very low scores for gainful work could
be attributed to the high number of elderly patients; theusual retirement age for Japanese workers ranges from60 to 65 years and a number of patients had already retired before their stroke occurred. Although driving andgainful work may be difficult activities for older patientswith stroke, the possibility of these patients performing
indoor activities, such as light housework and pursuing
hobbies with family support, must be explored. In addition, social activities are associated with family roles
and individuals’ reasons for living and are important
for the prevention of mental and physical frailties andimprovement in the overall quality of life. Occupational
therapists, in particular, should be involved in the seamless transition from providing instructions at the time ofdischarge to performing intervention activities at home.

Asian J Occup Ther 16: 19−27, 2020

Factors Associated With Social Activities at 3 Years
Post-Discharge
Previous reports have identified several predictorsof FAI in the long-term, including stroke severity [6,22], complications [7, 23], cognitive function [7], depression level [22–24], and ADLs [7]. Our study showedthat cognitive dysfunction and dependence in ADLs
are associated with inactivity according to the total
FAI, and these predictors were consistent with thosein previous studies. Similar to our findings, Pettersen
et al. demonstrated that cognitive dysfunction and low
BI score are associated with inactivity according to
the FAI 3 years post-discharge [7]. Social activities arecomplex processes that may involve the use of tools(e.g., vacuum cleaners, washing machines, and cars),demanding a higher cognitive function level. Therefore,cognitive dysfunction may be a strong predictor ofsocial inactivity. When providing support for social
activities to patients with stroke with cognitive dysfunction, family members and occupational therapists must
not immediately assume that the patients are incapableof performing social activities; instead, they should first
analyze the activities that the patients can perform andsubsequently assist them accordingly. Many studies
have also suggested that a low BI score is a predictor
of inactivity at 1-year post-discharge [25, 26]. Schepers
et al. [26] stated that patients who are more independent(in terms of self-care) have a better FAI, which is similar
to our results at 3 years post-discharge.
Furthermore, in this study, we categorized the activities based on the following activity contents: domestic,
outdoor, and leisure/work, and investigated the factors
associated with low activity levels in each category.
Although a few studies have also investigated FAI basedon separate categories [24, 25, 27], their results areinconsistent, and none have surveyed patients 3 years
post-discharge. In our study, we were able to elicit anumber of factors associated with the different categories. Sex was only associated with domestic activities,
such as cooking, laundry, and cleaning; men tended tobe more inactive in these. As domestic activities areusually regarded as women's work, especially in elderly
people, the results may have been affected by this social
standard [26]. Moreover, depression was only associatedwith leisure/work activities. A previous study showedthat approximately 30% of patients with stroke develop
post-stroke depression [28], and patients with stroke
living at home may be poorly treated for depression.
Although studies have emphasized the importance ofscreening for depression from the time of discharge andproviding appropriate treatment [29], the identificationof symptoms of depression in patients with stroke andthe appropriate treatment methods warrant further in-

Mutai H et al.

25

vestigation. Other studies have reported that post-stroke
depression is improved by encouraging participationin leisure activities through leisure education programs[30]. Creating environments and opportunities for patients with stroke to participate in leisure activities mayhelp improve symptoms of depression.
Factors Associated With a Decline in the Social Activity
Level From 1 Year to 3 Years Post-Discharge
Studies investigating factors associated with adecline in the social activity level from 1 to 3 years
post-discharge are scarce, and none of the existing studies have used multivariate analysis. One study employedunivariate analysis [9] and found that leg function andsocial inactivity at 1 year are predictors of a decline insocial activities from 1 to 3 years post-discharge. On
multivariate analysis, we identified independence in
ADLs 1 year post-discharge as a predictor of a decline
in total FIM scores, and in outdoor and leisure/work
subscale scores from 1 to 3 years post-discharge. Most
patients whose social activity level had declined 3 years
post-discharge showed independence in ADLs 1 year
post-discharge. Rehabilitation interventions focus on
individuals whose functions are gradually declining;
therefore, those who are functioning well tend to beoverlooked. Our results showed however, that attention
must be paid to all patients over the long-term to prevent
declines in social activity levels of high-functioning
individuals. Therefore, interventions to maintainor improve social activities of comparatively highfunctioning elderly patients with stroke must be considered in community-based integrated care systems inlocal communities in Japan.
Limitations
This study has some limitations. The lack of FAI
data on the social activities of study patients prior to
stroke onset prevented us from identifying whether they
had been socially inactive before onset or had become
inactive since the event. Future studies are required to
track the outcomes of patients whose status had beenassessed before stroke. Furthermore, many patients who
did not respond 1 or 3 years after discharge possibly
have had poor function; they may have dropped out asthey had entered an assisted living facility or had died.
Therefore, our results must be considered in light of thepossibility that our study population included a highproportion of patients whose function was comparatively good.
Since we used BI as a self-report, the reliability ofthe data may be lower than that rated by clinicians; theresults should therefore be interpreted with caution.

26

SOCIAL ACTIVITIES OF PEOPLE WITH STROKE

Conclusions
We investigated the social activities of patients withstroke living at home 1 and 3 years post-discharge following inpatient rehabilitation. The median FAI declined
significantly from 23 points at 1-year post-discharge to
19 points at 3 years post-discharge. The negative factors
associated with inactivity according to the total FAI at 3
years post-discharge were cognitive dysfunction and dependence in ADLs; sex (specifically male) and depression were characteristic negative factors associated withthe domestic subscale and leisure/work subscale scores,
respectively. Independence in ADLs was associated witha decline in the FAI from 1 to 3 years post-discharge.
Maintaining and increasing the social activity levelare essential for the prevention of mental and physicalfrailties and for improving the quality of life. Therefore,
health and social welfare-associated professionals, andparticularly occupational therapists working in local
communities must tailor interventions individuallyconsidering the identified negative factors; long-termchanges in social activities in high-functioning patientsshould also be considered.

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

Funding
This study was supported by University Grants in
Shinshu University.

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

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■ORIGINAL ARTICLE

Cost-Effectiveness of Individualized Occupational
Therapy for Schizophrenia:
Results from a Two-Year Randomized Controlled Trial
Takeshi Shimada1, Masayoshi Kobayashi2, Manami Ohori3,
Yusuke Inagaki4, Yuko Shimooka5, Ikuyo Ishihara6
1

Department of Occupational Therapy, Medical Corporation Seitaikai, Mental Support Soyokaze Hospital, Nagano, Japan
Department of Health Sciences, Graduate School of Medicine, Shinshu University, Nagano, Japan3
Department of Occupational Therapy, North Alps Medical Center, Azumi Hospital, Nagano, Japan
4
Department of Occupational Therapy, Nagano Prefectural Mental Wellness Center Komagane, Nagano, Japan
5
Department of Occupational Therapy, Social Medical Corporation Ritsuzankai, Iida Hospital, Nagano, Japan
6
Department of Occupational Therapy, Medical Corporation Aiseikai, Matsuoka Hospital, Nagano, Japan
2

Abstract: Objective: To evaluate the cost-effectiveness of adding individualized occupational therapy (IOT) to groupoccupational therapy (GOT) as standard care versus GOT alone for prevention of rehospitalization for patients withschizophrenia.
Methods: Data were collected from our previous randomized controlled trial from baseline psychiatric discharge to
2-year follow-up. The effectiveness was measured as the number of patients who were not rehospitalized, and the cost
outcome was defined as direct medical costs.
Results: A total of 109 patients were included: 53 in GOT + IOT and 56 in GOT alone. The number of patients who
avoided rehospitalization was significantly higher in the GOT + IOT (n = 37) condition compared with the GOT alone
condition (n = 16) ( p < .001). Adding IOT to GOT was associated with a 56.76% probability of being more effective at
reducing the rehospitalization rate and a 26.93% probability of being less costly than GOT alone. GOT + IOT had highoutpatient costs, but lower inpatient costs due to the lower rehospitalization rate; as a result, total medical costs werelower than for GOT alone.
Conclusions: Our results demonstrate that adding IOT to GOT is likely to reduce costs and the rehospitalization rate;thus, GOT + IOT is more cost-effective than GOT alone.
Keywords: schizophrenia, cost-effectiveness, rehabilitation, occupational therapy(Asian J Occup Ther 16: 29−34, 2020)

Introduction
In the treatment of schizophrenia, it is important not
only to reduce psychiatric symptoms but also to improve
cognition and to prevent relapse and rehospitalization.
To accomplish these aims, individualized intervention
in occupational therapy (OT) is needed. However, theexisting medical fee system for psychiatric OT in Japan
Received: 22 July 2019, Accepted: 25 February 2020
Corresponding to: Takeshi Shimada, Department of Occupational
Therapy, Medical Corporation Seitaikai, Mental Support Soyokaze
Hospital, 3057-1, Shiogawa, Ueda, Nagano, Japane-mail: ot@seitaikai.or.jp©2020 Japanese Association of Occupational Therapists

considers group treatment as standard practice. To improve the current situation of psychiatric OT in Japan, it
is necessary to demonstrate the effectiveness of individually tailored OT intervention.
The individualized occupational therapy (IOT) program was developed to facilitate proactive participationin treatment and improve outcomes for patients withschizophrenia [1–3]. To evaluate the effect of adding
IOT to group occupational therapy (GOT) as standard
care, we conducted a multicenter, single-blind, randomized controlled trial, in which we assessed cognition
using the Brief Assessment of Cognition in Schizophrenia (BACS) [4, 5] and the Schizophrenia Cognition
Rating Scale (SCoRS) [6, 7], intrinsic motivation using
the Intrinsic Motivation Inventory (IMI) [8], social

30

COST-EFFECTIVENESS OF INDIVIDUALIZED OCCUPATIONAL THERAPY

functioning using the Global Assessment of Functioning(GAF) [9], psychiatric symptoms using the Positive and
Negative Syndrome Scale (PANSS) [10], and treatment
satisfaction using the Client Satisfaction Questionnaire(CSQ-8) [11, 12] among patients with schizophrenia.
Furthermore, we utilized a multicenter 2-year prospective cohort study to evaluate the impact of the type ofoccupational therapy (GOT + IOT or GOT alone) thatpatients received on their subsequent rehospitalizations[3]. Findings of these studies demonstrated that adding
IOT to GOT resulted in significant improvements incognition and intrinsic motivation [2] and could prolong
the time to rehospitalization and reduce the risk of rehospitalization in comparison to GOT alone, in addition
to supporting good cognition at discharge and favorable
medication adherence [3]. Details of the IOT study havebeen published [1–3].
Therefore, the costs associated with rehospitalization for patients receiving GOT + IOT may decrease, but
the outpatient cost associated with averted rehospitalization may increase compared with GOT alone. However,the cost-effectiveness of adding IOT to standard carehas been not examined. This study evaluated costeffectiveness from the perspective of the health caresystem using our previous study data [2, 3] for GOT +IOT and GOT alone during a 2-year follow-up.

Methods
Participants and sites
Eligibility criteria for this study and patient disposition have already been reported [2, 3]. Of 260 patients
who were assessed for eligibility, 136 patients withschizophrenia or schizoaffective disorder (DSM-5) who
were recently hospitalized in a psychiatric hospital met
the criteria for the previous study and, of these, 68 wererandomly assigned to each of the GOT + IOT and GOT
alone groups [2]. Seven of these participants dropped
out at different points in that study [2]. Of those whocompleted the intervention, 18 did not meet the criteria[3]: 13 were hospitalized for over 1 year, 4 emigrated
to other regions after discharge, and 1 was excluded
for another reason [3]. In addition, two were excluded
during the 2-year follow-up period. Therefore, 109
patients comprised the final sample used for analysis. Of
them, 53 (48.62%) were from the GOT + IOT and 56(51.38%) from the GOT alone groups.
This study was conducted between February 2016
and March 2019 at six Japanese psychiatric hospitals:
one prefectural hospital, one general hospital departmentof psychiatry, and four private hospitals in Nagano,
Japan. This study was approved by the ethics committees of the School of Medicine, Shinshu University(3256); Medical Corporation Seitaikai Mental Support
Soyokaze Hospital; North Alps Medical Center Azumi
Hospital; Nagano Prefectural Mental Wellness Center
Komagane; Social Medical Corporation Ritsuzankai
Iida Hospital; Medical Corporation Aiseikai Matsuoka
Hospital; and Medical Corporation Akitsukai Nanshin
Hospital. All participants provided written informed
consent. This study was registered in the University
Hospital Medical Information Network Clinical Trials
Registry (UMIN-CTR) (UMIN000019569).
Interventions
The OT intervention methods have been reported
elsewhere [1–3]. We only describe the main features
here. The IOT is part of the hospital treatment that isprovided via a one-on-one approach by occupational
therapists. It consists of a combination of motivational
interviews, self-monitoring, individualized visits, craft
activities, individualized psychoeducation, and discharge planning. The main component of the program
specific to the OT profession was the incorporation ofcraft activities with individualized coaching by occupational therapists, which is designed to address andimprove cognition, the details of which were describedin our previous study [2]. The GOT is a standard activity-oriented group treatment that was already being
implemented at each study site and included the following programs: physical fitness, handicraft activities,
cooking, music, recreation, and psychoeducation [2].
The patients voluntarily selected any desired programfrom among these options and participated at an individualized rate. Craft activities are also used in the GOT
program; however, each patient voluntarily completes
the craft activities based on their preferences, and occupational therapists assist only when the patient requests
it.

Outcome measures
Clinical data on rehospitalization
Clinical data consisted of our previous study data [2,3]. The primary clinical outcome was the number of patients who were not rehospitalized. This was calculated
as the patients who did not rehospitalize from baseline
psychiatric discharge to the 2-year follow-up.
Service use
Service uses and medication (antipsychotics) were
investigated through diverse medical resources of inpatient and outpatient care.
Cost data
Cost data were defined from the mental health care

Asian J Occup Ther 16: 29−34, 2020

system perspective and involved only direct medical
costs, which were defined using receipts collected byeach study site collaborator. When a patient did notrehospitalize, the total cost was calculated as only theoutpatient cost. When a patient rehospitalized, the total
cost was calculated by adding the inpatient cost due torehospitalization to the outpatient cost. If a patient experienced multiple rehospitalizations during the follow-up
period, all inpatient and outpatient costs were included.
These were collected separately for inpatient and outpatient costs. Costs were collected as Japanese Yen (JPY)
based on the reference year from 2016 to 2018, and werethen converted to US dollars using the exchange rate forthe reference year June 7, 2019 (US$ 1.00 equals to JPY
108.43).
Statistical analyses
The calculation of the planned sample size wasdescribed in our previous study [2]; it indicated that 150
patients with 75 patients randomly allocated to eachgroup were needed.
The Mann-Whitney U test for continuous variablesand χ2 analyses for the categorical variables were used
to compare the groups with regard to demographic
and clinical values. The analysis of cost-effectivenessassessed the average direct medical costs per patient.
Analyses of service use, cost components, and total costs
compared GOT + IOT and GOT alone groups on average costs per patient from baseline psychiatric discharge
to 2-year follow-up. If the GOT + IOT group as theexperimental condition had higher cost outcomes thanthe GOT alone group as the control condition, the incremental cost-effectiveness ratio (ICER) was calculated as
the difference in the average annualized total costs per
patient divided by the difference in effectiveness (thenumber of patients who were not rehospitalized). The
ICER was calculated as (CGOT + IOT − CGOT alone)/(EGOT + IOT− EGOT alone), where C is the average per patient cost andE is the effectiveness. The uncertainty of differences inthe effectiveness and cost data was estimated using 95%
confidence intervals (CIs).

Results
Participant characteristics
Data on participant characteristics were collected at
the baseline (psychiatric discharge) and during a 2-year
follow-up after discharge. Of 109 patients (53 GOT +IOT, 56 GOT alone), which were collected with 2-year
follow-up, were used in this study [2, 3]. The GOT +IOT group was significantly lower age ( p = 0.03) andrehospitalization rate ( p < .001) than GOT alone group,and scores of BACS composite ( p = 0.01), IMI ( p <Shimada T et al.

31.001), PANSS ( p < .001), and CSQ-8 ( p < .001) weresignificantly higher in the GOT + IOT group than in the
GOT alone group.
Outcomes
A total of 53 (48.62%) patients were not rehospitalized during the 2-year follow-up period, of whom
37 (69.81%) were from the GOT + IOT group and 16(30.19%) from the GOT alone group. GOT + IOT grouppatients experienced significantly lower rehospitalization frequency during the 2-year follow-up period than
did the GOT alone group (χ2 = 18.54, p < .001).
Service use
Measures of service use by treatment group (GOT+ IOT; GOT alone) are described in Table 1. For mental
health inpatients, all inpatient days and occupational
therapy times for the GOT + IOT group were significant
shorter than those in the GOT alone group. In addition,
for mental health outpatients, all outpatient days, consultation with psychiatrists times, and home visit nursing
times were significantly longer in the GOT + IOT groupthan those in the GOT alone group.
Costs
Measures of service use and related costs by treatment group (GOT + IOT; GOT alone) are summarizedin Table 2. The GOT + IOT group generated significantly lower costs (US$ 116 454.66; 95% CI = 106 088.42–
126 820.89) than did the GOT alone condition (US$ 159
379.89; 95% CI = 146 579.61–172 180.18), representing
a significant cost reduction of US$ 42 925.24 per patient( p < .001) (Fig. 1). GOT alone generated higher total
costs than GOT + IOT, with 26.93% of the increased
costs attributable to increased inpatient service costs(Table 2). There was a significant difference (U = 212.0,
p = .020) between patients who were rehospitalized
following GOT + IOT (n = 16; US$ 162 137.07; SD =30 857.44) versus those hospitalized following GOT
alone (n = 40; US$ 183 739.39; SD = 31 452.93). Costs
associated with patients without rehospitalization did not
differ significantly (U = 224.0, p = .154) between GOT+ IOT (n = 37; US$ 95 465.44; SD = 16 188.75) andGOT alone (n = 16; US$ 96 958.69; SD = 16 501.89).
Total inpatient costs for GOT + IOT were US$ 32 952.24(95% CI = 18 334.90–47 569.58) significantly lower
than inpatient costs associated with GOT alone (US$107 166.53; 95% CI = 86 387.54–127 945.53) ( p <.001). Total outpatient costs for GOT + IOT were US$
83 502.42 (95% CI = 78 056.27–88 948.56) significantly
greater than those for GOT alone (US$ 52 213.36; 95%
CI = 43 906.32–60 520.40) ( p < .001). The difference
between GOT + IOT and GOT alone in services re-32

COST-EFFECTIVENESS OF INDIVIDUALIZED OCCUPATIONAL THERAPY

Table 1 Measures of service use by treatment group (GOT + IOT; GOT alone).
GOT + IOT (n = 53)

GOT alone (n = 56)

Mean (SD)

Mean (SD)

Mental health medical inpatient
All inpatient days
Occupational therapy times

93.30 (160.90)
53.24 (90.90)

Mental health medical outpatient
All outpatient days
Consultation with psychiatrist times
Outpatient occupational therapy times
Day care times
Home visit nursing times

636.70 (160.90)
44.78 (12.39)
41.48 (59.50)
57.11 (122.59)
30.11 (23.45)

Statistica

Effect sizebp331.79 (249.53)
167.02 (136.70)

712.5
783.0

0.49
0.45

< .001**< .001**398.21 (249.53)
30.96 (22.27)
35.58 (54.80)
33.89 (74.31)
22.11 (18.78)

712.5
819.0
1526.01499.51250.0

0.49
0.43
0.01
0.03
0.17

< .001**< .001**
.937
.775
.085

a

Comparison of GOT + IOT and GOT alone was conducted with Mann–Whitney U test.
Effect sizes were calculated using r coefficient.
** p < 0.01b

Table 2 Measures of costs by treatment group (GOT + IOT; GOT alone).
GOT + IOT (n = 53)

GOT alone (n = 56)

Mean (SD)

Mean (SD)

Mental health medical inpatient costs, US$
Occupational therapy
Medication
Inpatient total costs

1,080.23 (1,844.23)
10,879.23 (18,782.21)
32,952.24 (53,553.68)

Mental health medical outpatient costs, US$
Outpatient occupational therapy
Day careHome visit nursing
Medication
Outpatient total costs
Total costs, US$

Statistica

Effect sizebp3,388.72 (2,773.67)
38,720.50 (29,120.22)
107,166.53 (78,312.09)

783.0
712.5
725.0

0.45
0.49
0.49

< .001**< .001**< .001**858.55 (1,214.88)
3,370.94 (7,235.61)
1,604.72 (1,258.81)
75,024.21 (18,600.81)
83,502.42 (19,953.09)

721.88 (1,111.90)
2,000.61 (4,385.84)
1,182.43 (1,004.73)
46,471.97 (29,120.22)
52,213.36 (31,307.65)

1519.01499.51258.0
695.0
766.0

0.01
0.03
0.16
0.50
0.44

.903
.775
.094
< .001**< .001**

116,454.66 (37,978.86)

159,379.89 (48,241.85)

717.0

0.47

< .001**aComparison of GOT + IOT and GOT alone was conducted with Mann–Whitney U test.
Effect sizes were calculated using r coefficient.
** p < 0.01

1b

180 000

Costs by treatment group (US$)

160 000
140 000
120 000
100 000

ceived is partly explained by the lower rehospitalization
rate in the GOT + IOT group and the higher inpatient
service use costs in GOT alone group.

Discussion

Main findings
This is, to our knowledge, the first study to evaluate
the cost-effectiveness of adding IOT to GOT in com60 000
parison to GOT alone. Our results of cost-effectiveness
40 000
GOT + IOT
analyses demonstrated that adding IOT to GOT had
20 000
GOT alonegreater potential cost-effectiveness than GOT alone.
This cost saving was brought about by the addition of0
Inpatient
Outpatient
Total
IOT to GOT, which improved cognitive functioning and
costs
costs
costs
intrinsic motivation [2] and reduced rehospitalization
rates [3]. GOT + IOT had high outpatient costs, but
Fig. 1. Comparison of inpatient total costs, outpatient total
Figure 1. Comparisoncosts,
of inpatient
total
costs,
outpatient
total
costs,
andtotal
costs bytreatment
group
lower
inpatientcostswith a lower rehospitalization rate;
and total costs by treatment group (GOT + IOT;
consequently, total medical costs were lower than for
GOT alone).
± standard
error.
(GOT + IOT; GOT alone).
MeansMeans± standard
error.
80 000Shimada T et al.

Asian J Occup Ther 16: 29−34, 2020

GOT alone. The main drivers of differences in costs between GOT + IOT and GOT alone were inpatient costs
due to rehospitalization (Table 2). Furthermore, GOT+ IOT cost US$ 42 925.24 less per patient than GOT
alone, representing 26.93% more cost-effectiveness ofthe former approach. Sensitivity analyses, using 95%
CIs, attested to the robustness of the findings of benefits
and costs for IOT. Therefore, adding IOT to standard
care during hospitalization should be recommended not
only in terms of prevention of rehospitalization [3] but
also in terms of cost-effectiveness.
Clinical and cost-effectiveness relevance
Treatment choices to improve outcomes for schizophrenia have been explored to alleviate personal suffering and to reduce the high health care costs associatedwith the illness [13]. Schizophrenia is associated withfrequent rehospitalization during its clinical course, withconsiderable economic burden [14–20]. Hospitalization
has been identified as a significant cost driver [21, 22].
Estimates of the annual economic burden of schizophrenia in Japan in 2008 were JPY 2.77 trillion (US$ 23.8
billion) for total costs, while the total cost per patient
was JPY 3 538 751 million (US$ 30 298) [18]. Hence,
rehospitalization prevention is an important element inschizophrenia treatment, not only in terms of functional
improvement [23–25], but also with respect to costeffectiveness.
Adding IOT to standard care might help prevent
rehospitalization [2, 3]; as IOT intervention duringhospitalization is cost-effective and perhaps even costsaving, IOT should readily be accepted as a componentof schizophrenia treatment.
Issues of medical fee system
The existing medical fee system for psychiatric OT
in Japan considers group treatment as standard. For thisreason, GOT intervention is widely practiced for patientswith schizophrenia in many Japanese psychiatric hospitals, but IOT is rarely implemented in Japan. To improvethe current situation, it is necessary to demonstrate theeffectiveness of individually tailored OT interventions.
In our clinical experience, the number of patients
who can be treated with OT in the time permitted by the
medical fee system is 10–12 for GOT, but only 2–3 forIOT. Therefore, it is necessary to ensure IOT is added tothe medical fee system to ensure that IOT is practical in
psychiatric hospitals in Japan. As shown in our previous
studies [2, 3] and this study, our findings provide robust
evidence for shifting from traditional OT, which is basedon group treatment, to individualized OT, not only to
improve rehospitalization rates of patients with schizophrenia but also for cost savings due to less frequent33

rehospitalization.
Limitations
Some limitations should be noted. First, our methodfor determining the costs was a simple comparison of
direct medical costs of GOT + IOT and GOT alonegroups. For cost-effectiveness analysis, although the
Quality Adjusted Life Year (QALY) is recommended as
the outcome variable, we could not use QALY, because
quality of life values were not obtained in this study.
Second, we measured only direct medical costs in thisstudy, and did not include direct non-medical costs andindirect costs. The analysis was conducted from the perspective of the health care system, and thus did not address costs incurred by patients’ families or other social
welfare systems. In addition, costs for medications otherthan antipsychotics were not measured. Therefore, costs
might be slightly underestimated and savings slightly
overestimated. Third, because IOT is provided one-onone with an occupational therapist, the case load duringhospitalization of adding IOT to GOT is less than thatfor GOT. However, the cost due to the difference in caseload for GOT + IOT versus GOT alone was not collected. Therefore, it was not possible to investigate whether
conditions differed in terms of health service utilization
at the start of the trial. Finally, because this study was
conducted in Japan, the results may not be generalizable
to countries that have different health care systems.
Conclusion
This study provides support that adding IOT tostandard care results in reduced rehospitalization rates
at lower cost. Cost savings appeared probable for mostof the study participants. Although further confirmationis needed, the results of our studies of IOT provide datathat encourage the revision of Japanese psychiatric occupational therapy’s medical fee system.

Acknowledgments
This study was supported by the Japanese Association of Occupational Therapists (2016–01). The authors
declare no conflicts of interest. The authors would liketo express their gratitude to the participants for theircooperation. We would also like to acknowledge thesupport received from the following individuals: Tokiji
Hanihara, MD, PhD; Ai Nishi, OTR; Tomotaka Yoshida,
MD; Akane Machida, OTR; Shiho Murata, MD; Rumiko
Arai, OTR; Tadahiko Hikake, MD; Miki Nakamura,
OTR; Yasushi Haebara, MD; Ayumi Terashima, OTR;
Takashi Muto, MD; Maki Ueki, OTR; Koichi Matsuoka,
MD; and Shinichi Noto, OTR, PhD. We are also gratefulfor the cooperation and assistance of the following or-

34

COST-EFFECTIVENESS OF INDIVIDUALIZED OCCUPATIONAL THERAPY

ganizations: Mental Support Soyokaze Hospital, North
Alps Medical Center Azumi Hospital, Nagano Prefectural Mental Wellness Center Komagane, Iida Hospital,
Nanshin Hospital, and Matsuoka Hospital.

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JCP.12117tx1c.

■CASE REPORTS

Occupational Therapy Profession for Women Health–
Challenges for its Under Developed Services
Siew-Yim Loh1, Gail Boniface2, Lynette Mackenzie3, Lorie Richards4
1

Faculty of Medicine, University of Malaya, Jalan University
University of Wales, UK
3
University of Sydney, Australia
4
University of Utah, USA
2

Abstract: Occupational therapy has a pivotal role in the organization of health care, and has important role to improve
the health and quality of life of women by facilitating participation in meaningful occupations. The aim of this paper
is to present a summary of occupational therapy role for health of women, and an analytical perspective of the current
issues eroding its professional autonomy and contributing to a critical lack of progress in Malaysia. Three key rootcauses – with an emerging summative theme of “triple whammy”, was identified using root cause analyses technique.
The root causes were related to two internal and 1 external root-source:- (1) Low numbers of occupational therapists,(2) Low university- education occupational therapy programs, and (3) Entrenched medical governance hindering the
progress of therapy professionals. These interrelated key issues (roots) play a detrimental role in the advancement ofa cost-effective, evidence-based best practice of the profession, and reduces its significant contributions towards thehealthcare of all, including the issues of women health care. As a young profession compared to many other healthdisciplines, occupational therapy needs a mandate to protect its role autonomy, with enhance visionary pathway for
growth, and to expand its roles, including for the underserved area of women health, in Asia’s male dominated world.
Keywords: Occupational Therapy, women health, autonomy, medical dominance, Challenges, medical hagemony(Asian J Occup Ther 16: 35−43, 2020)

BackgroundOccupational therapy has a pivotal role in theorganization of health care, and improves health andquality of life by facilitating participation in meaningful
occupations [1, 2, 8, 9]. The steep rise in non-communicable chronic health conditions and the aging population(which are typically not curable through traditional medical approaches), have resulted in significant limitations
in daily participations [5]. This calls for the involvementof the currently, underdeveloped and also underutilised
occupational therapy services [6]. Occupational therapists use activities to impact patients’ physical, sensory,
cognitive, psychosocial, and emotional health, throughReceived: 16 January 2018, Accepted: 25 February 2020
Corresponding to: Siew-Yim Loh, Faculty of Medicine, University of
Malaya, Jalan University, 50603 Kuala Lumpur, Malaysia
e-mail: syloh@um.edu.my, siewyimloh@yahoo.com©2020 Japanese Association of Occupational Therapists

patient self-management, joint-protection, splint-fabrication, adaptive-technology, wheelchair-modification,
mindfulness, lifestyle activities and environmentalmodification are fundamental to patient population [7–9].
The growth of the health profession contributes
to better, newer services and more expanded roles –including women’s healthcare. A basic element driving
its profession to advance in its deliveries, is ‘job-autonomy’ – a concept closely related to workers’ motivation,satisfaction and well- being [10], which can translate tobetter performance and subsequently, effective care forpatients [11]. Professional autonomy or, the right to use
discretion and judgment within the scope of practiceof a profession, or an individual’s freedom to exercise
professional judgment in practice activities [12, 13] hasbeen observed as one of the numerous key challenges
faced by occupational therapists in an entrenched medical model across Asia. Although some physicians justified ‘job-autonomy’ as fundamentally essential for goodpatient care and embedded it in the national governance36

OCCUPATIONAL THERAPY PROFESSION FOR WOMEN HEALTH

structures as documented in the 2000 Warsaw Declaration [14], this idea has, ironically not been translated
into their practices with other health professions. The
World Federation of Occupational Therapy has issued
position statement that clearly stipulates the importanceof professional autonomy of the Occupational Therapy
profession [15]. Paradoxically, although the profession
champions independence and empowerment for its
clients, it is losing its own autonomy status in less developed countries like Malaysia [16, 17]. Occupational
therapists are denied the same level of autonomy andare governed by policy makers who are solely (if notpredominantly) represented by medical practitioners.
This level of control means that occupational therapists
are not able to assert their professional autonomy andmay experience repercussions if they do [18]. Since
2009, most Occupational Therapy department have notprogress (but in fact, has regressed) and are reorganizedfrom being an autonomous department, and placed
under the governance of medical rehabilitation doctors[16, 19]. Historically, such medical dominance took
place in the health care system in the USA more than
three decades ago [20, 21], where the documented ‘tugof-war’ for autonomy has been detailed as the struggle
between occupational therapy and physical medicine –an occupational injustice attempt to control occupational
therapy [21]. Evidence shows that the health profession
was coerced into the medical dominance over theiraffairs with restrictions on their practice [20, 22, 23].
Nevertheless, occupational therapists elsewhere havemade significant progress with regards to autonomyof the profession. In Canada, the University of Alberta
has pioneered the Faculty of Rehabilitation Medicine
which was championed by three autonomous health professions –i.e. the Occupational therapy, Physiotherapy
and Speech Therapy [24]. In sharp contrast, Malaysia is
encountering severe oppressive trend of medical dominance, with its healthcare budget for rehabilitation channelled into a medical program. The unprecedented riseof rehabilitation doctors in Malaysia possibly to address
the shortages of health manpower in rehabilitation, has
unanimously led to a serious decline in the job autonomy of occupational therapists [16]. This non-evidence
strategy to address shortage of health professionals forrehabilitative services, aggravates a medical governancesystem that stifles further development of the profession.
In short, occupational therapists in developed countries
have enjoyed significant advancement, job autonomy
and job recognition [25], but not those from developing
countries [26, 27].

Healthcare Changes in Malaysia
Globally, improvement in health care has resulted
in more people living with chronic conditions for indefinite periods of time. With this change, approaches
to manage chronic condition and its symptoms formaintaining patient independence and quality of life
over longer periods of time is needed [28, 29]. A shift
from the traditional doctor–patient relationship (curativefocused) to a paradigm of, patients working in partnership with health and therapy professionals (independence
and function-focused) can only occur if there are sufficient number of health professionals who are autonomous and trained [4, 28]. In the 2018 fiscal year [43],Malaysia was classified as an upper-middle-income
economy with a GDP of USD358.582 billion. The Malaysia Economic Transformation Programme identified
healthcare as one of its 12 National Key Economic Areas
in 2010, and highlighted a priority to ensure training ofhealth personnel to address the behavioural componentof lifestyle issues [30, 31]. Yet, health professions like
occupational therapy were still neglected, and a reason
may well be the low number of leaders in the disciplineand poor representation at the policy levels. With ashrinking healthcare budget, the grossly underutilised
and underdeveloped therapy services must be expanded,
while the exaggerated focus on the expensive medical
personnel for curative care model must be for a morebalanced and cost-effective workforce [28, 29].
The World Health Organization (WHO) estimatesthat non-communicable diseases accounts for 80 percent
of global burden of disease, and it’s the leading cause ofdeath and disabilities in Asia [32]. The associated riseof lifestyle-related chronic diseases (attributed to a complex constellation of social, economic, and behavioral
factors) can be better managed with direct, interdisciplinary approach and patient self-management [29], –which therapy services can help address with their wide
range of therapeutic and preventive services. For bothclinical and economic reasons, addressing women’s
health with patient self-management is a cost-effective
paradigm model across the prevention spectrum (primary, secondary, and tertiary). Establishing a pattern for
health early in life, providing strategies for mitigating
illness and managing it in later life, and for the wellbeing of the family unit (as women tend to care and cook
for the families), and ensuring mental health, occupa­
tional health while intervening lifestyle related NCD
should be steeped up. Stakeholders must take into consideration the social-political, occupational and economic forces (including a lack of job awareness, autonomy
and acknowledgement to the health profession) thathas resulted in inequalities between medical vs healthS Y Loh et al.

Asian J Occup Ther 16: 35−43, 2020

disciplines in high and low income countries. Engaging
the therapy professionals should be the way forward forbetter and cost-effective care management.

Occupational therapy role for the health andwellbeing of women
The sub-specialization in advancing women
health is a natural progression for this profession withpredominantly female dominated profession. As an
example, with breast cancer as the number one cancer
for women, therapeutic services are much needed which
include the more innovative, patient self-management
to educate and empower female patients in their health[34], hand therapy like lymphedema-management andupper-limb function, pelvic and sexual wellbeing health,pre/post natal care and psychosocial health [33–37].
Occupational therapy can contribute to the occupational
participation intervention of women in the continuum ofcancer care. Enabling engagement in occupational
performance of mothers, and adapting their social
environment to intervene and address mothers’ occupational needs are linked to physical and mental health[58]. Many other women-related health areas which
greatly requires therapeutic health services to improve
the quality of life, includes domestic violence, vulnerable mothers [37, 38], and those with sleep disorders,weight-obesity issues [39, 40], and the ever increasing
functional issues from the many non-communicable diseases with comorbidities that limits functional abilities
in daily living.

PurposeThe aim of this paper is to present an analyticalperspective of the current phenomenon and challenges
affecting health professional’s job autonomy and, toidentify key root-causes that stifled its progress. The
paper focus on key services for female population which
are grossly underutilized, as an emerging area of targeted healthcare.

MethodA core group of four occupational therapy leaders(with involvement in their country’s professional association, or has participated in the World Federation of
Occupational Therapists’ meeting or leading/advocating
occupational therapy education in their countries) were
specially invited to a focussed discussion. They reflected
and reviewed the problems hindering the profession’s
growth in Malaysia. An analytical approach to theissues were deliberated, and references to their home37

countries and data from the World Federation of
Occupational therapists were gathered to compare andcontrast between countries. The four leaders utilized asimple “root-cause analysis” technique [57]. This is amanagement technique that systematically appraise theproblem-at-hand to get to the bottom of the problem or
the unexpected event (ie. the dwindling job autonomy ofoccupational therapists).
The root-cause analyses [57] aim at improving
products or processes, via a sequential steps of i) describe the problem (dwindling job autonomy), ii) gathering data associated with the problem (data on therapists
in the country and from a world body), iii) identifying
potential causes for the problem (concurring on key
problem and brainstorming the causes), iv) identifying
which causes to be removed/changed in order to prevent
problems, v) identify solutions that will be effective inpreventing repeat problems, [vi) implement changes andv) observe changes to eliminate the problem]. We willpropose recommendation/s from these steps.

Findings on key issues
Most developed countries have made good progress
to address shortages of occupational therapy manpowerin the last few decades. In Canada, great progress isseen in the University of Alberta who have consolidated
their three key healthcare professionals into a Facultyof Rehabilitation Medicine [24]. In Malaysia, progressis slow and a strategic root-analyses of this area, help
us to pinpoint fundamental root-cause issues in thisfemale-populated profession, link to low job autonomy.
The root-cause technique enumerated two internal andone external root causes in line with the erosion of
professional autonomy. An emerging key theme was, adebilitating low job autonomy in the health professions
when compared to healthcare scenario in Canada, USA,UK and Australia.

Two Internal Root Cause
The two internal issues were- i) ‘low numbers (lowquantity)’ of occupational therapists in Malaysia, andii) ‘low-qualification/low-University level education
provision’ at university-based institution. Both theseroot factors are identified as contributors to the erosionof professional autonomy. Majority of the therapists in
Malaysia are still educated under the old British apprenticeship model of training by the Ministry of health. In
contrast, all developed countries have good progress inaddressing these two issues by improving training at
degree levels, and providing access to University programs in Universities under the Ministry of Education

38

OCCUPATIONAL THERAPY PROFESSION FOR WOMEN HEALTH(versus ministry of Health).

One External Root Cause
Malaysia have an additional strong external rootcause of ‘medical governance’ – which contributes tothe erosion of job autonomy and most decision makings
were made by a hierarchical medical discipline. This external root cause is contributed by a strange policy thatutilizes the dwindling health budget to produce more
rehabilitation doctors (instead of addressing a lack oftherapy workforce for the nation).

Discussion
A contributing external factor is a prevailing medical hegemony phenomenon, unique to the occupational
therapy professions who are predominantly female andare newer discipline to the healthcare scenario in Malaysia [16, 18, 21, 42]. As it’s a phenomenon not common
in developed countries, the leaders came up with a final
theme of “triple whammy” to capture the magnitude of
the root-cause problem and they reflected iteratively
on how it has contributed to stifles the progress in Malaysia. The four educational leaders concurred on theseroot causes, and agreed that they were interrelated, andtogether they posed a strong structural barrier to thetherapists’ autonomy within its rather traditional healthcare governance. These three ‘internal and external root
causes’ are deliberated below.
i) Internal root cause of Low manpower (low number) of
occupational therapists in Malaysia
Malaysia has an exceedingly low 1,395 occupational therapists (for over 32 million population), comparedwith 16,000 occupational therapists in Australia (apopulation of 25 million) and 33,383 occupational therapists in United Kingdom (for 65 million population)[41]. This figure translates to a ratio of one Malaysian
occupational therapist to 17,777 people, compared to
1: 556 for medical practitioners and 1:305 for nurses in
Malaysia [19]. Occupational therapists therefore havea tremendous challenge in being able to provide thenecessary interventions to improve the occupational
participation and quality of life for Malaysians. Withless than 2000 occupational therapists, they are servicing primarily public hospital (see Table 1), and aregrossly under-represented in many services as well as innon-traditional key service areas such as women care,
community health services. This inability to expand
their services will have a detrimental effect on holistic
cost-effective patient outcomes.
Malaysia, despite being classified as upper-middle-

Table 1 
Occupational therapists per practice setting in Malaysia,
2008–2014 (MOH 2016).
No of therapists
in 2008(25 million
population)

No of therapists
in 2014(30 million
population)

Public hospitals
Private settings
Educational settings

387
40
80

76%
8%
16%

1050
250
95

75.2%
17.9%
6.9%

TOTAL

507

100%

1395

100%

No

area

1
2
3

income economy does not compare well to other countries in terms of number of registered occupational therapists [43, 44]. Figure 1 presents an overall diagram of
the census of occupational therapists in the world with
USA leading as the number one country with the highest number of occupational therapists. The Malaysian
health care system highlights doctors and nurses, andoften missed out many of its long neglected healthcare
disciplines (Fig. 2)ii) I nternal root cause of low access to university-based
occupational therapy education in Malaysia
In Malaysia, educational programs for Occupational
Therapy is predominantly under the Ministry of Health,which is still offering the outdated diploma-statusprograms–equivalent to certificate in the USA. Only twohigher education institutions (the National Universityof Malaysia, and the University Technology Mara)
offer bachelor degree programs [16, 44]. A premier
university in Malaysia, The University of Malaya does
not offers discipline-specific program for occupational
therapy, despite having an academician fully qualified
in the field. It offers generic (Master/PhD Medical
science) research-based postgraduate program, but the
intake is greatly limited by the low numbers of potential
applicants with the needed bachelor degree level qualification. Compounding the issue in the country, one of
its University (UiTM) enforced race-based policy that
accepts only Malay ethnic students. Therefore, thenumbers of occupational therapists are grossly undersupplied. Table 1 showed the census of therapists in the
country, and Table 2 showed the ratio of occupational
therapists in relation to the general population.
In short, there is a serious, debilitating lack ofuniversity-level educational programs of international
standing which must be addressed urgently. In contrast,
Japan has 160 schools offering Occupational Therapy
programs. A sample of programs (Table 3) in at least 5other countries showed progress in number of schools(quantity) and ii) availability of postgraduate program(quality). University education is important in the professional education of occupational therapists [45]. The

Asian J Occup Ther 16: 35−43, 2020

S Y Loh et al.

Fig. 1. The number of practicing occupational therapists in the world.
Source: https://www.apeto.com/assets/vision-internacional-de-los-recursos-humanos-to-2016.pdf

Fig. 2. Schematic Overview of the Malaysia Health System; Source: Hussein RH (2016).

39

40

OCCUPATIONAL THERAPY PROFESSION FOR WOMEN HEALTH

Table 2 
Occupational therapists/population - across a sample ofcountries
Country

No of OT
(2016)

Population(2016)

OT per 100,000(2016)

Malaysia
USA
CanadaUnited Kingdom
Australia
Japan
Sweden1,500
113,200
9,827
36,04316,00047,7599,000

30,187,896
322,583,006
35,524,732
63,489,234
25,323,000
126,999,808
9,631,261

5
35
27
56
63
37
93

WFOT 2016
Table 3 
Number of Occupational Therapy programs in selected
WFOT member countries.
Country
CanadaNew ZealandSweden
UK
USA
India
Japan
Malaysia
Australia

Total population 2017

No of OT
programs

Level

36,286,378
4,604,871
9,920,624
65,336,540
326,474,013
1,349,516,523(1.34 billion)
126,323,715
31,025,632
24,641,662

15
2
10
59
160
19

Masters, PhD
Bachelors, PhD
Bachelors, Master, PhD
Bachelors, Master
Master, PhD
Bachelors, Master

140
3
17

Bachelors, Master
Diploma, Bachelors,
Bachelors, Master, PhD

OT = Occupational therapy. Source: WFOT (2016)

World Federation of Occupational therapists or WFOT
provides information about WFOT-approved Occupational Therapy programs from its member countries, tomeet the Occupational Therapy needs for the respective
countries in the world [41].
With a projected growth rate of 27 percent (between
2014 and 2024), occupational therapy is one of the fastest growing career fields in the United States [46, 47]. In
the USA and Canada, a Masters level has now become
the entry level qualification for licensing [48]. Table 4
showed the characteristics of occupational therapists
in a very large hospital in central Kuala Lumpur. There
were 175 health professionals (speech, physio and occupational) and 85 of them are occupational therapists.
Of these 85 mostly female occupational therapists, andmostly diploma holders but only five percent are pursuing postgraduate studies. More than 56 percent of thecurrent therapists surveyed are in service for less than
three years indicating that the profession is still young incomparison with other health disciplines, and has manypotentials to be developed.
As with many countries, the Malaysian occupational therapy population is uniquely female dominated, andresearch should also be initiated if gender issue could
be a contributing root-cause among its prevailing maleTable 4 The background of therapists in University Malaya Medical
Centre (Dec 2016) n = 175.
CharacteristicAll%

Occupational
therapist(n = 85)

FemaleMalay
Work duration at UMMC of 1–3 years
Highest qualification = Diploma
Pursuing post graduate studies

136
158
99
124
34

77.7
90.3
56.6
70.9
13.7

89%
91%
80%
85%
5%

dominated decision makers in Asia. Thus, unlike theirmainly postgraduate-qualified western counterpart countries, almost two third of the small number of therapistsin Malaysia are diploma holders. The training of healthprofessionals under Ministry of Health (an initiative
during the British Colonial rule) should be moved into
Universities. The Malaysian government has been extremely slow to acknowledge and advance the therapy
professions.
iii) External root cause on medical dominance- eroding
the professional autonomy
Occupational therapists, are educated to deliverpatient-centered care, emphasizing evidence-based practice, quality improvement approaches, and informatics[49]. In developed countries, occupational therapy is anautonomous profession [24, 50]. The autonomy of theprofession is characterised by the level of responsibility
the therapists have for the care of their patients, the levelof accountability in the profession (through registration
boards /professional bodies of associations/the public),
having a university level preparation for practice, having
a sound theory base with specialised skills for practice,having control over the quality of their own work, andworking within their own code of ethics [51]. Direct collaborative and interdisciplinary health team shares power
equally and members are empowered to make their own
informed evidence-based decisions in partnership [52].
With better University educated health professionals,
the redundant medical supervision and hegemony can beremoved for cost-effective access to rehabilitation services and for effective outcomes to be achieved [11, 21,42]. There is good evidence that many countries have
proven the cost-effectiveness of occupational therapist
led services, with good outcomes [52–54]. However,
the medical-model governance in Malaysia seems toerode autonomy and hindered progress of these healthdisciplines, and where, healthcare budget are redirected
to produce rehabilitation when the country’s needs fortherapy personnel are long neglected. Such occupational
injustice is seen as a violation on basic occupationalright towards inclusive participation in everyday occu-

S Y Loh et al.

Asian J Occup Ther 16: 35−43, 2020

pations for all persons (profession) in our society [55],whereby the therapists’ rights and responsibilities toindependently plan and advance their services in autonomous manner are violated. Piece (2009) alerts that suchsituation can lead to occupational-deprivation (i.e denied
opportunities and resources to engage in therapy provision), oppression (i.e. disempowered/marginalised by
the oppressive rehabilitation doctors), job dissatisfaction
and demoralisation in the workplace [56]. Consequently,
this affect not only the profession, but their services topatient care and the financial economic health outcomesof the nation.

The ‘triple whammy’ burdenInternationally, the healthcare changes that havecontributed to the rise and advancement of Occupational
Therapy profession are i) the alignment of the Occupational Therapy professional core philosophy with therecommendations of the World Health Organisationsuggesting its important role for health- social care, ii)
an aging population, iii) rising cancer incidences andiv) increased non-communicable chronic diseases, andv) the renewed significance of the value of occupationbased interventions in daily life to improve health andwellbeing of the population. However, this landscapeshift has not exerted much changes to the developmentof occupational therapy in Malaysia. In fact, we acknowledged a serious lack of progress of the professionin Malaysia. The three key root causes, which we categorized as the ‘triple whammy burden’ seems to project
the magnitude of the root-cause problem, that has ‘strangled’ the growth of occupational therapy in Malaysia.
Addressing the two internal root causes individually
may be difficult, if the external root cause (on medical
governance) is not collectively tackled. Stakeholders
including the Ministry of Higher Education, Ministry of
Health, Ministry of women and social welfare and the
local professional body, as well as its associated international body would need to meticulously reorganised
the organisational chart of the rehabilitation medicine
services. The model of rehabilitation medicine in University of Alberta should be used as the goal for management. Implementing and observing changes needed
include providing University degree program for therapy, ensuring the Public service department acknowledge
and give due recognition, rewards and promotion totherapy professionals including professorship at par withwestern counterparts.

Conclusion
Using Malaysia as a case study, a root-cause

41

analyses with four international health educators haveidentified three root-causes related to its professional
autonomy of occupational therapy profession. The magnitude of the root-cause problem with its thematic ‘triple
whammy burden’ label, justify the huge challenges thathinders its growth in Malaysia. The value of occupationbased interventions in daily life to improve health has
been recognized in the social landscape changes that
include rising aging, cancer, non-communicable chronic
diseases, and in specialised area of women health issues.
Occupational therapy services are particularly wellpositioned to address the needs of the person, the activities and occupations which people engage in to fulfil
their roles functionally and independently. The current
medical-model under which occupational therapy works
in Malaysia greatly reduced its role to better serve theneeds of diverse population including women care.
Sole medical doctors and curative care is no longer theanswer to an increasing non-communicable diseases
across the globe, innovative patient self-management in
direct partnership with better trained health professionals to improve their independence in daily activities andfor better quality of life is needed.

Recommendations
A manifesto for improving therapy services as front
liners, to address the rising chronic diseases is needed.
The medical dominance and occupational injustices overtherapy services must be stopped, to make way for
professional growth. An Asian-EU dialogue with more
research to highlight effective therapeutic deliveries intoday’s shrinking healthcare organisation is needed, toaddress the bulk of chronic disease conditions, prevent
illness, and promote wellness. International professionrelated bodies can provide the evidence-based outcome
findings to support practices, clinically and economically.
In terms of education, the model of autonomous
governance of Occupational therapy clinical and educational services (such as in USA, Canada, UK, Australia)
can be used as a guide for Malaysia. The American Council on OT Education, autonomously sets the standards
for the academic curricula and accredited the occupational therapy degree to be conferred to their graduates,
while an independent national examination for certification (i.e. upon graduation from an accredited program)provides the check and balance to safe practice in thefield of occupational therapy. Every state has licensure,and, a final determiner is what the payers will pay fortherapist’s key significant services. Malaysia needs toemulate and incorporate these self-governance model
which has been build-up over the years. More universitybased education for better healthcare deliveries must be

42

OCCUPATIONAL THERAPY PROFESSION FOR WOMEN HEALTH

put in place, starting at its premier university. Occupational therapy as a science-based health discipline, aims
to i) make valuable contribution for reducing disabilities
that affects the health and well-being of people, ii) positively influence health, welfare, education and vocation,and iii) positively influence the development of excellence within the profession, locally and internationally.
Job autonomy must be recognised to enable direct
cost-effective healthcare services in Malaysia.

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■ORIGINAL ARTICLE

A Systematic Review and Meta-Analysis
of Cognitive Functions Predicting Employment
of Individuals with Acquired Brain Injury
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: Background: Only 20% of the hospitals in Japan currently provide work support services for patients withacquired brain injury (ABI). Since the new employment quota system in Japan requires private companies to hire individuals with psychiatric disabilities as of April 2018, the number of employees with ABI is expected to increase. Thissocial background would encourage medical staff to rely more on neuropsychological assessment test scores to understand the cognitive abilities of those patients who need vocational support to transition from hospital to work.
Purpose: The purpose of the study was to clarify the subcategories of the Wechsler Adult Intelligence Scale that would
predict the work ability of individuals with ABI.
Methodology: A systematic review and meta-analysis were conducted to identify specific cognitive functions related towork ability. Four original articles from MEDLINE, CINAHL, ERIC, CiNii, and the ICHUSHI database that met study
inclusion criteria were analyzed.
Results: Results showed that there were four tasks under the verbal test—“vocabulary,” “digit span,” “arithmetic,” and“similarities”—and two tasks under the performance test—“block design” and “coding”—that were predictive variablesof work ability.
Conclusion: Assessing cognitive functions of individuals with ABI, such as “working memory,” “continuous attention,” “abstract thinking,” “vocabulary and expression,” and “time series processing,” could more effectively predict
work ability.
Keywords: acquired brain injury, work support, meta-analysis, neuropsychological assessment tool, cognitive function(Asian J Occup Ther 16: 45−53, 2020)

1. Introduction
There are an estimated 270,000 individuals withacquired brain injury (ABI) in Japan, and there are
70,000 in the labor force population between the ages of
18 and 65 [1]. According to a 2005 study, only 13.2% of
all hospitals in Japan provided work support for individuals with ABI, which increased to 20% in 2015, though
this was limited to certain types of hospitals, such as
recovery phase rehabilitation hospitals [2]. Recently,
Received: 2 March 2019, Accepted: 22 April 2020
Corresponding to: Moritoshi Kitakami, Department of Occupational
Therapy, Niigata University of Health and Welfare, 1398 Shimami-cho,
Kita-ku, Niigata-shi, Niigata, 950-3198, Japane-mail: kitakami@nuhw.ac.jp©2020 Japanese Association of Occupational Therapists

more individuals with ABI have been expected to work
since the new legal employment provision of 2018 wasenacted to include those with psychiatric disabilities in
the legal quota system. This provision requires privatecompanies employing more than 45.5 employees tomeet an employment rate of over 2.2% for individuals
with disabilities. Further, it requires these companies
to include individuals with psychiatric disabilities who
have been diagnosed as part of the disability certification
system—in addition to those with physical disabilities
and intellectual disabilities—in this quota rate [3].
In Japan, part of the role of occupational therapists(OTs) is to act as work supporters who provide transition
services from hospital to work using neuropsychologicalassessment tools, which provide necessary information about individual cognitive functions. The present
authors conducted a meta-analysis of the effectiveness46

A SYSTEMATIC REVIEW AND META-ANALYSIS OF COGNITIVE FUNCTIONS

of neuropsychological assessment tools in providing“work support” transition services from hospital to work
for individuals with ABI [4]. Results showed that theWechsler’s Adult Intelligence Scale (WAIS) “verbal
test” scores of the employment group were significantly
higher than those of the unemployment group. Although some studies showed a significant difference inintellectual functions between employment groups andunemployment groups [5–12], other studies demonstrated no such difference [13, 14]. Many previous studies
used three test scores (“verbal test,” “performance test,”and “full scale test”), but these WAIS scores are often
measured by therapists in a quiet room and not in a real
workplace. Therefore, they are not practically usablewith specific work environments in the vocational rehabilitation process. Furthermore, even though some previous studies used more detailed subtest items [15–18],
no consensus has been reached among them as to which
WAIS subtest items can predict the employability of
individuals with ABI.
Therefore, the purpose of this meta-analysis andsystematic review is to identify useful WAIS subtest
items that can predict employability of individuals with
ABI. In our study, such “useful” items were defined as
the items that contributed to the significant difference in
the WAIS subtest item scores between the employment
and unemployment groups.

2. Materials and methods
2.1 Material selection and eligibility criteria
The eligibility criteria for the targeted studies wereas follows: (1) studies that examine people with brain
injuries, (2) studies that examine an employment andunemployment group using the results from WAIS-R or
WAIS-III subtest items, (3) studies that list the average,
standard deviation, and number of samples for the employment and unemployment group WAIS subtest items,(4) studies that have been published in academic journals, and (5) studies featured in original papers written
in English and Japanese. The papers used in this study
comply with the ethical standards of the Declaration of
Helsinki.

3. Methods
3.1 Data collection
Using MEDLINE (1971), CINAHL (1981), ERIC
(1966), ICHUSHI of the Japan Medical Abstracts
Society (1977), and CiNii Articles (2005), we selected
research articles that examined useful WAIS subtest
items that could predict the employability of individuals with ABI. In addition to the database search, handsearches were conducted to exhaustively collect articles.
Search terms for causal diseases of ABI were: “stroke,”“brain damaged,” “head injury,” “cerebrovascular accident,” “cerebrovascular disease,” “brain injury,” “subarachnoid hemorrhage,” “cerebral infarction,” “cerebral
hemorrhage,” “encephalitis,” “cerebral hypoxia,” “brain
tumor,” “CVA,” and “CVD.” Search terms related towork were: “return to work,” “getting a job,” “employment,” “workplace resettlement,” “social reintegration,”and “vocational rehabilitation.” These searches were
performed on October 19, 2019.
3.2 Measures
The Risk of Bias Assessment Tool for Nonrandomized Studies (RoBANS) was used for qualitative evaluation of the collected research articles. The validity andreliability of the RoBANS has been verified [19]. Basedon the criterion judgment of the RoBANS, the risk ofbias was assessed for the following six domains: (a)selection of participants, (b) confounding variables, (c)measurement of intervention (exposure), (d) blinding ofoutcome assessment, (e) incomplete outcome data, and(f) selective outcome reporting. Research articles were
evaluated using “High◦− ,” “Low◦+ ,” and “Unclear◦? .”More “Lows◦+ ” indicated better article quality.
3.3 Data Integration
Using Review Manager (RevMan) version 5.3.5(Copenhagen: The Nordic Cochrane Centre, The Coch­rane Collaboration, 2014), we tested the means and standard deviations of the predictive WAIS subtest items, aswell as some of the data obtained from the research articles, at a significance level of 5%. Given that continuous
variables were collected for the present article, meanvalues were used as a scale for effect size calculations.
Meta-analysis was conducted with the DerSimonian and
Laird method, a statistical method for integrating thecollected data, to enable the results of the present study
to be utilized for the prediction of employability of othergroups.
The results of the sensitivity and significance testsof all integrated data for the fixed effect model andrandom effect model were produced using Comprehensive Meta-Analysis Version 3 (Biostat Incorporated).
When the results were consistent, we supposed thepresence of sensitivity and those results were includedin the present study. When the results were inconsistent,
we supposed the absence of sensitivity and those results
were excluded from the study. Statistical specificity was
also tested using Review Manager (version 5.3.5), andthe I 2 statistic was calculated. According to the Higgins
et al. study [20], specificity should be high when the I 2
statistic is above 50%, which was the case in the present

Kitakami M et al.

Asian J Occup Ther 16: 45−53, 2020

Result of literature search

Result of literature search（Japanese）（English）（n=1,205）（n=2,571）

47

Duplicate papers（n=610）Papers excluding duplicate papers（n=3,166）
Not applicable to eligibility
criteria（n=3,162）

Applicable to eligibility criteria（n=4）

Papers that corresponded to analysis（n=4）
Fig. 1.

Selection process for the literature search.

study.
3.4 Testing Publication Bias
A symmetric Funnel plot was produced from all
the integrated data, using a 10% level of significance, assuggested by Egger’s test [21].

4. Results
4.1 Collecting and selecting the studies
From the literature database, 3,776 articles wereextracted. There were 1,677 MEDLINE, 808 CINAHL,
86 ERIC, 718 CiNii, and 487 ICHUSHI articles. However, 3,162 studies did not meet the inclusion criteria,
and 610 were duplicates. No studies were obtained
through a hand search and only four studies met theinclusion criteria set by the present study (Fig. 1).
4.2 Characteristics of the selected studies
Selected studies included three case-controlled
studies (75%) and one prospective cohort study (25%).
Table 1 shows that most of the cases included brain
injury or stroke. All of the selected studies showed thatthe criterion judgment of the RoBANS was evaluated as“Low◦+ ” in (a) selection of participants, (b) confound-ing variables, and (c) measurement of intervention(exposure), “Unclear◦? ” in (d) blinding of outcome
assessment, and (e) incomplete outcome data (withthe exception of one study, which was evaluated as“Low◦+ ”), and Low◦
+ ” in (f) selective outcome reporting. The time elapsed since the occurrence of brain
injury was 12.5 to 51.7 months, and the employment
rate of individuals with brain injury was 34.5 to 52.6%(Table 1).
4.3 Efficiency of the WAIS subtest items
4.3.1 Verbal test
As a result of data integration from the fourstudies, there was a significant difference between theemployment and unemployment groups’ test scores in“vocabulary” (mean difference of 0.97; 95% CI [0.16,
1.78], p = 0.02); no statistical heterogeneity was found ( p= 0.64, I 2 = 0%; Fig. 2). Further, integration of the data
resulted in a significant difference in “similarities” (meandifference of 1.42; 95% CI [0.56, 2.28], p = 0.001).
Again, no statistical heterogeneity was found ( p = 0.56,
I 2 = 0%; Fig. 2). There was also a significant difference
in “arithmetic” (mean difference of 1.16; 95% CI [0.42,
1.91], p = 0.002); no statistical heterogeneity was found( p = 0.78, I 2 = 0%; Fig. 2). Additionally, significant

2010

17)

Japan

Japan

Japan

Japan

Country

28.1 (10.7)

36.0 (11.3)

40.9 (14.3)

32.1 (10.7)

Traumatic head injury 26,
Cerebral vascular disease 6,
Hypoxia encephalopathy 3,
Brain tumor 3
Traumatic head injury 70,
Stroke 37,
Hypoxia encephalopathy 3,
Encephalitis & Meningitis 3
Traumatic head injury 18,
Cerebral vascular disease 9,
Brain tumor 1,
Hypoxia encephalopathy 1

Case-control
study

Case-control
study

Prospective
cohort study

Average age(SD)Traumatic head injury 60

Disease and quantity of data

Case-control
study

Research
design

20/9

91/22

29/9

56/4

Male/
Female41.7 (57.1) months

50.6 (72.4) months

WMS-R, WAIS-III,
WCST, BADS

WAIS-R, RBMT,
TMT

WAIS-R, WMS-R,
RBMT, TMT,
Kanahiroi test,
CAT, BADS

WAIS-R

employment group:
12.5 (27.3) months
unemployment group:
25.4 (39.7) months
employment group:
51.7 (83.2) months
unemployment group:
18.0 (19.4) months

Neuropsychologicalexamination used

Elapsed period after
brain injury
(SD)

10/19

40/73

20/18

26/34

Employed/
Unemployed

SD: standard deviation
WAIS-R (III): Wechsler Adult Intelligence Scale-Revised (III), WMS-R: Wechsler Memory Scale-Revised, RBMT: The Rivermead Behavioral Memory Test, TMT: Trail Making Test,
CAT: Clinical Assessment of Attention, BADS: Behavioral Assessment of the Dysexecutive Syndrome, WCST: Wisconsin Card Sorting Test

Akamine et al.18)

Sawada et al.

2015

2008

Youine et al.16)

Tomita et al.

1999

Year

15)

AuthorTable 1 Research papers that corresponded to the analysis

34.5

35.4

52.6

43.3

Employment
rates
(%)

48
A SYSTEMATIC REVIEW AND META-ANALYSIS OF COGNITIVE FUNCTIONSAsian J Occup Ther 16: 45−53, 2020

Kitakami M et al.

49

Figure Fig.
2. Results
themeta-analysis
meta-analysisof the employment
and unemploymentgroupsusing
WAIS“verbal
2. Resultsofof theof the employment
and unemploymentgroups using the WAIS
“verbaltest”thesubtestitems.
test” subtest items.

difference was found in “digit span” (mean difference of
0.95; 95% CI [0.25, 1.65], p = 0.008), and no statistical
hetero­geneity was found ( p = 0.89, I 2 = 0%; Fig. 2).
There was no significant difference in “information”(mean difference of 0.67; 95% CI [−0.14, 1.47], p =0.11); no statistical heterogeneity was found ( p = 0.12,
I 2 = 49%; Fig. 2). Finally, there was no significant difference in “comprehension” (mean difference of 0.51;
95% CI [−0.61, 1.63], p = 0.37), and no statistical
hetero­geneity was found ( p = 0.17, I 2 = 41%; Fig. 2).

50

A SYSTEMATIC REVIEW AND META-ANALYSIS OF COGNITIVE FUNCTIONS

4.3.2 Performance Test
Data integration from the four studies resulted ina significant difference between the employment andunemployment groups’ test scores in “picture completion” (mean difference of 1.05; 95% CI [−0.26, 2.36],
p = 0.12), and statistical heterogeneity was found ( p =0.06, I 2 = 59%; Fig. 3). There was also a significant
difference in “coding” (mean difference of 1.37; 95% CI[0.63, 2.11], p = 0.0003), but no statistical heterogeneity
was found ( p = 0.71, I 2 = 0%; Fig. 3). A significant
difference was found in “block design” (mean differenceof 1.91; 95% CI [0.99, 2.83], p < 0.0001); no statistical
heterogeneity was found ( p = 0.64, I 2 = 0%; Fig. 3). In
addition, there was no significant difference in “picturearrangement” (mean difference of 1.11; 95% CI [−0.76,
2.98], p = 0.25); statistical heterogeneity was found( p = 0.002, I 2 = 80%; Fig. 3). There was no significant
difference in “object assembly” (mean difference of
0.61; 95% CI [−0.31, 1.53], p = 0.20), and no statistical
heterogeneity was found ( p = 0.43, I 2 = 0%; Fig. 3).
Finally, no significant publication bias was found acrossall tests.

5. Discussion
The useful WAIS subtest items that could predict
employability of individuals with ABI included fourtasks under the verbal test (“vocabulary,” “digit span,”“arithmetic,” and “similarities”) and two tasks under the
performance test (“block design” and “coding”).
The “vocabulary” and “digit span” tests require one
to have abilities such as working memory or continuous
attention [22]; however, jobs that require employees
to have considerable working memory assets can posedifficulties for ABI people in the workplace [23]. Recent
studies clarified that the working memory of individuals
with ABI could predict job retention two years after
disability occurrence [24]. Other studies showed that
50% of ABI functional limitations are related to attention deficit, and that even typing becomes a vocational
limitation in the workplace [23]. Furthermore, attention
deficit has repeatedly been shown as one of the negative
factors affecting employment of individuals with ABI[12, 17].
The “similarities” subtest requires abstract thinking
through identification of commonalities among multiple
sources of information [24]. The “block design” subtest
in the perceptual reasoning index also requires abstract
thinking. Sawada et al. [17] suggest that a certain
decrease in abstract thinking abilities would make it difficult for an individual to cope with unknown tasks. One
study shows that 73.1% of workers with ABI reported
their difficulties in the workplace through the following

statement: “when I face some new problems, I tend to
get confused and have no idea how to cope with them”[23]. We can learn from this study that abstract thinking
abilities in the workplace may significantly impact job
retention. Moreover, “vocabulary” ability has been
repeatedly identified as an important workplace asset
where tasks such as paperwork and communication withcoworkers using appropriate expressions are required toperform the job properly [14].
The “coding” subtest in the perceptual reasoning
index requires one to cope with sequential tasks correctly and in a timely manner [24]. One study shows that
53.4% of workers with ABI reported that they might receive attention due to their impairments and supervisors
might indicate that “their work is rather slow” [23]. Thisimplies that sequential and systematic coping abilities
are some of the key assets for retaining one’s job. “Blockdesign,” as mentioned earlier in terms of abstract thinking, requires one to have a capacity for trial-and-error
when new problem-solving skills are needed to perform
challenging tasks [24]. It has also been shown that
53.4% of workers with ABI reported that “it was hard tochange the working behavior accordingly when such asudden change in my thinking and my flexible behavior
is expected” [23]. For workers with ABI, limitations intheir capacity for trial-and-error thinking and behavior
change might negatively affect their ability to keep theirjobs.
Given these cognitive requirements, test items suchas “vocabulary,” “digit span,” “arithmetic,” “similarities,” “block design,” and “coding” may be related to
key cognitive functions necessary for the employabilityof individuals with ABI. It is suggested that occupational therapists use these findings to more effectively andefficiently assess and train their patients with ABI.
The employment rate of individuals with brain
injuries was 40.7% one year after injury occurrence,and 40.8% two years after injury occurrence; as such,the time elapsed after brain injury was found to have noeffect on employment rate [25]. On the other hand, it
has been reported that the unemployment rate increases
when the support period extends long after brain injury
occurrence [26]. The employment rates in the fourstudies examined in this paper were similar to those ofprevious studies, and the employment rates didn’t tend
to change in the period after brain injury.
Given that the present study analyzes only Japanese
papers, its generalizability is limited. Further researchis needed to accumulate the results of WAIS subtest
items from various countries, and to analyze these withrespect to differences in social policy, welfare systems,
work support programs, racial heterogeneity, test-taking
culture, and other confounding factors between coun-

Asian J Occup Ther 16: 45−53, 2020

Kitakami M et al.

51

Fig. 3.
of theofmeta-analysisof the employment
unemploymentgroupsandusingunemployment
the WAIS “performancetest”using
subtest items.
Figure3. Results
Results
the meta-analysis
ofandtheemploymentgroupsthe WAIS“performance test” subtest items.

tries. Such differences may affect the employability of
ABI patients, their performance on neuropsychologicaltests, and the strategies and resources they utilize to
procure and retain employment. We have endeavored to
begin this process with a Japanese sample, and hope that
others will follow in due course. One possible reason
for why we could not find English articles on the WAIS
subtest items is that some Western academics have been
critical about using neuropsychological test results topredict employability [27]. Rather than excluding neuro­
psychological test results from these considerations, it isnecessary to study these in tandem with the perspectivesof family members, employers, and employees.
The present study is also limited because it included
the results of only four studies in its analysis. However,identifying the useful WAIS subtest items related to
specific cognitive functions that predict employabilityof individuals with ABI has practical implications for
medical and vocational rehabilitation processes. Further
studies are encouraged to use these neuropsychologicalsubtests for daily assessment and intervention whenplanning and developing evidence-based vocational

52

A SYSTEMATIC REVIEW AND META-ANALYSIS OF COGNITIVE FUNCTIONS

rehabilitation programs for individuals with ABI.

6. Summary and Conclusions
A systematic review and meta-analysis wereconducted to identify specific cognitive functions, asmeasured by the WAIS subtest items, that would predict
work ability of individuals with ABI. As a result, wefound that the cognitive functions of “working memory,”“continuous attention,” “abstract thinking,” “vocabulary
and expression,” and “time series processing” were relevant for predicting employability.
In previous studies, there was no consensus on therelationship between WAIS scores and employment.
Based on the results of this study, we think that the“vocabulary,” “digit span,” “arithmetic,” “similarities,”“block design,” and “coding” subtests, which test thecognitive functions specified above, are useful WAIS
subtests for predicting employability. These findings
can be used effectively in vocational rehabilitation to
design efficient and effective work support services forindividuals with ABI. Further studies are encouraged to
explore the relationship between these neuropsychological subtests and employability for other populations, andto examine its potential applications in rehabilitation
settings.

Conflicts of Interest
The authors declare no potential conflicts of interest
with respect to the research, authorship, and/or publication of this article.

Acknowledgements
We would like to thank all the authors of theprevious publications that were used in our systematic
review.

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■ORIGINAL ARTICLE

Usefulness of the Dual-Task Stepping Test
to Determine the Independent Toileting Abilityof Patients with Stroke Who Could Perform Steppingin a Seated Position
Takayuki Watabe1, 2, Hisayoshi Suzuki2, Jun Nagashima1, 2,
Shuichi Sasaki3, Nobuyuki Kawate4
1

Showa University Fujigaoka Rehabilitation Hospital
Showa University, School of Nursing and Rehabilitation Sciences
3
Kitasato University Hospital
4
Showa University School of Medicine
2

Abstract: Introduction: This study aimed to identify the usefulness of the dual-task stepping test to determine theindependent toileting ability of patients with stroke.
Method: Sixty-seven stroke in-patients who were able to perform stepping in a seated position were enrolled in the
study and underwent the dual-task stepping test. The relationships of the test results with other assessments (Berg
Balance Scale, Mini-Mental State Examination, and the Attentional Rating Scale) with toileting ability, and with factors
affecting toileting ability were investigated by regression analysis.
Results: Patients with low dual-task performance tended to have poorer balance, attentional, and cognitive abilities.
The results of the dual-task stepping test and rates of independent toileting were distributed as follows: severe dual-task
disability, 15.6% (5/32), mild dual-task disability, 64.7% (11/17); and normal dual-task ability, 94.4% (17/18). The dualtask stepping test results revealed a significant relationship between dual-task disability and toileting ability ( p < 0.01).
Logistic regression analysis showed that the dual-task stepping test had the highest odds ratio for toileting ability ( p =0.00; odds ratio, 14.50).
Conclusion: The dual-task stepping test was useful for determining independent toileting ability. This assessment is
rapid and does not require special equipment or infrastructure, and has the potential for wide application in clinicalpractice.
Keywords: stroke, toileting, dual-task, assessment, rehabilitation(Asian J Occup Ther 16: 55−62, 2020)

Introduction
Independent toileting is an important activity ofdaily living (ADL) [1, 2]. For in-patients with stroke,
independent toileting ability is essential for independent
living because it is an activity that normally requiresa standing position, and therefore, has a high risk for
Received: 21 April 2019, Accepted: 29 April 2020
Corresponding to: Takayuki Watabe, Showa University Fujigaoka Rehabilitation Hospital, Rehabilitation Center, 2-1-1 Fujigaoka Aoba-ku
Yokohama-shi, Kanagawa 227-8518, Japane-mail: taka1021@cmed.showa-u.ac.jp©2020 Japanese Association of Occupational Therapists

falls [3]. However, it is difficult to determine independence in this area owing to the number of components
involved in toileting, such as motor function required totransfer between a toilet and a wheelchair, lower body
dressing while standing, cognitive function required tocontrol urination and defecation, and attention required
to perform some of these functions simultaneously.
The association between toileting ability and several
rehabilitation evaluations have been reported, including
the evaluation of motor function, Berg balance scale(BBS) [4], the Stroke Impairment Assessment (SIAS)[5], and the Functional Assessment for Control of the
Trunk (FACT) [6]. Evaluations of cognitive function,such as the Mini-Mental State Examination (MMSE) [6],56

DUAL-TASK STEPPING TEST AND STROKE

hemispatial neglect [7], and aphasia [8] have also been
included. The BBS score is a significant predictor for
the independent performance of most activities of toileting [4]. BBS cannot be considered a strong predictor for
toileting ability, because it does not relate to the ability
to control urination and defecation, which is an essential
component of toileting. By clinical experience, even apatient with good physical balance does not always have
independent toileting ability. Therefore, to evaluate independence in toileting, it is important to assess motor,
cognitive, and attention functions simultaneously.
In recent years, dual-tasking (performing a motorand cognitive task simultaneously) has attracted attention as an indicator of performance ability. Patients withstroke have decreased dual-task ability compared withthat of healthy elderly [9, 10] Also, independent walking
and falls among patients with stroke are associated withchanges in motor performance when a cognitive task
is added, such as counting backward while walking
or performing repetitive utterance tasks while sitting
unsupported [11–18]. Therefore, it is important to assess
motor performance ability during dual-task conditions.
Although there are reports regarding dual-task ability
and ADL [19–21], we are unaware of any reports thathave investigated the role of dual-task assessment methods in determining the independent toileting ability ofpatients with stroke.
We previously investigated 55 patients with stroke
and identified a relationship between toileting ability
and the results of a dual-task assessment involving a
cognitive task that was performed while the subject
stepped in place in a seated position [22]. During thistest, we observed the participants’ ability to perform thetask in the seating position with a comfortable speed for
30 seconds. The evaluation was performed by using asimple calculation wherein the associations among variables were statistically evaluated. The results showedthat while motor performance was poorer during thedual-task compared with during a single task, there wasno change in cognitive performance. We found that independent evaluation of toileting ability using dual-task
was possible with 93.8% probability and when using
BBS probability was 74.2%. In our previous study, theassessment required a personal computer monitor andother equipment. Furthermore, it was challenging to findan assessment method that could be easily performedin clinical practice. Accordingly, there is a need for aneasy-to-administer assessment in clinical conditions.
Therefore, this study aimed to identify the usefulness ofthe dual-task stepping test to determine the independent
toileting ability of patients with stroke who can perform
stepping in a seated position.

Table 1 Subject characteristics (n = 67).
Age (years)
Sex
Diagnosis

Disability

Leg BRSTime since onset (days)
Means of mobility
Toileting ability
Attentional rating Scale(points)
BBS (points)
MMSE (points)
FIM, total of motor
items (points)*
FIM, total of cognitive
items (points)*−
M/F
Cerebral infarction
Intracranial hemorrhage
Subarachnoid hemorrhage
Right hemiplegia
Left hemiplegia
No paralysis
III
IV
V
VI
−
Ambulatory/wheelchair
Independent/assisted

67.5 ± 13.5
38/29
42
16
9
23
27
17
2
5
23
20
57.9 ± 43.0
31/36
33/34

−

15.0 ± 16.4−−

36.1 ± 16.0
23.3 ± 8.3
67(46.0–80.5)
29(24.5–33.5)−−* Median (interquartile range).
BBS, Berg balance scale; BRS, Brunnstrom’s recovery stage;F, female; FIM, Functional Independence Measure; M, male;
MMSE, Mini Mental State Examination.

Subjects and Methods
Subjects
All patients were recruited from the 128 patientswith stroke admitted to our hospital between January
and December 2017. Exclusion criteria were as follows:patients were excluded if they were within 2 weeks
of onset or when the onset of stroke was more than 6months prior, history of brain injury, no ADL independence prior to onset, inability to follow simple verbal
instructions, presence of pain that would affect theassessment, and instructions from the attending physician to restrict sitting up. Following exclusions, a totalof 90 patients were enrolled. Among them, only thoseparticipants who could successfully step in place for
30 seconds while seated in a 40-cm-high chair were included in the study. Sixty-seven patients who were able
to complete this task became the study subjects. The
study subjects’ characteristics are shown in Table 1. All
participants provided informed consent. This study wasapproved by the Ethics Committee of Showa University
School of Health Sciences (approval number: 366). The
study was conducted in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later
amendments or comparable ethical standards.

Asian J Occup Ther 16: 55−62, 2020

Methods
Developing the Dual-Task Stepping Test
We developed, in the following order, the motor
tasks, cognitive tasks, and the dual-task. The motor
task included a common denominator for toileting that
required the involvement of autokinetic movements of
the lower limbs, including maintenance of balance, andcould be performed in a seated position. These requirements would ensure testing of a wide range of subjects,
including wheelchair users. Further, the task required aseries of repeated motions to enable performance assessment, and performance assessment had to be simple andrequire minimal equipment. Consequently, the task thatwas selected was stepping in place for 30 seconds while
seated in a 40-cm-high chair. This task was performed
at a comfortable and constant pace and allowed forsynkinesis. Stepping was also used as a motor task in aprevious study [22] and had obtained highly valid results
for an independent evaluation of toileting. To select thecognitive task, we aimed to create a task that included
the following requirements: 1) requires a certain degreeof effort, even by those who have maintained cognitive
function, 2) allows for multiple repetitions of tasks
with an identical level of difficulty to create a minimum
learning effect, and 3) has reassessment reliability toprovide an estimate of the patient’s independent toileting
ability during hospitalization. Consequently, the task weselected was to have the subjects recall the componentsof the lunch they ate on the assessment day (or breakfast, if the assessment was performed before noon).
For subjects who did not take their food orally, the task
was to list the types of medications they were currently
taking. The usefulness and validity of these cognitive
tasks have been confirmed in a previous study [23].
The subject’s toileting ability assessment consists ofdual-task: the motor task (stepping in place) and an cognitive task (to answer the lunch menu).
Data-gathering procedures
The subjects’ dual-task ability was assessed by
the performance of the motor task under the dual-task
conditions based on results that have been established inprevious studies [22, 24]. The examiner assessed threesigns: (1) stepping stopped for 1.0 second or longer
midway through the task; (2) stepping did not stop, but
the feet were not more than half of the foot lifts before
subjects answered the question; and (3) irregular pace.
Sign 1 was indicative of severe dual-task disability, andsigns 2 and 3 indicated mild dual-task disability. An absence of these signs indicated normal dual-task ability.
The assessment procedure started with the subject seatedin a 40-cm-high chair in a quiet private room. Assessors

Watabe T et al.

57

were provided with a predetermined assessment form
for the dual-task stepping test (Fig. 1). Assessors carefully read the assessment procedures to the subject who
was seated in the assessment chair and then carried out
the evaluation. A single time assessment was performed
for each patient. Assessors did not know the toileting
ability of the subject.
Methods of Analysis
1. Comparisons of the groups classified according to theresults of the dual-task stepping test and each assessment
Data collected at the time of the evaluation included baseline data regarding age, sex, diagnosis, strokeaffected side, Brunnstrom’s recovery stage for the legs,
time since the onset of stroke in days, means of mobility,
toileting ability, and the total score of motor-related andcognitive-related items of the Functional Independence
Measure (FIM), that were available from the subjects’
medical records. The toileting ability for individual
patients was determined using three procedures: (1)ability assessment in the toileting training scene by atherapist, (2) nurse assessment of the performance of
toileting within ward life, and (3) attending physician’s
independent judgment of toileting ability following daily
morning conferences. These procedures were identicalfor all subjects. Assessment methods used as part of data
gathering included dual-task stepping test and BBS [25],
MMSE [26], and attentional rating scale (ARS) [27],which are generally used in our clinic. The data from
BBS, MMSE, and ARS were extracted from the hospitalrecords of each research participant, classifying research subjects according to the dual-task stepping test.
Comparisons of the groups classified (severe dual-task
disability, mild dual-task disability, normal dual-task
ability) basic information, and the different assessments
were compared statistically.
Fisher’s exact test was used to compare the threedual-task stepping test groups (severe dual-task disability, mild dual-task disability, normal dual-task ability)and each assessment to examine concurrent validity. The
findings were with regards to the dual-task stepping test
groups and sex, diagnosis, side affected by stroke, andmeans of mobility. The Steel-Dwass test was used forcomparisons between the dual-task stepping test groups
and age, Attentional Rating Scale, BBS, and MMSE.
2. 
Relationship between the seated position dual-task
stepping test and toileting ability
The standard for independent toileting was a score≥ 6 on the FIM. Findings from the dual-task stepping
test and the rates of independent toileting were statistically compared. The accuracy of the determination of

58

DUAL-TASK STEPPING TEST AND STROKE

Fig. 1.

Dual-task stepping test assessment form and instructions.

independent toileting was assessed using the dual-task
stepping test classification (severe dual-task disability,
mild dual-task disability, normal dual-task ability). Furthermore, the groups classified by the BBS (score ≤ 35,
severe balance disability; 36–45, mild balance ability;and ≥ 46, normal balance) [28] and the rates of independent toileting were statistically compared.
Logistic regression analysis was performed using
independent toileting ability or inability as the dependent variable. The independent variables were normal/
low dual-task stepping test results (sign 1 not observed/
observed), normal/low BBS score (cut-off, 46 points)[25], normal/low MMSE score (cut-off, 24 points) [26],young/old age (relative to 70 years), and normal/low
Attentional Rating Scale score (cut-off, 0 points) [27].
Fisher’s exact test was used for comparing the relationships between dual-task stepping test groups or BBS
and toileting ability. Logistic regression analysis was
performed to identify factors determining independent

toileting ability. The software used for this analysis was
JMP Pro version 13, with statistical significance set toless than 5%.

Results
Comparisons of the Groups Classified According to
the Results of the Dual-Task Stepping Test and Each
Assessment
All 67 subjects willingly completed the cognitiveand dual-task stepping tests. The classification of thegroups according to the dual-task stepping test was asfollows: 32 subjects had a severe dual-task disability,
17 had a mild dual-task disability, and 18 had a normal
dual-task ability. There were no significant differences
between the groups for sex, diagnosis, and side affectedby stroke. There were significant differences between
the groups regarding their means of mobility ( p < 0.01).
There was a significant correlation between the groups

Watabe T et al.

Asian J Occup Ther 16: 55−62, 2020

59

Table 2 Comparison of classifications according to the dual-task stepping test and each assessment.
Severe dual-task
disability(n = 32)

Mild dual-task
disability(n = 17)

Normal dual-task
ability(n = 18)

Test statistic

p-value

Sex

Male
Female

14
18

12
5

12
6

−

0.14*

Diagnosis

Cerebral infarction
Intracranial hemorrhage
Subarachnoid hemorrhage

18
8
6

12
4
1

12
4
2

−

0.81*

Side affected by stroke

Right hemiplegia
Left hemiplegia
No paralysis

8
17
7

7
4
6

8
6
4

−

0.27*

Means of mobility

Wheelchair
Ambulatory

24
8

9
8

3
15

−

< 0.01*61.0 ± 12.5

S-N: 2.52
S-M: 1.38
M-N: −1.17

0.03†
0.34†
0.46†

2.4 ± 4.4

S-N: 5.71
S-M: 4.74
M-N: −1.97< 0.01†< 0.01†0.11†< 0.01†< 0.01†0.32†< 0.01†
0.01†
0.14†

Age (years)
Attentional rating Scale(points)−−

71.8 ± 12.5

26.6 ± 16.4

66.0 ± 13.9

7.3 ± 9.8

BBS (points)−

32.0 ± 18.1

42.7 ± 9.5

46.8 ± 8.8

S-N: −4.04
S-M: −3.24
M-N: 1.42

MMSE (points)−

18.9 ± 9.5

25.9 ± 4.9

28.5 ± 2.1

S-N: −4.51
S-M: −2.90
M-N: 1.86* Fisher’s exact test.
† Steel-dwass test. BBS, Berg balance scale; MMSE, Mini Mental State Examination; S, Severe dual-task disability; M, Mild dual-task disability;
N, Normal dual-task ability

regarding age; older patients demonstrated poorer dualtask performance compared to younger patients ( p =0.03). There were significant differences between groups
regarding their BBS, MMSE, and the Attentional Rating
Scale scores ( p < 0.01). In conclusion, participants withpoorer dual-task assessment scores tended to have poor
motor, attentional, and cognitive functions and were ofhigher age (Table 2).
Relationship Between the Dual-Task Stepping Test andToileting Ability
The rates of independent toileting for the threegroups were as follows: severe dual-task disability,
15.6% (5/32); mild dual-task disability, 64.7% (11/17);
and normal dual-task ability, 94.4% (17/18). This relationship between the groups and toileting ability wasstatistically significant ( p < 0.01). The rates of independent toileting for the groups classified by the BBS wereas follows: severe balance disability, 24.1% (7/29); mild
balance disability, 40.0% (6/15); and normal balance,
87.0% (20/23) ( p < 0.01). The dual-task stepping testclassification was more accurate than that of the BBS,
and the rate of independent toileting in the group iden-tified as having normal dual-task ability was very high(94.4%).
Analysis of Toileting Ability Using Logistic Regression
The results of the logistic regression analysis withindependent toileting ability or inability as the dependent variable revealed that the dual-task stepping test
( p < 0.01), BBS ( p = 0.01), and MMSE ( p = 0.03) weresignificant indicators of toileting ability (Table 3). The
odds ratio was 14.50 for the dual-task stepping test,
9.69 for BBS, and 9.25 for the MMSE, indicating thatthe dual-task stepping test was the strongest indicator of
toileting ability.

Discussion
Dual-task ability is assessed by the performanceof a motor task under dual-task conditions. Woollacott
et al. [24] reported that elderly persons tended to givepriority to a cognitive problem under dual-task conditions, with the result that their motor performance wasdiminished by the secondary task. In our previous study
involving the dual-task evaluation of in-patients with

60

DUAL-TASK STEPPING TEST AND STROKE

Table 3 
Logistic regression analysis with toileting ability as a dependent variable

Age
Dual-task stepping test
BBS
MMSE
Attentional Rating Scale

Likelihood ratio(chi-square)

Odds ratio

p-value

0.57
11.61
7.28
5.57
0.40

1.94
14.50
9.69
9.25
1.84

0.45
< 0.01
0.01
0.03
0.53

BBS, Berg balance scale; MMSE, Mini Mental State Examination

stroke, although there was a drop in motor performance
under dual-task conditions, there was no change identified in cognitive performance [22]. In attempting to classify patients, we assumed that sign 1 (stopped stepping)
represented a clear decrease in dual-task ability because
the cognitive task of remembering the last meal caused
a temporary but total loss of attention to the stepping
activity, while sign 2 (feet were not more than half ofthe foot lifts before subjects answered the question) andsign 3 (irregularly pace) represented a milder decreasein dual-task ability because signs 2 and 3 indicated their
reduced attention paid to stepping. Patients who did nothave any of these signs had the normal dual-task ability
because they were able to distribute their attention toboth tasks adequately. This assessment involved simultaneous motor and cognitive tasks, and participants’dual-task ability was assessed based on their motor
performance. Because the elements of motor, cognitive, and attentional functions were involved from the
beginning of the test, we predicted that all the tested
functions would be reflected in the results. Following
the classification of our subjects based on the results ofthe dual-task ability test, we found that the groups weresignificantly different for BBS, MMSE, and Attentional
Rating Scale scores. This confirmed that our assessment
could accurately test for motor, cognitive, and attentional functions, and provided criterion-related validity that
our test was actually a dual-task assessment. Further,
we also found significant differences in the mean ages
between the groups. Our findings that aging reduces
dual-task ability are consistent with previously published research [29–31].
In this study, we were able to assess dual-task thatappealed to using physical and cognitive functions usedsimultaneously, which differs in the quality of movement when compared to walking or standing (commonlyused motor tasks). There were three possible reasons forthis. First, many of the study subjects required assistancewith ADL and had a total score of 67.0 points for FIM
motor items; therefore, they experienced a high degreeof difficulty with movement even while seated andrequired an increased amount of attention to perform
motor tasks. Second, we used a relatively difficult cognitive task of recalling the contents of the last meal, which
may have created a high level of interference. Third,
there are differences in the way the brain works when
walking and when stepping in a seated position. Apartfrom the initiation of walking and changing directions,
walking is performed subconsciously by central patterngenerators of the spinal cord [32]. This involves minimal activation of the prefrontal area, where conscious
decisions are made that require an additional amount ofattention [33]. On the other hand, stepping while seatedinvolves a high level of conscious activity during thelifting of the feet. Therefore, interference from the recall
task, which requires activation of the prefrontal area, isexpected to affect performance. For these reasons, thedual-task ability can be assessed even when an activity
is performed in a seated position, supporting the relevance and applicability of the dual-task stepping test
among patients with stroke who have physical impairments, including wheelchair users.
The results of this study demonstrated a relationship between dual-task assessment and toileting ability.
Assessments related to toileting ability that included
other evaluations, such as the BBS, have also been noted[4–8]. However, unlike our study, other studies have notreported a relationship between dual-task assessments.
Dynamic standing is associated with an increase inbody sway, activates the prefrontal area, and requires
conscious postural control [34]. In this study, patientswith stroke who had some physical disability needed acertain level of attention to maintain dynamic standing
while their clothes were pulled down. To perform thisfunction, they must also focus their conscious attention
on other events, such as pulling their clothes down with
one hand. Additionally, greater cognitive and attentionfunctions are required to control urination and defecation. This may be why toileting ability was determinedwith higher accuracy by the dual-task assessment that
included elements of motor, cognitive, and attentional
functions, unlike the BBS, which is an assessment ofmotor function. Only this test was developed with thegoal of reflecting the ability to simultaneously focus
attention on two events while assessing motor, cognitive, and attentional functions; therefore, the extent ofthese disabilities was not controlled when the subjects
were being selected. It is therefore difficult to determine
whether the cause of low scores for the dual-task assessment was increased attention given to the action due tomotor function impairment, increased attention given to
the recall task due to decreased cognitive function, or
impairment of the ability to properly divide one’s attention between two tasks. In all cases of disability, motor,

Watabe T et al.

Asian J Occup Ther 16: 55−62, 2020

cognitive, and attentional functions need to be assessedin greater detail to investigate its underlying cause.
Toileting for persons who had a stroke can involvea high risk of falling. Generally, elaborate observations
are necessary to judge independence in toileting. However, an evaluation can be easily divided into sections
by observers. This assessment is significant for clinicalpractice because it can be used to evaluate toileting
ability, and will be helpful when considering whether
the independence level based on the dual-task ability isnormal. In Japan, the level of toileting independence ofan in-patient with stroke is often decided during a teamconference. When team members insist that a patientwith poor balance has toileting independence, they can
use the results of this evaluation as objective evidence tosupport their judgment.
This study had some limitations. Interpretations of
the results were limited to the subjects of the present
study, and it was a single-center study; therefore, it lack­ed external validity. Additionally, the sample size wasrather small. Only one measurement was performed, andthe reassessment reliability was not studied. Additionally, the movements were not observed in the real toilet
setting; therefore, whether patients were able to perform
toileting activities is not known. Finally, it was difficult
to obtain normative values for dual-task assessments.

Conclusion
Toileting ability of patients with stroke can beevaluated using a dual-task assessment. Our dual-task
stepping test was useful for determining independent
toileting ability. This study found that toileting ability
was affected more than balance, attention, or cognitive
functions by the dual-task stepping test, which has widespread use in clinical practice.

Conflicts of interest
Funding: This research did not receive any specific
grant from funding agencies in the public, commercial,or not-for-profit sectors.

Acknowledgments
We are sincerely grateful to everyone at the Occupational Therapy Department at Showa University Fuji­ga­oka Rehabilitation Hospital who significantly helpedwith the implementation of this study.

61

Abbreviations
ADL, Activities of Daily Living
BBS, Berg Balance Scale
CPG, Central Pattern Generator
FACT, Functional Assessment for Control of Trunk
FIM, Functional Independence Measure
MMSE, Mini Mental State Examination
SIAS, Stroke Impairment Assessment

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■ORIGINAL ARTICLE

Out-of-home Activity Accessibility Checklist
for Parents of Children with Gross Motor Dysfunction
Asuka Kenmochi1, Chieko Karashima2
1
2

Aoi-tori Plus (Child development support centre), Aoi Gakuen School Corporation, Japan
Department of Physical and Occupational Therapy, Graduate School of Medicine, Nagoya University, Japan

Abstract: Background: Parents of children with gross motor dysfunction often face obstacles when performing out-ofhome activities with their children. However, little is known concerning their situation.
Objective: This study aimed to develop an out-of-home activity accessibility checklist for parents of children withgross motor dysfunction that clarifies their situation during these activities.
Method: Parents of children with gross motor dysfunction participated in semi-structured interviews to generate atentative accessibility checklist. Then, Delphi questionnaire survey was conducted to determine appropriate checklist
items.
Result: Fifteen participants involved in the semi-structured interview and 124 tentative checklist items were generated.
Then, 56 participants involved in Delphi questionnaire survey and tentative checklist items was reduced to 39. Thesechecklist items were grouped under the domains of obstacles, coping strategies, and required assistance and resources.
Most obstacles were caused by the lack of equipped infrastructures.
Discussion: Most obstacles faced by parents of children with gross motor dysfunction were caused by the lack of infrastructures that were barrier-free. The parents had to collect extensive information prior to outings as coping strategies.
Therefore, parents require society level environment improvement in order to participate in out-of-home activities. The
checklist may provide local communities with valuable information to construct more accessible environments andinclusive communities.
Keywords: gross motor dysfunction, family support, social participation, parents(Asian J Occup Ther 16: 63−69, 2020)

Introduction
Children with gross motor dysfunction face various
obstacles when participating in out-of-home activities;
activities performed outside the home such as leisureactivities and IADLs, compared with children without.
Furthermore, their parents may face additional obstacles
during outings with their children.
There are several factors that would limit the participation of children from out-of-home activities such as
gross motor dysfunction [1], maladaptive behaviours [1],family relationships [2], parent fatigue [3, 4], unsuitable
Received: 4 October 2019, Accepted: 22 April 2020
Corresponding to: Asuka Kenmochi, Aoi-tori Plus (Child development
support centre), Aoi Gakuen School Corporation, 4-12, West 11, South17, Obihiro, Hokkaido 080-0021, Japane-mail: kenmochiasuka@gmail.com©2020 Japanese Association of Occupational Therapists

environments [3, 5–7], and attitude and behaviours of
the general public [4–6, 8]. Previous studies mostly
examined the participation in out-of-home activities thatwere focused on leisure or school activities.
In terms of environmental assessment, many accessibility checklists had been developed and applied[9–11]. These checklists aimed to evaluate how a community, specific place, event and activity etc. accessible
for people with disabilities to generate inclusive environment. Therefore, these checklist items did not reflect
their individual factors that disturb their participation.
The participation in out-of-home activities is also
limited for parents when they go out together with theirchildren who have gross motor dysfunction. For example, Davis et al. (2010) indicated that some families ofchildren with gross motor dysfunction gave up leisureactivities, such as family trips, due to difficulties in finding convenient barrier-free destinations. In addition toleisure activities, parents may need to go out with their

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ACCESSIBILITY CHECKLIST FOR PARENTS OF CHILDREN WITH DISABILITIES

children for instrumental activities of daily living (IADL)
such as shopping, financial management, or child rearing [12].
Currently, it is unclear what specific obstacles parents of children with gross motor dysfunction encounterin social settings of IADLs compared with leisure activities. Therefore, the purpose of this study was to establish
an out-of-home activity accessibility checklist for theseparents to document their obstacles, coping strategies,
and required resources when they perform out-of-homeactivities with their children.

MethodStudy design
The Delphi technique, an established method todevelop diagnostic criteria or new evaluation tools fordiseases and medical conditions, was used to determine
the appropriate checklist items to evaluate the out-ofhome activity accessibility for parents of children withgross motor dysfunction [13, 14]. In this study, parents
were recruited if they (a) had children with gross motor
dysfunction; children with physical disability (e.g.,cerebral palsy, spina bifida, etc.) and that affect theirmobility aged between two and 18 years, (b) were theprimary caregiver, (c) had children who lived with them,and (d) had children who, at least once a month, visiteda paediatrician, occupational, or physical therapist at our
cooperating institutions.
The Delphi questionnaire was developed using
the following process that would establish the out-ofhome activity accessibility checklist items. First, faceto-face semi-structured interviews were conducted withsome participants. The transcribed data were analysed
to generate a tentative accessibility checklist. Througha revision process, the first-round Delphi questionnaire
was developed by assessing the appropriateness of eachtentative checklist item. Other participants were asked toanswer the three rounds Delphi questionnaires in orderto reach a consensus in the tentative items by ratingthem on a five-rank Likert Scale. Finally, the accessibility checklist items to be used were obtained from thosethat achieved a consensus of ≥ 80%. The protocol forthe research project was approved by the Ethical Committee of the university. Informed consent was obtained
from all participants prior to data collection.

Procedure to establish the out-of-home activity accessibility checklist items
Qualitative study to formulate first-round Delphi questionnaire
Step 1. Generate tentative out-of-home activity accessibility checklist items
Participants residing in the central and west-central
region of Japan participated in this process between
October 2014 and March 2015. Face-to-face semi-structured interviews were conducted to explore any possible
items for the accessibility checklist. By considering
concrete examples of outings for IADLs and leisureactivities, the participants answered the following
questions: obstacles encountered, coping strategies, andforms of assistance or resources that were required when
they went out with their children with gross motor dysfunction. The first author of this paper, who carried out
the interviews, was not associated with the collaborative
institutions or the study participants.
Each interview was audio-recorded with the participants’ consent and transcribed verbatim. The entire transcript was cut into minimal meaning units, and the units
were deductively divided into the domains of obstacles,
coping strategies, and required assistance and resources.
Then, inductive analysis [15] was taken to discern similarities among the meaning units. Similar meaning units
were grouped together and categories were developedby naming these groups. These categories created thetentative accessibility checklist items. After the analysis
for both IADLs and leisure activities were finished, thetentative accessibility checklist items were examined
whether they were specific for IADLs, leisure activities,
or were a common feature to both. Both of the authors
were involved in the entire analysis process.
Step 2. Develop first-round Delphi questionnaire consisting of the tentative items
The tentative accessibility checklist items fromboth the obstacles and coping strategies domains were
sorted by three processes: planning and preparing
for the outing, transit, and performance of the aimed
activities at the destination. Next, the prototype firstround Delphi questionnaire was developed. A five-rank
Likert Scale was applied to examine how appropriate
the tentative items were as an out-of-home activity
accessibility checklist for the parents of children withgross motor dysfunction using a range from one (definitely inappropriate) to five (definitely appropriate).
The participants residing in the central region of Japan
were involved in the revision process for the first-round
Delphi questionnaire prototype between July and August
2016. They were asked to answer the first-round Delphi

Kenmochi A et al.

Asian J Occup Ther 16: 63−69, 2020

65

questionnaire prototype and to give their opinions
regarding the ambiguity of the questionnaire items, any
issues regarding answering the questionnaire items, thelayout of the questionnaire, and any further comments
or suggestions. Based on their responses, the first-round
Delphi questionnaire was revised and finalized.

spina bifida, and one had chromosomal abnormalities. A
total of 124 tentative checklist items were generated by
the qualitative procedure from step 1. Of the tentative
items, 80, 34, and 10 were classified in the obstacles,
strategies, and required assistance and resources domains, respectively.

Delphi questionnaire survey
A different set of participants living in westernJapan participated in the Delphi questionnaire survey
to assess the accessibility checklist items. The survey
was iterated three times (Hsu et al., 2007) and wasgiven once every three months between September
2016 and May 2017. The authors sent each round of thequestionnaire to the collaborating institutions, where
the staff provided the questionnaires to the participants.
After the participants filled out the questionnaire, they
were collected and sent back to the authors. In the firstround survey, the participants answered the first-round
Delphi questionnaire developed through the qualitative
study. During the second and third-round surveys, theparticipants who participated in the previous surveys
reassessed the same questionnaire items but also took
into account the score distribution from the previous
questionnaire that was shown by a band chart. Some
items of the questionnaire in the previous rounds werereassessed, modified, or newly added based on the opinions from the open-ended comment box in the previous
surveys. The questionnaire also asked the participants
for information regarding themselves and their child(sex, age, diagnosis, etc.). The tentative accessibility
checklist items were narrowed down to those thatprovided concise information associated with the performance of out-of-home activities of parents of children
with gross motor dysfunction. A consensus was definedas ≥ 80% agreement as determined by the results fromthe third-round survey [16, 17].

Step 2. Develop first-round Delphi questionnaire consisting of the tentative items
Three participants participated in a revision process.
Based on their feedback, the tentative checklist items
were reconsidered, modified, or integrated. As a result,
the total number of tentative items was reduced to 115.
Of these, 72, 34, and nine were classified into the obstacles, strategies, and required assistance and resources
domains, respectively. The revised list of items formed
the first-round Delphi questionnaire.

Results
Qualitative study to formulate first-round Delphi questionnaire
Step 1. Generate tentative out-of-home activity accessibility checklist items
Fifteen participants involved in the semi-structured
interview, and the data of 14 participants were analysed.
One participant data was excluded because she could
not answer all of the questions. The average length of
the interviews was 31 ± 9 (range, 13–45) minutes. All
the participants were female (mothers) and were 42 ±5 (range, 31–48) years old. Their children were 6 ± 5(range, 2–16) years old of which 11 had cerebral palsy(including periventricular leukomalacia, PVL), two had

Delphi questionnaire survey
Forty-three of 56 participants (77%) completed
three rounds of the iterative survey (Table 1). Twentyfour and six new items were added to the second-roundand third-round questionnaire, respectively. As a result,a total of 145 tentative items were examined in the thirdround questionnaire survey. In the third-round questionnaire survey, the average age of the participants was 41± 5 (range, 31–50) years, and the age of their children
was 8 ± 5 (range, 2–18) years. Of these children, 21(48%) had cerebral palsy (including PVL, infantile encephalitis, etc.), 10 (23%) had anomalies of the central
nervous system (including spina bifida, hydrocephalus,etc.), eight (18%) had chromosomal abnormalities, one(2%) had developmental motor retardation, and five(11%) had no described conditions. Thirty-seven of 44(84%) children required assistance to move around outdoors to some degree. Since 39 of the 145 (27%) items
had a consensus of 80% or greater, they were adopted
into the accessibility checklist (Table 2).

Discussion
This study developed an out-of-home activity
accessibility checklist items for the parents of children
with gross motor dysfunction. The checklist consistedof 39 items to obtain information regarding the processof out-of-home activities in terms of obstacles, coping
strategies, and required resources.
Similar to previous studies [3, 4, 18, 19], most of
the study participants were mothers even though theinclusion criterion was primary caregivers. In the qualitative study process, 57% of children required assistanceto move outside to some degree and, of these, 71% had

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ACCESSIBILITY CHECKLIST FOR PARENTS OF CHILDREN WITH DISABILITIES

Table 1 Demographic characteristics of subjects and their children
with gross motor dysfunction
Round

1

2

3

51
1
3

45
1
3

39
1
3

40 ± 541 ± 541 ± 5

GenderFemaleMale
Not described

32
23
1

29
20
1

25
18
1

Age (years)

7±5

8±5

8±5

Diagnosis
Cerebral palsyc
Nervous system deformityd
Chromosome abnormality
OthersNot described

31
10
9
2
5

31
5
9
0
6

21
10
8
1
5

Assistance with outdoor mobility
Requires assistanceIndependent
Not described

47
7
2

41
7
2

37
5
2

Use of facilities
Developmental support centrese
Special classrooms
Special schools

20
6
24

15
6
24

10
4
24

Subjects
GenderFemaleMale
Not described
Age (years)
Childrena

Note. a The number of subjects and their children are not the same dueto the inclusion of one parent of twins with movement disorders.
bMultiple answers were allowed under the diagnosis category.
c
Cerebral palsy included periventricular leukomalacia, infantile

encephalitis, etc.
d
Nervous system deformity included spina bifida, hydrocephalus, etc.
eDevelopmental support centres are facilities that provide medicaltreatment and education for pre-school children with disabilities.

cerebral palsy. In the third-round Delphi questionnaire
survey, 83% of children required assistance to moveoutside to some degree and, of these, 48% had cerebral
palsy. The Japanese Ministry of Health, Labour andWelfare (2008) reported that 83% of children withgross motor dysfunction required assistance to moveoutside to some degree, and, of these, 48% had cerebral
palsy. Therefore, the third-round Delphi questionnaire
survey participants represented the children with grossmotor dysfunction in Japan well. However, there wasa discrepancy in distribution of disorders and severity
between the qualitative study process and questionnaire survey participants, and this may lead to a large
increase in number of tentative checklist items in thesecond-round questionnaire survey.
This study focused on the accessibility for parentsof children with gross motor dysfunction when they
perform out-of-home activities in terms of IADLs andleisure activities. However, the parents take care of theirchildren whenever they go out with their children eventhough they perform leisure activities. In particular,
parents collected extensive information regarding places
they could visit for leisure activities, such as family
trips or dining (#28–32), prior to their outing. The
results from this study also indicated that some gave up
these activities when they felt inconvenienced by theirchildren based on the destination information and experiences from the past (#2, 3). In addition, the parents had
more care burdens during prolonged outings for leisureactivities since they involved feeding (#21), bathing(#25–27) as well as washroom assistance (#17–19).
Previous studies also showed that prior unfavourable experiences due to unsuitable environments and attitudes
and behaviours of the general public negatively affectedfamily leisure activities [3, 4].
In the obstacles domain, there were two types ofchecklist items: individual level items relating to children (e.g. #1, 2) and families (e.g. #15, 20), and society
level items relating to environment (e.g. #5–12) andsocial attitude (e.g. #3, 4, 13). The majority of items (23items) were society level items. Several studies havealso reported that unsuitable environments and attitudes
and behaviours of the general public limited the participation of children with disabilities and their families[3, 4, 6, 8, 21]. Furthermore, all the items established in
the required assistance and resources domain required
society level improvement (#35–39). These results
indicate that many obstacles were due to physical andsocial environments and that society level improvement
is required to overcome these challenges. Recently, thenumber of occupational therapists involved in community development is increasing [22]. Since occupational
therapists are unique professionals with diverse knowledge regarding medical disabilities and environment
evaluation [23], occupational therapists may help in
encouraging families of children with gross motor dysfunction to participate in out-of-home activities throughtheir involvement in community environment coordination, educational activities to enhance the understandingof disabilities to the public as well as their direct intervention with children.
Limitations to our study may include the lack of
certain background information of participants such as
severity of their child gross motor dysfunction, major
mode of transport, marital status, employment status,
socioeconomic status, and educational background. This
information may have affected the outcome of our study.
In addition, there is no existing nationwide statistical
data with this type of caregiver information to compareKenmochi A et al.

Asian J Occup Ther 16: 63−69, 2020

67

Table 2 Consensus ratio and characteristics of the determined checklist items (n = 43).
Questionnaire item
Obstacles domain
1. Planning and preparing for outings#1 Restriction in the type of destination due to weather#2 Hesitation or resignation of outing due to lack of human resources for child care
#3 F ew or no appropriate places for children with disabilities to play safely(e.g., environment/other children)
2. Transit#4 Lack of parking for those with disabilities (e.g., insufficient number/misuse by general public)#5 Lack of space to move wheelchairs in parking lot#6 No roofs over parking lot#7 No elevators at station#8 Roundabout route to elevator#9 Complicated layout of large stations#10 Large number of stairs at subway stations#11 Long distance between entrance gate to boarding area at stations#12 Large gap between train and platform#13 Worries in moving around crowded stations by wheelchair (e.g., attitude of general public)#14 Uneven footpaths#15 Difficulty in using umbrellas while pushing wheelchair
3. Performance of aimed activities at destination#16 Long wait times for crowded elevators (e.g., insufficient number/ thoughtlessness of general public)#17 Lack of equipped restrooms for people with disabilities(e.g., insufficient number/misuse by general public)#18 Lack of space to move wheelchairs in restroom#19 No appropriate change tables for people with disabilities#20 Difficulty in handling both shopping cart and wheelchair at grocery stores#21 No appropriate chairs for children with disabilities at restaurants#22 Rough walkways at tourist sites#23 Few equipped attractions for people with disabilities at amusement parks#24 Narrow entrance gates for wheelchairs#25 Slippery floors at pools/public baths#26 Limited space to take care of child at pools/public baths#27 Difficulty in taking adolescents of the opposite sex to pools/public baths(e.g., environment/social stigma)
Coping strategies domain
1. Planning and preparing for outings#28 Plan to re-visit familiar facilities#29 Reserve a private room or other appropriate environment for dining out#30 Check facility for barrier-free access (e.g., ramps and elevators)#31 Check availability of washrooms for those with disabilities#32 Check discount information for people with disabilities(i.e., if the facility has a discounted entrance fee, it may be equipped for people with disabilities)
3. Performance-aimed activities at certain places#33 Use of a shoulder bag or backpack to take care of their children#34 Bring children’s extra clothes
Required assistance and resources domain#35 Improve restroom environment (e.g., include change tables for people with disabilities)#36 Equip rooms for rest/meals etc. for people with disabilities#37 Improve footpaths, and reduce the number of barriers, stairs, and potholes#38 Implement footpaths with roofs#39 Increase parking area for people with disabilities

Categoryclassification

Consensus
ratio
(%)

Purposea

Factorb

95
81
93

C
L
L

I
I
S

83
88
95
86
86
84
84
81
88
81
81
91

C
C
C
C
C
C
C
C
C
C
C
C

S
S
S
S
S
S
S
S
S
S
S
I

81
86

C
C

S
S

88
95
91
84
93
86
84
88
91
88

C
C
P
L
L
L
L
L
L
L

S
S
I
S
S
S
S
S
S
S/I

81
86
84
81
86

L
L
L
L
L

86
88

C
C

98
81
95
93
93

C
C
C
C
C

Note. a Classification by purpose of out-of-home activities. C: common items for both IADL and leisure activities. P: particular items for IADLs
such as grocery shopping, dropping off and picking up children from school, etc. L: particular items for leisure activities such as family trips, etc.
bClassification by level of obstacles: S, society level; I, individual level.

68

ACCESSIBILITY CHECKLIST FOR PARENTS OF CHILDREN WITH DISABILITIESwith the participants in this study. Furthermore, although
the purpose of this study was to clarify the accessibility
checklist items for both parents, most of the study
participants were mothers. Therefore, several checklist
items reflecting the opinion of fathers should be addedin future studies.

Conclusion
To our knowledge, this study is the first to clarify
the accessibility of out-of-home activities from theperspective of parents since many prior studies wereconducted through the perspective children. Most of
the obstacles encountered by parents during outings
with their children with gross motor dysfunction camefrom society level issues such as lack in barrier-free
infrastructures. Prior to going out for leisure activities,
parents would have to collect extensive information
regarding their destination in order to mitigate issues
during their outing. Based on these results, parents require society level improvements, and the checklist may
provide local communities with valuable information to
construct more accessible environments and inclusive
communities. Further studies are necessary to develop a
more practical use for this accessibility checklist.

Acknowledgements
The authors would like to acknowledge the timeand effort of all participants, cooperators of associatedfacilities for this study.

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

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■ORIGINAL ARTICLE

Joint Tightening in Hemiplegic Handwriting
Yuhki Fujisawa, Yasutomo Okajima, Hiroyuki Hashidate, Hisako Nakano
Kyorin University, Japan

Abstract: Objective: Handwriting, which consists of multiple joint movements in the upper extremity, is a suitablemodel to investigate motor control after hemiplegic stroke. We analyzed pen tip movement during handwriting in relation to the finger and wrist to reveal tightening and joint linkage that control writing movements done by a hemiplegic
hand.
Methods: Thirteen right-handed individuals with right-sided mild hemiplegia after a stroke and 14 age-matched,right-handed controls were included. Movements of the pen tip, finger, and wrist were recorded using a three-dimensional movement analyzer. We investigated their writing performance by measuring writing time, variabilities of pen tip
kinematics and trajectory. Movement linkage of the joints during writing was quantified by calculating the ratio of the
trajectory size at the finger or wrist to that at the pen tip.
Results: The time needed for writing and the kinematic variability did not differ between the hemiplegic and control
groups. The tight linkage of the pen tip with the finger and wrist joint movement was found in hemiplegic handwriting,which was similar to nondominant hand use in the controls. The linkage parameter of hemiplegic handwriting significantly correlated with writing time and kinematic variability of the pen tip movement.
Conclusion: Individuals with dominant-hand hemiplegia, in an attempt to produce consistently legible writing, may
tighten the joint linkage of the finger and wrist to reduce the freedom of motion to control writing and simultaneously
slow their writing speed, potentially resulting in increased kinematic variability of the pen tip movement.
Keywords: handwriting; stroke; hemiplegia; three dimensional movement analysis; manual function(Asian J Occup Ther 16: 71−81, 2020)

INTRODUCTION
Hemiplegia is characterized by weakness and impaired coordination, which disrupts smooth and separate
individual joint movement sequences [1]. Damage to themotor pathway in the brain may result in the abnormal
linkage of individual joint movements, which is ascribedto the unintended co-contraction of muscles in the extremities [2]. Clinical grading scales of hemiplegia, suchas the Brunnstrom Recovery Scale [3] and the Fugl–
Meyer Assessment [4], are structured to emphasize thisabnormal movement linkage. Meanwhile, the performance of the hemiplegic extremities, especially that of
the hand, is measured quantitatively by standardized
Received: 7 August 2019, Accepted: 19 May 2020
Corresponding to: Yuhki Fujisawa, Department of Physical Therapy,
Faculty of Health Sciences, Kyorin University, 5-4-1, Shimorenjaku,
Mitaka, Tokyo 181-8612, Japane-mail: yfujisawa@ks.kyorin-u.ac.jp©2020 Japanese Association of Occupational Therapists

manual function tests, such as the Box and Block Test
(BBT) and the Nine-Hole Peg Test. Lin et al. [5] reported that both scores correlated well. However, correlations with hemiplegia grade, as measured by the Fugl–
Meyer Assessment, were lower, which was likely due tothe manual activities of daily living (ADLs). Handwriting may be categorized as a manual ADL [6]. In fact,
Platz et al. [7] demonstrated that a dissociation between
motor function scores (Fugl–Meyer Assessment andBBT scores) and ADLs were measured by the modified
Barthel Index.
Handwriting is a multi-joint movement involving
the thumb, fingers, wrist, and, occasionally, the elbow.
Each joint moves in relation to the others, and joint
tightening has been observed in uncoordinated handwriting movements. Tightening of the finger and wrist
joint linkage may reveal similar movement trajectoriesof the finger and wrist during handwriting. Harada andcolleagues [8] focused on the relationship between the
movements of the pen tip and holding a pen. They compared movement trajectory sizes between right and left

72

HEMIPLEGIC HANDWRITING

handwriting. The size of the wrist movement trajectory
to the pen tip ratio was smaller for the dominant handthan for the nondominant hand in healthy individuals.
This meant that the pen tip movement for nondominantside handwriting was firmly linked to the hand. Further­more, the pen tip movement for the nondominant side
handwriting was dependent on the movement of theproximal hand segment. This linked movement of the
distal pen tip with the proximal hand was termed theproximodistal linkage of movement. Conversely, thepen tip for the dominant side handwriting moved independently of the finger and hand movements. This wastermed proximodistal separation.
In this study, the speed, kinematics, and morphological consistency of writing were measured as basic
parameters of handwriting performance. Ratios oftrajectory sizes representing movement linkage or separation, as described above, were analyzed in relation to
those performance parameters and the manual function
scores in individuals with hemiplegia. We investigateddifferences in these parameters between the dominant
and nondominant hands, between different letter sizes,
and between individuals with dominant-hand hemiplegia and controls. We hypothesized that writing with thedominant hand in patients with dominant-hand hemiparesis would retain characteristics of writing with thedominant hand and that this would differ from writing
done by the nondominant hand. We assumed that in individuals with dominant-hand hemiplegia, the parametersindicating hemiplegic handwriting performance would
not simply correlate with task-specific manual motor
function scores. Further, we believed that tightening thelinkage of the finger and wrist joints would dominate asa compensatory mechanism in hemiplegic handwriting.
This study may facilitate further understanding of writing with a hemiplegic hand, emphasizing the importanceof joint linkage strategies that may compensate forhemiplegia.

METHODS
ParticipantsThis was a nonrandomized case-control study.
Thirteen right-handed individuals (six males and sevenfemales, mean age = 69.1 yr, and standard deviations(SD) = 12.9 yr) with mild right-handed hemiplegia secondary to first onset of cerebral infarction (frontal cortex:
four, corona radiate: one, pons: two, and unknown: four)or hemorrhage (putamen: one and thalamus: one) wererecruited from the stroke unit or ambulatory rehabilitation clinic of Kyorin University Hospital. The time fromstroke onset to study inclusion ranged from 7 to 40
days (median: 20 days). Fourteen right-handed healthy

volunteers (10 males and 4 females, mean age = 71.7
yr, and SD = 11.0 yr) were enrolled as age-matched
controls (P = 0.57). Only individuals who could write
legible characters in a 2-cm square frame were included.
Those with sensory deficits, apparent dementia, aphasia,
or unilateral spatial hemineglect were excluded. Past
medical histories, affecting central or peripheral nervous
systems, such as stroke, cervical myeloradiculopathy,
and peripheral neuropathy, were denied. Participants
were recruited from senior societies in the local community. This study was approved by the Ethical Board ofFaculty of Medicine, Kyorin University. Participants
provided informed consent. To statistically analyze thedifferences, the number of control participants was not
fewer than that of the stroke participants.
Clinical evaluation of manual functions
Handedness, the hand used for writing, drawing,
and tooth brushing, was determined using the Edinburgh
Inventory [9] interview. The Edinburgh score ranges
from −100 (completely left-handed) to +100 points(completely right-handed). All individuals with hemiplegia were classified as having mild paresis of stages
4–6, according to the Brunnstrom Recovery Scale.
Grip strength and the BBT [10] scores were obtained toshow the manual function of both hands. The Smedley
Hand Dynamometer® (MIS, Tokyo, Japan) was used formeasuring grip strength. In consideration of individual
differences in both grip strength and BBT scores, weused the index of the ratio of the right hand to the left
hand for these two parameters.
Three-dimensional handwriting analysis
Sitting on a regular wooden dining chair with awooden desk, participants wrote a Japanese Hiragana
character. Handwriting movement was analyzed usinga three-dimensional movement analyzer, Liberty® (Polhemus, VT 05446, USA), which consists of a magnetic
field generator, a stylus pen with a position sensor in
the tip, and two small-block sensors (Fig. 1). The block
sensors were placed at the dorsal surface of the index
metacarpal head (finger) and the distal end of the radius(wrist). Three-dimensional coordinates of the pen tip
and two block sensors were recorded at a sampling
frequency of 240 Hz each. Individuals were required
to write the Japanese Hiragana character (Fig. 2D) in
four differently sized squares (2.0, 5.0, 7.5, and 15.0cm) in free typeface (their regular typeface) using theirright and left hands. This is a basic Japanese character
that corresponds to the letter a in the English alphabet.
The individuals wrote 10 characters in each frame witheach hand, for a total of 80 characters. They were told towrite at a comfortable speed and were instructed “not toFujisawa Y et al.

Asian J Occup Ther 16: 71−81, 202073

pen tip to the geometric center of its trajectory plottedagainst the trajectory length (Fig. 2C). The average
distance plots were obtained from 10 writing repetitions,and SDs calculated for the plots were divided by themean of each plot. The grand mean of all SD/means was
assumed to represent the trajectory-shape variability ofthe pen tip [11].
The linkage of the pen tip to the finger and wrist
movement was examined in terms of movement size.
The average distance from the geometric center to the
movement track represented the size of the movement.
This proximodistal linkage was defined by the average
distance for the finger and wrist track divided by thatof the pen tip [8] (Fig. 2A). When this ratio was near 1during writing, the holding of the pen was assumed tobe tightly fixed to the pen.

Fig. 1. Experimental system
A: An apparatus measuring three-dimensional coordinates ofthe sensors.
B: A transmitter yielding a constant magnetic field.
C: A ballpoint pen with a position sensor is installed in its tip.
D: Cube-shaped position sensors, 2.8 × 2.2 × 1.5 cm, fixed at
the metacarpophalangeal joint surface of the index finger
and at the distal end of the radius.

hurry and ignore legibility” and “not to intend to write
too beautifully.” Recorded coordinate data were analyzed with Matlab® software (Mathworks, Tokyo 1070052, Japan). Since the analyzer samples data at equal
time intervals, the data were converted into intervals of
equal length by spline interpolation [8].
Parameters representing handwriting characteristics
The time needed to write a character was averaged
for each character’s size and each hand. Kinematicfeatures of handwriting movement were illustrated as
the instantaneous speed of the pen tip plotted against the
track length from the initial point of writing and wereexpressed as a percentage of the total length (Fig. 2B).
The average speed plots were obtained from 10 writing repetitions, and SDs were calculated for all plots.
The SD was then divided by the mean for each plot tocompute the grand mean of all SD/means, which was
assumed to represent the kinematic variability of the
pen tip movement [11]. Morphological variability of thewriting trajectory was defined by the distance from theStatistical analysis
We used a paired t-test to indicate differences between the right and left hands for grip strength and BBT
to ensure that the manual function of the hemiplegicright hand was truly lower than that of the left hand.
Three factors, that is, group of the individuals (hemiplegia vs. control), hand used (right vs. left), and frame sizeof writing (four sizes), were analyzed statistically for
differences in writing time, kinematic and track–shapevariability, and proximodistal linkage parameters, usinga three-way analysis of variance (ANOVA) with repeated measures for two factors (hand side and writingframe size). Estimated marginal means and 95% confidence intervals of the parameters were calculated. Post
hoc Bonferroni comparisons were made to show differences when a significant interaction between any of
the three factors was found by the three-way ANOVA.
We analyzed the relationship between any pairs of theseparameters for the hemiplegic hand using Pearson’s correlation coefficient to find determinants of hemiplegic
handwriting proficiency. The level of significance for all
analyses was set at 5%. Finally, IBM SPSS Statistics for
Windows, version 24.0 (IBM Corp, Armonk, New York)was used for the analysis.

RESULTS
Functional evaluation of the hemiplegic hand
All participants were right-handed. The Edinburgh
handedness scores were 70–100 (mean = 94.6 and SD= 8.4) and 55–100 (mean = 92.1 and SD = 12.2) for thehemiplegic and control groups, respectively. The mean
and SD of the grip–strength ratio of the right to left handwere 0.80 (SD = 0.21) for the hemiplegic group and 1.07
(SD = 0.11) for the control group. The mean and SD of
the BBT ratio of the right to left hand were 0.82 (SD =74

HEMIPLEGIC HANDWRITING

Fig. 2. Writing tracks and correlations of writing parameters
A: An example of the Japanese syllabic character handwritten by a control individual. Ten tracks of writing movements with the pen tip,
metacarpal head of the index finger, and radial end of the wrist in a 2-cm square are layered. The tracks of the index finger base, pentip, and wrist were of a similar shape. Average distances from the pen tip, finger, and wrist to the geometric center of their tracks areshown by p, f, and w, respectively.
B: Pen tip speed is plotted against length along the writing tracks expressed as a percentage. Ten trials are layered, and the average plots
are illustrated as small crosses. These plots indicate the kinematic features of the pen tip movement. The kinematic variability wasdefined by the coefficient of variation in the difference in speed from the mean.
C: Distances of the pen tip from the geometric center of the track are plotted against the length along the writing tracks. Ten trials ofwriting are layered, and the average plots are illustrated as small crosses. These plots indicate the morphology of the pen tip track. Thismorphological variability was defined by the coefficient of variation of difference from the averaged distance.
D: The Japanese Hiragana character adopted for this study.

Asian J Occup Ther 16: 71−81, 2020

0.17) for the hemiplegic group and 1.05 (SD = 0.10) forthe control group. Both the grip strength and BBT weresignificantly lower in the right hand than in the left handin the hemiplegic group (paired t-test, p < 0.001).
Time needed to write a character (Table 1)
The time needed for writing did not differ between
the hemiplegic and control groups (ANOVA, F(1, 25) =1.79, p = 0.193). Writing time was significantly greaterfor the left than for the right hand (F(1, 25) = 8.90,
p = 0.006) and for larger-sized letters (F(3, 75) = 53.18,
p < 0.001). A significant interaction was found between
the group and side of the hand used (F(1, 25) = 6.96,
p = 0.014) between which a multiple comparison
showed that it took more time in the hemiplegic groupfor right-handed writing in the 2-cm (Bonferroni test,
p = 0.045) and 5-cm ( p = 0.048) frames.
Handwriting variability (Table 1)
The kinematic variability (Fig. 2B), as definedby the coefficient variation of the pen tip speed, did
not differ between the hemiplegic and control groups(F(1, 25) = 2.28, ANOVA, p = 0.144) or between righthanded and left-handed writing (F(1, 25) = 2.20, p =0.151). However, it decreased significantly when theframe size for writing increased (F(3, 75) = 150.31, p <0.001).
In addition, the track–shape variability (Fig. 2C) did
not differ between the groups (F(1, 25) = 4.18, ANOVA,
p = 0.52) or between right and left hand writing (F(1, 25)= 0.98, p = 0.331). It was significantly less for largersized writing (F(3, 75) = 76.56, p < 0.001). A significant
interaction was found between the group and the handside (F(1, 25) = 4.65, p = 0.041) and between the size
and the hand side (F(1, 25) = 3.21, p = 0.028).
Multiple comparisons indicated that group differences in shape variability were significant for righthanded writing in the 2-cm (Bonferroni test, p = 0.011)
and 7.5-cm ( p = 0.014) frames and were insignificant
for right-handed writing in the 5-cm frame ( p = 0.083)
and 15-cm frame ( p = 0.072). There was a significant
difference between the right and left hands only in the
2-cm frame in the control group ( p = 0.011).
Between-size differences in track–shape variability
were significant for the 2/7.5-cm (Bonferroni test,
p = 0.002) and 2/15-cm ( p < 0.001) size pairs in righthanded writing in the control group and for the 2/5-cm( p < 0.001), 2/7.5-cm ( p < 0.001), 2/15-cm ( p < 0.001),
and 5/15-cm ( p = 0.016) size pairs in left-handed
writing in the control group. Differences were alsosignificant for the 2/5-cm ( p < 0.001), 2/7.5-cm ( p <0.001), 2/15-cm ( p < 0.001), and 5/15-cm ( p = 0.02)
pairs in right-handed writing in the hemiplegic group. In

Fujisawa Y et al.

75

left-handed writing in the hemiplegic group, differenceswere significant for the 2/5-cm ( p < 0.001), 2/7.5-cm( p < 0.001), 2/15-cm ( p < 0.001), 5/7.5-cm ( p = 0.03),
and 5/15-cm ( p <0.001) size pairs. In general, track–
shape variability tended to increase in right-handed writing in the hemiplegic group as well as in smaller-sizedwriting in both the hemiplegic and control groups.
Proximodistal linkage of handwriting movements(Table 1)
The proximodistal linkage (Fig. 2A), which was
defined as the ratio of movement track diameter of thefinger to the pen tip (finger–pen ratio), was significant
for the group (ANOVA, F(1, 25) = 6.05, p = 0.021), sideof handwriting (F(1, 25) = 14.80, p = 0.001), and frame
size (F(3, 75) = 9.41, p = 0.001). Those defined as thewrist–pen ratio were significant and/or marginally significant for the group (F(1, 25) = 4.21, p = 0.051), sideof handwriting (F(1, 25) = 17.4, p < 0.001), and frame
size (F(3, 75) = 10.28, p = 0.001). Interactions in thefinger–pen ratio were found for the factors of the groupand side of handwriting (F(1, 25) = 6.89, p = 0.015),
side of handwriting and frame size (F(3, 75) = 1.40, p =0.001), and for all three included factors (F(3, 75) = 1.40,
p = 0.006). Interaction in the wrist–pen ratio was found
for the side of handwriting and frame size (F(3, 75) =5.43, p = 0.002) and for all three factors (F(3, 75) = 5.80,
p = 0.001).
Multiple comparisons of the finger–pen ratio revealed significant group differences for all four frame
sizes (Bonferroni test, 2-cm: p = 0.004, 5-cm: p = 0.001,
7.5-cm: p = 0.009, and 15-cm: p = 0.009) in righthanded writing. Right–left differences were also significant for all four sizes of right-handed writing in thecontrol group (2-cm: p < 0.001, 5-cm: p < 0.001, 7.5-cm:
p = 0.007, and 15-cm: p = 0.015). Size-related differences were significant for all right-handed writing size
pairs in the control group (2/7.5-cm: p = 0.003, 2/15-cm:
p < 0.001, 5/7.5-cm: p = 0.002, 5/15-cm: p < 0.001, and7.5/15-cm: p < 0.001), apart from the 2/5-cm pair. It wassignificant only for the 7.5/15-cm pair of left-handed
writing in the control group ( p = 0.001). Size-relateddifferences in the hemiplegic group were not found forany pair of sizes in either right-handed or left-handed
writing.
Group differences in the wrist–pen ratio were found
for the 2-cm (Bonferroni test, p = 0.015) and 5-cm
(Bonferroni test, p = 0.011) frames of right-handed
writing. Right–left differences were significant for all
four sizes in the control group (2-cm: p < 0.001, 5-cm:
p < 0.001, 7.5-cm: p = 0.014, and 15-cm: p = 0.012) andfor the 7.5-cm frame in the hemiplegic group ( p = 0.02).
Between-size differences in right-handed writing were

d

c

b

a

(2.35, 4.07)

0.25(0.22, 0.29)

0.17(0.16, 0.19)(sec)

Kinematic variability(SD/mean)Track shape variability(SD/mean)Control

3.21(0.75, 0.82)

0.73(0.69, 0.77)(ratio)Wrist/pen-tip(ratio)(0.74, 0.82)

0.78(0.81, 0.88)

0.84(0.18, 0.21)

0.19(0.26, 0.33)

0.29(3.12, 4.91)

4.02

Hemiplegia

1

1

1

1

1

4.21

6.05

4.18

2.28

1.79

b

b

d

b, d

.051

.021

.052

.14

.19

Significant difference for interactions among side, group, and writing size.

Significant difference for interactions between side and writing size.

Significant difference for interactions between side and group.

Significance, determined with an analysis of variance, was set at a P value of <.05.

0.78

Finger/pen-tip

Movement size ratio

P(0.68, 0.76)

0.72(0.75, 0.81)

0.78(0.17, 0.19)

0.18(0.24, 0.30)

0.27(2.75, 4.02)

3.38

Rt

(0.76, 0.82)

0.79(0.81, 0.87)

0.84(0.18, 0.20)

0.19(0.25, 0.31)

0.28(3.20, 4.50)

3.85

Lt

(95% CI)F(95% CI)

Side

1

1

1

1

1

df

17.4

14.8

.98

2.2

8.9

F

b, c

b

< .001c, db, c, d

001

.33

.15

.006

P

(0.70, 0.77)

0.73(0.76, 0.83)

0.79(0.21, 0.24)

0.23(0.32, 0.39)

0.35(2.55, 3.65)

3.10

2cm

Table 1 Estimated Marginal Means and 95% Confidence Intervals (CI)a

Estimated marginal meandfaEstimated marginal mean

Writing time

ParametersGroup

Estimated Marginal Means and 95% Confidence Intervals (CI)

Table 1(0.72, 0.77)

0.74(0.77, 0.83)

0.80(0.17, 0.20)

0.18(0.25, 0.3)

0.27

(2.83, 4.08)

3.45

5cm
3.73

7.5cm

(0.73, 0.78)

0.76(0.79, 0.84)

0.81(0.16, 0.18)

0.17(0.22, 0.28)

0.25(3.06, 4.39)(95% CI)

Estimated marginal meanSize

(0.76, 0.8)

0.78

(0.82, 0.86)

0.84(0.14, 0.16)

0.15(0.20, 0.24)

0.22(3.51, 4.86)

4.18

15cm

3

3

3

3

3

df

10.28

9.41

76.56

150.31

53.18

F

.001

.001

c

c, d

c, d

< .001< .001< .001P

76
HEMIPLEGIC HANDWRITING

Fujisawa Y et al.

Asian J Occup Ther 16: 71−81, 2020

77

Fig. 3. Correlation between writing time and proximodistal linkage in handwriting
The writing time was significantly correlated with the movement–size linkage defined as finger–pen or wrist–pen for all frame sizes ofwriting by the hemiplegic hand. See text for the definitions of the movement–size ratios, finger–pen, and wrist–pen.

significant for all size pairs in the control group (2/7.5cm: p = 0.001, 2/15-cm: p = 0.001, 5/7.5-cm: p < 0.001,
5/15-cm: p < 0.001, and 7.5/15 cm: p = 0.002) except
for the 2/5-cm pair, similar to the finger–pen ratio, andwas significant for the 7.5/15-cm pair in the hemiplegic
group ( p = 0.03). However, no size-related differenceswere found in left-handed writing, in either the control
or hemiplegic groups.
In general, the proximodistal linkage was high,causing tightly linked movement of the pen tip with thefinger and wrist in left-handed writing in the control
group and both right-handed and left-handed writing in
the hemiplegic group. In contrast, it was low for righthanded writing in the smaller frames in the control group,
indicating a separation of the pen tip movement fromthe finger and wrist movement.
Characteristic determinants of writing by the hemiplegic
hand
The ratio of hemiplegic right-handed grip strength
to left-handed grip strength marginally correlated withthe same BBT score ratio (r = 0.553, p = 0.05). The
grip–strength ratio of the hemiplegic hand correlatedwith track–shape variability for right-handed writing inthe 2-cm (r = −0.712, p = 0.006), 5-cm (r = −0.727, p =0.005), and 7.5-cm size frame (r = −0.642, p = 0.018).
However, the BBT ratio did not correlate with writing
time, kinematic variability, or proximodistal linkage
parameters.
As shown in Fig. 3, the Pearson’s correlation coef-

78

HEMIPLEGIC HANDWRITING

Fig. 4. Correlation between kinematic variability and proximodistal linkage in handwriting
The kinematic variability was significantly correlated with the movement–size linkage (both finger–pen and wrist–pen) for all frame
sizes of writing by the hemiplegic hand.

ficients of both finger–pen and wrist–pen ratios showing
proximodistal linkage for the hemiplegic right handwere significant for the writing time (r = 0.61–0.90, P =0.03–< 0.001) and kinematic variability for all four sizes(r = 0.63–0.88, p = 0.06–< 0.001; Fig. 4).
Other correlations were significant between writingtime and kinematic variability (r = 0.859 for the 2-cm
frame, r = 0.914 for the 5-cm frame, r = 0.939 for the
7.5-cm frame, r = 0.897 for the 15-cm frame, and p<.001) and between kinematic variability and trajectory-shape variability (r = 0.563 for the 2-cm frame, p =0.045; r = 0.688 for the 7.5-cm frame, p = 0.009; andr = 0.792 for the 15-cm frame, p = 0.001).

DISCUSSION
Handwriting and the manual function of the hemiplegic
hand
Speed and accuracy, or writing time and consistency of writing trajectory, are assumed to be major indicators of movement performance, but they may represent
a trade-off [12] as accuracy decreases with increasing
speed. However, regarding writing, the movement ofhandwriting becomes automatic and consistent after
years of practice [13]. Freeman [14] found that writingtime is relatively constant regardless of writing size,that is, the isochrony property of adult handwriting, incontrast to the immature handwriting of children wherewriting time changes in proportion to the size of writing,Asian J Occup Ther 16: 71−81, 2020

and is ascribed to a constant pen tip movement speed.
Wright [15] investigated this property by the sofisticatedmethods. Viviani & Terzuolo [16] measured instantaneous pen tip speed during writing and plotted it against
time. They found that this speed profile maintained asimilar shape even with faster or larger writing. This
kinematic property of pen tip movement, or handwriting
rhythm, is called space–time invariance. In other words,
smaller kinematic variability is evidence of more mature
handwriting. Morphological invariance of writing [15,17] is another writing characteristic that is individuallyacquired. To date, no reports focus on changes in theseinvariance properties caused by stroke hemiplegia.
Only grip strength showed a moderate correlation
with morphological variability. In other words, only
weakness affected the morphological consistency ofwriting. However, other parameters, such as writing
time, kinematic variability, and proximodistal movement
linkage, were irrelevant to either grip strength or BBT.
There is no reason that BBT and/or grip strength would
be correlated with handwriting parameters since BBT
assesses the proximal rather than the distal movement of
the upper extremity, and grip strength simply represents
the strength of the distal musculature. This study only
included individuals with hemiplegia who could write
legible characters. Therefore, hemiplegia was mild andless varied in terms of severity. In principle, handwriting
is categorized as an activity involving various factors,
such as individual customs and aesthetic consciousness. Therefore, it was expected that the parameters in
the present study would not be strongly related to themanual or proximal arm function as measured by grip
strength or BBT, respectively.
We introduced parameters quantifying kinematicand morphological variability of writing, on the basis of
the studies of Viviani and Terzuolo [16] and Castielloand Stelmach [17] respectively, both of which gradedthe clinical severity of ataxia [11]. In the present investigation, significant differences in both measuresof variability were found for some of the frame sizes
between the hemiplegic hand and the healthy dominant
hand and between the dominant and nondominant handin the control group. In addition, a larger variability inthese parameters was ascribed to less controllability of
the hemiplegic hand and the nondominant hand.
Increased proximodistal linkage in hemiplegic hand­writing
Handwriting involves multiple joint systems that
include the fingers and wrist. A single character or lettercan be written using numerous joint movement patterns.
However, each joint moves smoothly in a coordinatedmanner, resulting in writing with similar kinematics andFujisawa Y et al.

79

morphology. Lacquaniti [18] demonstrated that the wristand elbow became increasingly involved in dominant
handwriting with increasing writing size. In contrast, thewrist and elbow, rather than the thumb and fingers, aremainly used in nondominant handwriting irrespectiveof writing size. Meulenbroek et al. [19] reported suchlinkage between pen tip movements and finger or wrist
movements in circle-drawing. However, circle-drawing
may differ from handwriting in its mechanisms of movement control. Circle-drawing is done principally throughthe visual feedback information of drawn lines, whereas
handwriting is accomplished without correction basedon feed-forward control acquired after the daily activityof writing during childhood.
The relationship in movement size between the pen
tip and finger/wrist was the major focus of the present
investigation and elucidated the proximodistal linkage
of movements as first proposed by Harada et al. [8].
Contrary to their expectation, they could not indicate asignificant increase in the proximodistal movement linkage of the hemiplegic handwriting. Only in hemiplegic
cases with position sense impairment did the pen tip
move in linkage with the finger and hand for dominantside handwriting. However, two issues may prevent us
from drawing conclusions from their study. The firstwas the inclusion of the patients with position sense impairment, which might have obscured minor differencesin handwriting between the patients with dominant-handhemiplegia and the controls. Position sense impairment
caused ataxia, which would cause a large variabilityof handwriting kinematics and morphology [11]. The
other problem was the exclusion of small-sized writing.
Harada et al. [8] did not include small-sized writing forstatistical analysis, which would require a separation in
the distal movements. Our study revealed that writing
size was a major determinant of writing time, variability,and proximodistal linkage parameters.
Factors affecting proximodistal movement linkage
In hemiplegic handwriting, both writing time andkinematic variability significantly increased, regardlessof writing size, as the trajectory–size ratio of the finger
or wrist to that of the pen tip approached 1 (Figs. 3 and
4). In other words, proximodistal linkage in hemiplegia
correlated with longer handwriting time and larger kinematic variation. Writing time correlated positively withkinematic variability regardless of writing size, indicating that a trade-off rule was not necessarily applicableto the relationship between writing time and kinematic
variability. In addition, kinematic variability correlated
positively, in part, with morphological variability.
However, the morphological variability did not correlatewith writing time. This suggests stronger morphological

80

HEMIPLEGIC HANDWRITING

invariance than time and kinematic invariance in writing
with the hemiplegic hand.
Proximodistal linkage is not always pathological,
as has been seen in individuals with severe hemiplegia.
Osu et al. [20] investigated the targeted reaching movement in healthy volunteers and demonstrated that the
flexor and extensor muscles of the arm co-contracted sothat freedom of motion could be lessened for easier control and higher performance of the intended movement.
It is important to maintain the same shape of the writing,irrespective of hemiplegia, as characters should be written legibly. Individuals with dominant-hand hemiplegia
may tighten joint linkage of the upper extremity andslow their writing speed, resulting in the disruption ofkinematic invariance of the pen tip movement. This ismost likely done in an attempt to yield consistent writing shapes.
Conclusion
Handwriting may be categorized as an ADL. Individuals with stroke hemiplegia of the dominant hand reacquire writing while adapting to hemiplegia. Legibility
is seemingly more important than writing speed, as
writing could result in nonsense without being legible.
In this study, individuals with hemiplegia could write
legibly by slowing their writing speed, which mightcause greater kinematic and/or shape variability, andby tightening the finger and wrist joints as if they weremoving as a solid block. This helped them control thehemiplegic hand by reducing the degree of freedomof motion. The results of this study may be helpful inunderstanding the fine manual movement of individuals
with hemiplegia. A reduction in the degree of freedom of
motion by tightening the joint linkage was important inaccomplishing dexterous movement with the hemiplegic
hand.
The conclusions of this study were obtained froma limited number of participants. With a larger sample
size, we could have produced greater statistical data.
The instructions given to the participants for the experiment were important as the writing performance by thehemiplegic hand might depend on the instructions. In
this study, participants were instructed to write at theirown speed, neither too quickly nor too slowly. If they
had been asked to write as fast as possible, ignoring
legibility, different results would have been obtained.
Further studies are needed to address these issues.

Acknowledgments
This work was supported by JSPS KAKENHI
Grant Numbers JP23500615, JP18K10758.

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[4] Fugl-Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind
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[8] Harada T, Okajima Y, Takahashi H. Three-dimensional
movement analysis of handwriting in subjects with mild
hemiplegia. Arch Phys Med Rehabil 2010; 91: 1210–7.
[9] Oldfield R. The assessment and analysis of handedness:
the Edinburgh inventory. Neuropsychologia. 1971; 9: 97–
113.
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norms for the Box and Block Test of manual dexterity.
American Journal of Occupational Therapy. 1985; 39(6):386–91.
[11] Fujisawa Y, Okajima Y. Characteristics of handwriting ofpeople with cerebellar ataxia: Three-dimensional movement analysis of the pen tip, finger, and wrist. Phys Ther
2015; 95: 1547–58.
[12] Fitts PM. The information capacity of the human motor
system in controlling the amplitude of movement. J Exp
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[13] Tucha O, Tucha L, Lange KW. Graphonomics, automaticity and handwriting assessment. Literacy. 2008; 42:
145–55.
[14] Freeman FN. Experimental analysis of the writing movement. Psychol Monogr. 1914; 17: 1–46.
[15] Wright CE. Evaluating the special role of time in the control of handwriting. Acta Psychol (Amst). 1993; 82: 5–52.
doi: 10.1016/0001-6918(93)90003-A.
[16] Viviani P, Terzuolo C. Space-time invariance in learned
motor skills. In: Stelmach GE, Requin J, editors. Tutorials in motor behavior. Adv Psychol. 1980; 1: 525–33.
[17] Castiello U, Stelmach GE. Generalized representation

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[18] Lacquaniti F. Central representations of human limb
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coordination in loop writing. Acta Psychol (Amst). 1998;
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■CASE REPORT

Development of a Finger Extension Assistance Splint
for a Hemiplegic Upper Limb After Stroke- A Case Report
Ryo Sakai1, Makoto Haraguchi2, Masayuki Kanamori3,
Katsunori Yamada3, Keiji Ishida1, Yasutaka Kobayashi1
1Department of Rehabilitation, Faculty of Health Science, Fukui Health Science University, Japan
Department of mechanical engineering, Faculty of Engineering, Osaka Institute of Technology, Japan3
Department of Rehabilitation Occupational Therapy, Fukui General Hospital, Japan
2

Abstract: Background: Paralysis of the upper limb after stroke affects daily life. Our objective was to examine theclinical effects of our newly developed finger extension splint, which was made by specially processing a shape memory alloy, in a chronic stroke patient.
Design: Comparison of the clinical effects of the splint use pre- and post-treatment.
Patient: A 70-year-old man who developed right thalamus hemorrhage 15 years previously presented with right hemiplegia.
Intervention: Training was performed 30 minutes/day for 10 weekdays for the fingers on the paralyzed side. Taskoriented training, such as block stacking, was performed.
Results: Upper limb function evaluation results (pre vs post-treatment): grip strength, 9.3 vs 12.1 kg; upper-extremity
subtest of the Fugl-Meyer Assessment of Motor Function, 42 vs 54 points; Wolf Motor Function Test (functional ability
scale), 47 vs 50 points; time, 389.2 vs 308.2 seconds, and the Box and Block Test: 11 vs 15 and 8 vs 15 with and without the splint, respectively.
Conclusion: When training was conducted using this splint, improvement of upper limb function was observed.
Keywords: stroke, arm function, splint(Asian J Occup Ther 16: 83−86, 2020)

1. Introduction
Stroke causes motor paralysis in the unilateral
upper and lower limbs due to ischemic or hemorrhagic
lesions in the brain. Increased muscle tension (spasticity)
is difficult to treat and greatly affects activities of dailyliving (ADL).
Orthopedic therapy is used to apply continuous
tension to muscles and joints, mainly to prevent the
progression and deformation of joint contractures associated with spasticity. Although previous studies report
Received: 27 August 2019, Accepted: 16 September 2020
Corresponding to: Ryo Sakai, Department of Rehabilitation, Facultyof Health Science, Fukui Health Science University, 55-13-1 Egami,
Fukui City, Fukui 910-3190, Japane-mail: r-sakai@fukui-hsu.ac.jp©2020 Japanese Association of Occupational Therapiststhat static splints may to be sufficiently effective inpreventing joint contractures due to spasticity [1, 2, 3],attenuation of the effects of spasticity was reported withthe use of dynamic splints, such as dorsal support functional braces [4], dynamic hand splints [5], and spider
splints [6].
The degree of motor paralysis and spasticity varies
between individuals, and it is important to use a splintthat is appropriate for the patient’s condition [7]. Previous studies have shown that each joint needs to beproperly tensioned, but most dynamic splints pull theentire finger, including the interphalangeal (IP) andmetacarpophalangeal (MP) joints. Thus, proper tension
is not applied to each joint. We treated patients by prescribing that they wear spider splints, but we found that,in some patients, the MP joints were excessively extended due to the effect of the balance of muscle tension in
the internal and external muscles. Therefore, as the first

84

FINGER EXTENSION ASSISTANCE SPLINT FOR A HEMIPLEGIC UPPER LIMB AFTER STROKE

Fig. 1. Structure of the finger extension assistance splint. (a) Details of the structure of the finger extension splint. (b) Splint installation.
SMA = Shape memory alloy.

Fig. 2. Comparison of finger extension movement with and without the splint. State of finger extension without the splint (a) and withthe splint (b).

step, we have developed a splint that responds to thedegree of paralysis and spasticity in individual patientsand provides tension to the IP joint independently. In
this study, we used finger extension assistance splints fora chronic stroke patient and report clinical effects basedon a comparative pre- and post-treatment study.

2. Methods
2.1. Structure of orthosis and method of fabrication
We developed a new splint that can support finger
extension in hemiplegic patients with spasticity (Fig.
1). This device uses a shape memory alloy (SMA) wirewith superelastic properties. When the finger is flexed,
the SMA with a bent beam shape is deformed, and an
assist force in the extension direction is generated in the
distal IP and proximal IP joints. To reduce pain in thecontact area, a heat-shrinkable tube with high cushioning properties is placed at the tip and base of the finger.
The material at the base of the finger is a steel wire,
which can handle various finger thicknesses. The lengthof the splint can be altered to fit the individual’s fingers.
Because the degree of spasticity varies between individ-

uals, the assist power of this device can be adjusted bychanging the diameter of the SMA.
2.2. Participant
A 70-year-old man, who developed right thalamus
hemorrhage 15 years earlier, presented with right hemiplegia. Range of motion was reduced in his upper righthand and fingers due to spasticity and muscle shortening, although he could perform ADL independently.
2.3. Interventions and outcomes
The patient trained for 10 days of 2 weeks, 30 minutes/day. Task-oriented training was performed according to previous research [8, 9], with the finger extension
splint attached to II-V fingers (Fig. 2). The patient performed a task of moving beanbags and wooden blocks
as task-oriented training. The difficulty level of the task
was gradually increased according to the success rateof the task, while providing feedback regarding the task
execution time to the patient. Evaluation of upper limb
function was performed pre- and post-intervention andincluded grip strength, upper-extremity subtest of theFugl-Meyer Assessment of Motor Function (FMA-UE),Sakai R et al.

Asian J Occup Ther 16: 83−86, 2020

85

Table 1 Upper limb function evaluation results before and after
training with the splint

Fig. 3. The patient is wearing the splint and is able to movethe blocks (Box and Block Test).

Wolf Motor Function Test (WMFT), Functional Ability
Scale (FAS)/Time, and the Box and Block Test (BBT).
BBT measurements were obtained twice, with and without the splint (Fig. 3). Evaluation of spasticity was with
the Modified Ashworth Scale-elbow, finger (MAS-elbow,
finger).
This research was conducted with the approval of
the Nittazuka Medical Welfare Center Ethics Review
Committee (ethics examination number: Shinrin 28–
71). We explained the study to the subject in writing
and verbally, and obtained consent. The authors declare no conflict of interest.

3. Results
Upper limb function evaluation results, pre- vs posttreatment, were: grip strength, 9.3 vs 12.1 kg; FMAUE, 42 vs 54 points; WMFT FAS, 47 vs 50 points; time,389.2 vs 308.2 seconds; Motor Activity Log-Amount ofUse (MAL-AOU), 0.33 vs 0.41 points; Motor Activity
Log-Quality of Movement (MAL-QOM), 0.30 vs 0.34
points and BBT, 11 vs 15 (when wearing a splint) and 8
vs 15 (when not wearing a splint) (Table 1). There wasno change in MAS.

4. Discussion
In this case, although flexion of the fingers was
possible, voluntary extension movement was weak, andit was difficult to release an item once grasped. Whentraining was conducted using this splint, improvementof upper limb function was observed. Before and after
treatment, the amount of improvement for the patient
was as follows: grip strength was 2.8 kg; the FMA-UE
and WMFT-FAS were 12 and 3 points, respectively; the
WMFT-time was 81 seconds, the MAL-AOU and MAL-

OutcomePre-treatment

Post-treatment

Changevalue

Grip (kg)FMA-UE
MAS-elbow
MAS-finger
WMFT-FAS
WMFT-times (second)
MAL-AOU
MAL-QOM
BBT: without splint
BBT: with splint

9.3
42
1
3
47
389.2
0.33
0.30
8
11

12.1
54
1
3
50
308.2
0.41
0.34
15
15

2.8
12
0
0
3
81
0.08
0.04
7
4

FMA-UE = Upper-extremity subtest of the Fugl-Meyer Assessmentof Motor Function; MAS = Modified Ashworth Scale; WMFT = Wolf
Motor Function Test; FAS = Functional Ability Scale; MAL = Motor
Activity Log; AOU = Amount of Use; QOM = Quality of Movement;
BBT = Box and Block Test
Outcomes with improvements post-treatment are indicated in bold.

QOM were 0.08 and 0.04, respectively; and the BBT
was 7. In comparison, previous studies have reported
a grip strength, according to the Minimum Clinically
Important Difference (MCID), of 2.9 kg, an FMA-UEof 4.25–7.25, 1 point for WMFT-FAS, a WMFT-timeof 19 seconds, 0.5 points for MAL-AOU and QOM,
and a BBT of 5.5 [10, 11, 12, 13]. Thus, although thegrip strength and the frequency of paralyzed hand use
in daily life did not exceed the MCID, the changes inmotor function evaluations such as FMA-UE, WMFT
and BBT did exceed the MCID, which was clinicallysufficient. When this splint is used in conjunction withtask-oriented training, bending and stretching exercisesof the fingers are repeated, and it is considered thatmotor learning effects are produced [5, 9, 14, 15]. Thesestudies suggest that hand splints can be used for motor
learning training and improving neural plasticity, such as
motor cortex priming and reorganization in the brain. In
addition, by performing task-oriented training under theabove-mentioned environment, we believe that the treatment effect will not only extend to finger movements
but also to the entire upper limb. The treatment effect inthis case was not limited to the motor learning effect offinger extension; notably, improvements in grip strengthand object handling ability were observed.
Dynamic splints increase muscle tissue stability,
limit unnecessary movements that impair hand function,
supplement weak muscles, and maintain the naturalanatomical alignment of the hand [16]. Unlike theconventional splint, our splint allows fine adjustment oftension and size for each finger, provides tension parallel to the extension direction of the finger, and provides
appropriate assistance along the normal structure of the

86

FINGER EXTENSION ASSISTANCE SPLINT FOR A HEMIPLEGIC UPPER LIMB AFTER STROKE

finger. In addition, our splint is smaller and lighter, andhas the advantage of being less noticeable in everyday
life situations. We believe that the development of
splints with a structure like ours that follows the anatomy and anatomical functions of the finger is necessary.

5. Study limitations and future researchThis study includes one case. We recommend
further large-scale studies to investigate the state ofmuscle tone more objectively and quantitatively using
physiological tests, such as evoked electromyography.
In addition to this splint, we are developing a splintthat provides separate tension to the MP joint. In the
future, we will study the structure and methodology thatprovide proper tension to the distal interphalangeal andproximal interphalangeal joints, respectively.

Acknowledgments
We thank the students at Fukui Institute of Technology who helped develop this splint, and the staff at therehabilitation section of Fukui General Hospital.

References[1] Blackmore AM, Garbellini SA, Buttigieg P, Wells J. A
systematic review of the effects of soft splinting on upper
limb function in people with cerebral palsy. An AACPDM
Evidence Report. Initial publication in AACPDM Org.
October 2006.
[2] Choi JB, Ma SR, Song BK. The effect of resting hand
splint on hand pain and edema among patients withstroke. J Ecophysiol Occup Hlth. 2016; 16(1&2): 37–41.
[3] Lannin NA, Cusick A, McCluskey A, Herbert RD.
Effects of splinting on wrist contracture after stroke: arandomized controlled trial. Stroke. 2007; 38(1): 111–6.
[4] McPherson JJ, Becker AH, Franszczak N. Dynamic splint
to reduce the passive component of hypertonicity. Arch
Phys Med Rehabil. 1985; 66(4): 249–52.
[5] Chang W-D, Lai P-T. New design of home-based dynamic hand splint for hemiplegic hands: a preliminary study.

J Phys Ther Sci. 2015; 27(3): 829–31.
[6] Tanabe H, Nagao T, Tanemura R. Application of constraint-induced movement therapy for people with severe
chronic plegic Hand. Asian J Occup Ther. 2011; 9(1):7–14.
[7] Hoffman HB, Blakey GL. New design of dynamic orthoses for neurological conditions. NeuroRehabilitation.
2011; 28(1): 55–61.
[8] Nelles G, Jentzen W, Jueptner M, Müller S, Diener HC.
Arm training induced brain plasticity in stroke studied
with serial positron emission tomography. Neuroimage.
2001; 13(6): 1146–54.
[9] Taub E, Uswatte G, Bowman MH, Mark VW, Delgado
A, Bryson C, et al. Constraint-induced movement therapy
combined with conventional neurorehabilitation techniques in chronic stroke patients with plegic hands: a caseseries. Arch Phys Med Rehabil. 2013; 94(1): 86–94.
[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.
[11] 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 chronic
stroke. Phys Ther. 2012; 92(6): 791–8.
[12] 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 singleblind randomized clinical trial. Stroke. 1999; 30(11):2369–75.
[13] Chen H-M, Chen CC, Hsueh I-P, Huang S-L, Hsieh C-L.
Test-retest reproducibility and smallest real difference of
5 hand function tests in patients with stroke. Neurorehabil
Neural Repair. 2009; 23: 435–40.
[14] Prakash J, Mondam S, Srinivasan M, Abbina AK. Effectiveness of dynamic wrist splint on deltoid muscle activity using functional task practice in post stroke patients.
Int J Physiother Res. 2013; 2(2): 30–5.
[15] Pitts DG, O’Brien SP. Splinting the hand to enhance
motor control and brain plasticity. Top Stroke Rehabil.
2008; 15(5): 456–67.
[16] Radomski LCM. Occupational therapy for physicaldysfunction. 6th ed. Baltimore, MD: Wolters Kluwer/
Lippincott Williams & Wilkins; 2007.

■ORIGINAL ARTICLE

Validation of the Developed Eating Activities
Questionnaire in Working People with Disabilities:
A Cross-Sectional StudyYuto Tashiro1, Yuichi Nishida1, Ayaka Yamaoka1, Yusuke Suzuki1,
Takayoshi Horii2, Hiroaki Arai2, Yutaka Yamaguchi2, Naoya Wada2,
Isao Yokota3, Tomoki Aoyama1
1

Kyoto University
OMRON
3
Hokkaido University
2

Abstract: Objectives: There are only a few functional evaluations that non-medical personnel can perform and interpret without guidance. Here, we have created a questionnaire that focused on eating activities, which can be used
to evaluate motor function easily because most people could relate to eating activities. This study aimed to verify thereliability and validity of the developed questionnaire by comparing it with clinical evaluations for upper extremity
function.
Methods: This was a cross-sectional study. Patients who have cerebrovascular disease history with disabilities in theupper limb were included in the study. The questionnaire on eating activities was answered by the patients themselves.
Upper extremity function was evaluated with the Fugl-Meyer Assessment (FMA). Work efficiency was evaluated with
the General Aptitude Test Battery. Reliability of the questionnaire was assessed by test-retest reliability. Validity wasevaluated using a correlation analysis.
Results: The study included 16 participants. The results indicated that all items had sufficient reliability. The correlation
between the questionnaire score of the hand and the FMA score of the wrist, hand, and arm was statistically significant.
Conclusions: The developed questionnaire was reliable and significantly related to clinical evaluation of upper extremity functions. This questionnaire is of great value to patients with stroke to understand their functions.
Keywords: patient-based questionnaire, patient-based medicine, eating activities questionnaire, fugl-meyer assessment,
upper extremity function, work efficiency(Asian J Occup Ther 16: 87−93, 2020)

Introduction
According to a WHO study, more than a billion
people or about 15% of the world’s population are
estimated to live with some form of disability [1]. The
number of people with disabilities is increasing. This isbecause people are aging, and chronic health conditions
with disability are rising. Of patients with stroke, 70%
Received: 24 March 2020, Accepted: 29 September 2020
Corresponding to: Yuto Tashiro, Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University,
53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japane-mail: tashirow.y@gmail.com©2020 Japanese Association of Occupational Therapists

have disabilities in the upper limbs and 40% in thechronic phase [2, 3]. Most people with brain injury wantto live a normal everyday life after the injury, such as
returning to work, earning their subsistence and participating in society [4]. Impairments after stroke often
interfere with activities of daily living (ADLs). Patients
may have difficulties caring for themselves such as indressing, eating, and other daily tasks [5] Work disability is often associated with personal suffering and loss of
income, diminished productivity, increased medical andsocietal costs, and can be addressed through vocational
rehabilitation [6, 7]. This results in limited actions andhas an impact on the level of activity and participationin different life areas [8].
To understand patient’s disabilities, medical staff

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VALIDATION OF THE DEVELOPED EATING ACTIVITIES QUESTIONNAIRE

uses clinical evaluations, expertise, and International
Classification of Functioning, Disability and Health(ICF) concept. Since the aspects of impairments, activities, and participation limitations together with contextual factors are incorporated into the same conceptual
framework, the multidimensional model of the ICF canbe used [9]. In actual rehabilitation scenes, the medical
team follows the clinical pathway and mainly works on
exercise such as muscular strength training, Range of
motion (ROM) exercise, and walking. The ICF participation item (hobbies and work), which can be demandor hope, may be restricted because the medical teamcannot tackle them after patients are discharged. Afterdischarge, patients return to society, and their activities
can be restricted because they do not sufficiently understand how much motor function they have. The crucial
problem is that patients cannot understand their ownfunctions.
The idea of Patient-Centered Medicine (PCM) is
the key to solving this problem. PCM is a concept of
capturing an individual, not a disease [10, 11]. In otherwords, medical staff should understand the characteristics of each patient treat and care so as to suit theperson and improve the therapeutic effect. To increase
the therapeutic effect, it is important for not only the
medical staff but also patients themselves to understandthe state of their own body. There are few functional
evaluations (e.g., Patient-Based Questionnaire) that general people who are not medical personnel can monitor
and understand by themselves [12–14]. Moreover, mostPatient-Based Questionnaires ask about symptoms, pain,or feeling. There are no questionnaires for patients tounderstand their function by themselves. For this reason,
we have developed a function evaluation tool thatanyone can easily perform.
In order to be evaluated by everyone, we developed
the assessment tool based on the ADLs. This includes
walking, transferring, and dressing, but we especially
focused on eating. We assumed that motor functions of
the upper extremities could be evaluated, besides ADLs,
as they rely on various tools (forks, spoons, chopsticks)
and the hands for eating. Kinematic analysis is generally
used in the clinical research to evaluate the effects of
the intervention [15–17] or research motor function
recovery after stroke [18–20]. Kinematic movements
evaluated in the previous studies were limited to pointing or reaching, but in one case a drinking task wasalso evaluated to determine natural movement performance in daily living [21]. People can easily imagine
these movements, but expertise and special tools arenecessary for evaluations. In order to evaluate without
expert knowledge and special tools, we developed anevaluation tool using a questionnaire, assigned scoresfor each function of the upper extremities, and created aconversion table so that the person with disabilities canvisualize their own motor function. Anyone can evaluate their motor functions using the questionnaire if its
contents and scores are related to the clinical evaluation.
Additionally, from the viewpoint of vocational rehabilitation, there is a possibility of finding work by easily
evaluating motor function in a patient-oriented manner.
Thus, this study aimed to verify the reliability andvalidity of the developed questionnaire by comparing
it with the clinical evaluation of motor function. In addition, the upper limb function and work efficacy werealso analyzed together.

Methods
Study design
This was a cross-sectional study.
Subjects
We targeted physically handicapped persons who
mainly have upper limb dysfunction. In July 2018, at
a place where many persons with physical disabilities
work without utilizing cognitive function, the facility
manager invited all staff with disabilities of the upper
limbs and obtained measurements of those who provided consent. Measurements were carried out within
the facility. The ethics committee of Kyoto University
approved the study (No. R1612). Informed consent was
obtained from all participants before enrollment. The
eligibility criteria included (1) impairment in the upper
limbs and (2) a history of cerebrovascular disease. The
exclusion criteria included (1) inability to use the fingers
and upper limbs on both sides, (2) severe neurologicaldisease, (3) severe cardiovascular disease, and (4) significantly low cognitive function.
Measurement item
The following measurement items were evaluated:(1) basic information (age, sex, past medical history),(2) Eating Activities Questionnaire (the questionnaire
on movements in eating), (3) Fugl-Meyer Assessment(FMA, clinical assessments of upper extremity function), and (4) General Aptitude Test Battery (GATB,
work efficiency).
Basic information
Data on age, sex, past medical history, and strengthof disabilities were self-reported by the participants(Appendix 1). Data on the dominant hand and paralyzed
side were also reported.

Tashiro Y et al.

Asian J Occup Ther 16: 87−93, 202089

Fig. 1. A peg board and a finger dexterity board.
Rods are replaced from the upper row to the lower one.
Subjects assembled and/or dissembled the nails and washers.

Eating Activities Questionnaire
An orthopedic surgeon, a physical therapist, and afactory manager working with persons with disability
created this questionnaire. We analyzed the necessary
upper limb functions and observed their eating behavior
related to the action. The upper limb functions required
for each dietary movement were analyzed and weighted
with points. The researchers filled out the questionnaireas they listened to the responses of the subjects.
Questions about various daily meal actions canbe answered with can or cannot. The contents of thequestionnaire are about drinking, eating with a fork or
chopsticks, and so on (Appendix 1). In each question,
we extracted the necessary upper limb functions and independently weighted point (a) (Appendix 2). Moreover,point (b) is 1 if the answer to each question was “Yes”,
and it was 0 if the answer was “No.” By multiplying (a)and (b), the score is calculated. The maximum score is
80 points for the total items about the fingers, 37 points
for the total items about the arm, and 17 points for the
total items about the trunk. The minimum score is 0 foreach part.
We asked the questionnaire again one week after
the first measurement for test-retest reliability.
Clinical assessments of upper extremity functions
We evaluated the upper extremity functions by the
Fugl-Meyer Assessment (FMA) [22]. The test on theupper limb consists of four parts (A, arm; B, wrist; C,
hand; and D, coordination). The score is based on theability to perform isolated movements within and outof synergy patterns. There are 33 items, and each item
is graded from 0 to 2 points. The maximum score is 66

points. We measured not only the paralyzed side but
also the healthy side to compare with that in the Eating
Activities Questionnaire.
Work efficiency
Work efficiency was evaluated using the General
Aptitude Test Battery (GATB) [23], which was developed in the USA and revised for the Japanese populationby the Ministry of Health, Labor and Welfare. There are
12 paper tests and 4 apparatus tests, but we conducted
only the apparatus tests in this time. It can evaluate twofunctions: (1) arm dexterity and (2) hand dexterity. Arm
dexterity is evaluated by two tests with a peg board, andhand dexterity is evaluated by two tests with a finger
dexterity board (Takei Scientific Instruments, Niigata,Japan) (Fig. 1).
(1)-1: The number of rods that were replaced from theupper row to the lower one with their paralyzed
upper extremity in 15 s is counted. After performing the test three times, the best score is converted
to the final score using a conversion table. The
maximum score is 139, and the minimum score is-67.
(1)-2: The number of rods that were turned over withthe paralyzed upper extremity in 30 s is counted.
After performing the test two times, the best scoreis converted to the final score. The maximum
score is 156, and the minimum score is -104.
(2)-1: Subjects combine nails and washers and pierce
the pairs into a hole with their paralyzed arm.
An observer counts the pairs they combined andpierced in 1 min 30 s. They can try the test only
once, and the score is converted to the final one.

90

VALIDATION OF THE DEVELOPED EATING ACTIVITIES QUESTIONNAIRE

The maximum score is 156, and the minimumscore is -30.
(2)-2: Subjects disassemble the combined nails andwashers, insert the nails into the hole on the upperstage, and attach the washers to the stick with
their paralyzed hand. An observer counts thepairs they disassembled in 1 min, and the result isconverted to the final score. The maximum scoreis 91, and the minimum score is -34.
Sample size
The sample size in the correlation analysis was calculated using the G*Power 3 program (Heinrich-HeineUniversität Düsseldorf, Düsseldorf, Germany). A sample
size of test-retest reliability of 10, 7, and 5 for detecting the value of ICC of 0.7, 0.8, and 0.9, respectively,
involved two observations. A sample size of 13 wasnecessary for the analysis, with a planning value of correlation of 0.61, alpha = 0.05, and power = 0.8 [24].
Statistical analysis
To confirm the reliability of the Eating Activities
Questionnaire, the total scores of both arms, both hands,
and trunk were compared between the first and second
results of the questionnaire. We filled the questionnaire
again 1 week after the first measurement for test-retest
reliability, which was estimated by intraclass correlation
coefficient (ICC) [25, 26]. ICC was calculated using the
SPSS version 20.0 software (SPSS, Chicago, IL, USA).
The validity was investigated by correlation analy­
sis [24]. Results on the paralyzed side were used foranalysis in consideration of the ceiling effect. The
Spearman’s rank correlation coefficient was calculatedwith the questionnaire results, FMA, and GATB. The
correlation analysis was performed using JMP Pro
version 12.2 (SAS Institute, Cary, NC, USA), with a
P-value < 0.05 considered as significant.

Results
The total number of subjects was 16. Of the 16 subjects, 10 (62.5%), who were available for measurement
for the second time, retested the questionnaire after 7
days. Basic information (age and sex), questionnaire
results, and FMA and GATB scores are shown in Table 1.
Reliability
Test-retest reliability is shown in Table 2. The ICC
value was 1.00 (95% confidence interval [CI], 1.00 to1.00) for the right arm, 0.869 (95% CI, 0.526 to 0.969)
for the left arm, 0.994 (95% CI, 0.974 to 0.999) for theright hand, 0.883 (95% CI, 0.570 to 0.972) for the left
hand, and 1.00 (95% CI, 1.00 to 1.00) for the trunk.

Table 1 Subjects’ characteristics*    Variables
Age (years)
Men (%)
Dominant hand (right)
The Questionnaire (point)
Arm
Hand
Trunk
Fugl-Meyer Assessment (point)
Arm
Wrist
Hand
Work efficiency (point)
Test 1
Test 2
Test 3
Test 4
Arm
Hand

Subjects (n = 16)
48.75 ± 10.33
13 (81.3)
9 (56.2)
13.88 ± 15.39
28.56 ± 31.60
12.5 ± 5.63
19.81 ± 12.55
4.31 ± 4.21
6.44 ± 6.43
−60.25 ± 5.29
−89.31 ± 11.64−13.44 ± 13.86−18.19 ± 12.32−149.56 ± 16.00−31.63 ± 25.70* Values are mean ± SD or percentage.

Overall, these results indicated that all items had sufficient reliability [27].
Validity
The correlations among the questionnaire, FMA,
and GATB scores for the hand are shown in Fig. 2. A
significant correlation was found between the questionnaire score of the hand and FMA score of the wrist (r =0.746) and hand (r = 0.847). However, there was nocorrelation (r = 0.136) between the questionnaire scoreof the hand and the GATB score of hand dexterity andbetween the FMA score of the wrist (r = 0.372) or hand(r = 0.443) and the GATB score of hand dexterity.
The correlation among the questionnaire, FMA,
and GATB for the arm is shown in Fig. 3. There was asignificant correlation (r = 0.858) between the questionnaire score of arm and the FMA score of the arm. There
was no correlation (r = 0.310) between the questionnairescore of arm and the GATB score of arm dexterity, buta weak correlation (r = 0.593) was found between the
FMA score of arm and the GATB score of arm dexterity.

Discussion
In this study, the Eating Activities Questionnaire
was examined along with the traditional clinical assessment (FMA) and work efficiency assessment (GATB).
The test-retest reliability of the Eating Activities
Questionnaire was confirmed, and upper limb functions
per the questionnaire and FMA were significantly correlated. There was no significant correlation between thequestionnaire and work efficiency.

Tashiro Y et al.

Asian J Occup Ther 16: 87−93, 2020

To evaluate reliability, test-retest reliability is commonly used. As shown in Table 2, since the ICC between
the questionnaires given twice was significantly higher[28], its reliability was certain [29]. People with disabilities could easily understand questions and sentences ofthe developed questionnaire, and there was always no
influence on interpretation. The confidence interval waswide in the upper left limb, probably because of a large
number of right-handed subjects in the study.
In this study, upper limb functions per the questionnaire and FMA were significantly correlated. The
research team independently evaluated the eating movements and constructed an algorithm for estimating upper
limb function, but as a correlation was found with theindex that has been used in the past, it may be sufficientfor functional evaluation. Previous studies have shown
the association between kinematic movements such as
drinking task and FMA [17]. The drinking task also includes reaching, grasping, and lifting the glass from thetable. Although the kinematic movement in the drinking
task may be a subjective and qualitative assessment, theelements included in the kinematic movement are consistent with those of clinical assessments (FMA, ARAT).
The correlation between kinematic movements and clinical assessments is due to this consistency. In this study,
since the contents of the questionnaire are kinematic
actions such as a drinking and grasping something to eat
with the hand, it is thought that the relationship between
the questionnaire and FMA was strong. From theseresults, it is possible to grasp the upper limb functionof the patient with stroke from the questionnaire on theeating activities.
There was no significant correlation between thequestionnaire and work efficiency because work efficacy includes elements of technology and speed; it may
not have been dependent on simple functions. Fromthe point of motion control, the movement is closely
related to the individual, task, and environment. It has
been also reported that the exercise of muscles of upper
limb changes depending on the height of the desk [30]and in this study, the motor functions of the personwith disabilities might not be fully measured underuniform conditions. Because it includes elements suchas smoothness and time, it is thought that its association
with motor function evaluation was low. This is why thequestionnaire was not directly related to work efficiency.
On the contrary, people with disabilities can determine
their motor function from this questionnaire. Therefore,
it is different from the previous questionnaire that they
can assess themselves regarding daily life and social activities by understanding what they can presently do andwhat they are not good at. It is also possible to obtainthe necessary abilities and circumstances to be able to

91

work.
There are several limitations in this study. First, although a significant correlation was seen, the number ofsamples was small. In order to use the FMA index, thedisease was limited to cerebrovascular disease; but theeating activities questionnaire created could be used toevaluate upper limb function regardless of the disease.
Thus, the number of samples should be increased in the
future studies.
Second, because GATB involves only assemblingor replacing, the content may not be insufficient asevaluation of work efficiency (e.g., typing). Third, there
were few female subjects. Fourth, this was a crosssectional study. Therefore, any cause-effect relationshipamong the questionnaire, FMA, and GATB remains
unknown.
In the future, it is thought that the questionnaire willbe the cutting edge for disabled persons’ return to society, employment support, and support for hobby activities. When generally used as a function evaluation tool,
it is important to apply the questionnaire in not only
functional evaluation but also a wide range of diseases(muscular dystrophy, multiple sclerosis, etc.) and fields(manufacturing, processing industry, desk work, etc.). It
may also be used as an evaluation of rehabilitation [31].
In this study, the reliability of the developed questionnaire was confirmed, and the validity of that on
motor function and work efficiency was investigated.
The questionnaire was found to be significantly related
to the clinical assessment of upper extremity functions
in patients with stroke. Since the Eating Activities Questionnaire is a self-writing type questionnaire and canconvert scores, it is possible to self-monitor the motor
functions. Using this questionnaire, people can evaluate
themselves and understand their functions.

Acknowledgments
The authors thank the staff and workers at Omron
Kyoto Taiyo and Taiyo no Ie for their help with the datacollection. We also thank Editage (www.editage.jp) for
the English language editing.

Disclosures
Approval of the research protocol: This study wasapproved by Ethic Review Committee in this facility(approve No. R1612) regarding research protocol including the voluntary participation, do not harm, confidentiality, anonymity and only assess relevant componentsof this study. Informed consent: In this study, we explained about this research sufficiently in document andoral to those who would participate beforehand, then this92

VALIDATION OF THE DEVELOPED EATING ACTIVITIES QUESTIONNAIRE

study targeted for only those who gained consent fromthe person’s free will. Explained items were following:
the title and outline of this research including the objective, measurement items and its duration, disadvantages
arising from becoming subjects, freedom of refuse
to become subjects at any time, be able to withdraw
consent from as required even after subjects and theirfamily agree, protection of privacy and no reward ispaid. Registry and the registration no. of the study/trial:
N/A. Animal studies: N/A.

Author Contribution
YT wrote this paper. TH, HA, YY, NW conducteddata collection. YT, YN, AY, YS, IY, TA designed study.
YT, YN, AY, YS analyzed data. All co-authors confirmed
this research.

Funding
This study was supported by the Japan Agency for
Medical Research and Development.

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■ORIGINAL ARTICLE

Practical Usefulness of Clothes Hangers HungOver Chair Backrests to Dry Pullover Garments
Among Healthy Individuals and Patientswith Hemiplegia
Honami Tachibana1, Takaki Kafuku2, Yoko Kimura2, Miyuki Nakagawa2,
Terumi Kawaguchi3, Hiromi Fujii4, 5, Kazutaka Sakamoto5, Kazumi Hirayama4, 5
1

Gonohe General Hospital
Tohoku Medical College
3
General Rehabilitation Mihono Hospital
4
Yamagata Prefectural University of Health Sciences, and the Area of Occupational Therapy
5
Graduate School of Health Sciences, Yamagata Prefectural University of Health Sciences
2

Abstract: Purpose: Hanging washed pullover garments to dry with one hand poses a challenge in daily life forpatients who are forced to use their unilateral upper extremity. We hypothesized that a hanger hooked onto the backrestof a chair (backrest hanger) would facilitate easy hanging of pullover garments that need to be dried with one hand; inparticular, one can place a pullover garment on the backrest hanger and then pull the hanger along with the garment
upward to separate them from the backrest. The present study aimed to demonstrate the practical usefulness of a backrest hanger for patients with hemiplegia.
Methods: This study included 20 healthy volunteers and 16 patients with hemiplegia. Participants were requested tohang a sweatshirt to dry with one hand only (the non-dominant hand for healthy volunteers and the non-paralytic handfor patients with hemiplegia) using a backrest hanger, pinch hanger, and a bath towel rack. Patients with hemiplegia
performed the task after being instructed regarding how the greatest number of healthy individuals used each tool.
Participants were requested to rate their level of ease in hanging the sweatshirts, and the total time required to complete
the task was measured.
Results: Both healthy volunteers and patients with hemiplegia reported the backrest hanger to be the easiest mode of
hanging sweatshirts, and it required significantly shorter amount of time as compared to the other two tools.
Discussion: The findings indicate the high practical usefulness of the backrest hanger method.
Keywords: hanging, washed garments, hemiplegia, chair backrest(Asian J Occup Ther 16: 95−101, 2020)

1. Introduction
Pinch hangers, bath towel racks, and clothes hangers are often used for hanging washed pullovers to dry.
Hanging clothes with one hand is not easy, irrespectiveof the tools used [1]. This particularly poses a challenge
to patients with orthopedic diseases and hemiplegia,
Received: 30 May 2020, Accepted: 7 October 2020
Corresponding to: Honami Tachibana, Gonohe General Hospital, 17-3,
Sawamukai, Sannohe Gun Gonohe Machi, Aomori, 039-1517, Japane-mail: takakafu@rinken.ac.jp©2020 Japanese Association of Occupational Therapists

as they are forced to use the unilateral upper extremity
owing to various reasons. Among the abovementioned
tools, clothes hangers are best suited for hanging
pullover garments considering the appearance of dried
garments. However, hanging a washed pullover garment
on a clothes hanger is a task that is usually considered to
be extremely difficult to accomplish without the use ofboth hands because one hand inserts the hanger inside
the garment, and the other adjusts the garment’s positionon the hanger. One method for hanging front-opening
garments with one hand requires one to first hang thegarment on a chair’s backrest, insert the hanger into thegarment by using the opening in front of the garment,

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UTILITY OF CHAIR BACKREST TO HANG GARMENTS

Fig. 1. Tools used for hanging.
Backrest hanger (left), pinch hanger (center), and bath towel rack (right). The arrow on the backrest hanger denotes a hook tohang the clothes on the backrest.

and finally pull the hanger’s hook upward along withthe garment [2]. However, this method is inconvenient
for hanging pullover garments. We hypothesized thata clothes hanger hooked onto the backrest of a chair(backrest hanger) would facilitate better hanging for
pullover garments that need to be dried with one hand;in particular, one can place a pullover garment on abackrest hanger and then pull the hanger along withthe garment upward in order to separate them from thebackrest.
This study aimed to demonstrate the usefulness of abackrest hanger for one-handed clothes hanging by observing healthy volunteers and patients with hemiplegia
who used only one hand to attempt to hang a pullover
garment on a backrest hanger, a pinch hanger, and abath towel rack; after this the results for each tool werecompared.

2. Methods
Participants
The study included 20 healthy volunteers (11women; Mage = 21 ± 2 years; range = 18–31 years),and 16 patients with hemiplegia due to cerebral infarction or hemorrhage (10 women; Mage = 64 ±13 years;
range = 44–85 years). The median intelligence of bothgroups was scored using the Hasegawa Dementia Rating
Scale-Revised [3]. The score for the healthy sample
was 30/30 points (range = 29–30 points), while, for thehemiplegic patients, it was 26/30 points (range = 24–29
points). All patients were in the chronic phase and regularly visited the daycare facilities.
This study was conducted in accordance with
the Declaration of Helsinki after approval from theInstitutional Review Board of Tohoku Medical College(approval number, 411). All participants provided writ-ten consent after receiving a detailed explanation of thestudy.
Equipment
The participants performed tasks while sitting ina chair in order to prevent themselves from falling [4].
Participants were requested to hang a washed pullover
garment with one hand using a backrest hanger, pinch
hanger, and bath towel rack as shown in Fig. 1. The
pullover garment used in this task was a sweatshirt (dryweight, about 430 g) that was washed and dewatered for7 minutes (weight after dewatering, about 620 g). The
sweatshirt was placed in a basket within the reach of theparticipant. A backrest hanger was prepared by hanging
a clothes hanger over a chair backrest via a wire hookattached to the backrest, as indicated by the arrow in
Fig. 1. A pinch hanger was used by hanging it on a laundry pole.
Participants hanging the pullover garment to dry
were recorded at 30 frames per second using two digital
video cameras (NV-GS300; Panasonic Inc, Osaka). The
camera was set at lateral side from the side of the handused for the task and another camera was set diagonallybehind on the opposite side. Images from these twovideo cameras were recorded synchronously and analyzed with a digital motion picture waveforms real-timesynchronous recording system (The Teraview, Gigatex
CO., Ltd.) for analysis.
Procedure
Healthy participants were included in Experiment 1,
while patients with hemiplegia were included in Experiment 2.
Experiment 1. Participants were requested to hanga sweatshirt to dry in any way using only their nondominant hand and three tools mentioned above. Their

Tachibana H et al.

Asian J Occup Ther 16: 95−101, 2020

order was counterbalanced, and the experiment was conducted after the participants had practiced to satisfaction.
After completing the task with all the three tools, theparticipants were asked to subjectively rate how easily
the sweatshirt was hung to dry with respective tools.
Furthermore, after the sweatshirt had dried, the participants were asked if they would wear it as is and go out.
Subsequently, we reviewed video images of allhealthy participants and measured the total time required
to hang a sweatshirt with each of the tools (hereinafterreferred to as “hanging operation time”). In addition, we
selected the method of hanging adopted by the largest
number of participants for each tool, summarized the
key points, and used them for the participants of Experiment 2. We instructed how to hang a sweatshirt to thepatients depends on the results of Experiment 1, sincethose patients have never washed cloth after stroke.
The sweatshirts were hung to dry indoors synchronously with respective tools, as explained to patientswith hemiplegia in Experiment 2, and lengths of timerequired for drying (hereinafter referred to as “dryingtime”) were measured. When the bath towel rack wasused, however, one side of the sweatshirt was dried, andthen turned over for the other side to dry, as the sweatshirt was held in half.
Experiment 2. Patients with hemiplegia wererequested to hang a sweatshirt to dry with their nonparalytic, using the three tools mentioned above. An
examiner provided instructions regarding the hanging
process for each tool, and patients performed the task
after practicing to satisfaction. The three tools wereagain counterbalanced, and the participants were asked
to subjectively rate their ease in hanging the sweatshirt
to dry, and whether they would wear it as is and go out.
Further, the time taken to hang the sweatshirt was measured for each of the tools.
Analysis
Overall, four aspects were analyzed:
Subjective assessment of ease of hanging. The
participants rated the tasks as “very easy,” “somewhat
easy,” “neither easy nor difficult,” “somewhat difficult,”
or “very difficult”. Total responses for each of the options were counted.
Finish and acceptability of sweatshirts to be worn
outside. Drying was considered done when the weightof the sweatshirt became equal to its dry weight measured before washing. In addition, the participants wereasked if they felt comfortable wearing those sweatshirts
outside, and the yes/no responses were counted.
Hanging operation time. The duration required tocomplete the hanging task (from removing the sweatshirt from the basket to taking the hand off of the hung97

sweatshirt) was measured using video images. The total
hanging operation time for all three tools was comparedusing the Friedman test both in the Experiment 1 and 2.
If differences were observed, data with the 3 tools were
subjected to 2-group comparisons by Wilcoxon’s signed
rank test, and the significance level was < 1.6% after
Bonferroni correction. In Experiment 2, any patient who
could not use a tool was excluded from comparison.
Furthermore, the hanging operation time for healthy
participants and those with hemiplegia was comparedfor each tool. Mann-Whitney U test was used to test
differences, and the significance level was < 5%.
Drying time. The duration from when a dewateredsweatshirt was hung until when the sweatshirt wasconsidered dry was measured. A hung sweatshirt wasconsidered dry when its weight became equal to its dry
weight measured before washing

3. Results
Experiment 1 (Healthy Volunteers)
Subjective assessment of ease of hanging. The
backrest hanger was rated as the easiest tool to use(Table 1).
Finish and acceptability of sweatshirts to be worn
outside. The sweatshirts hung to dry with backrest
hangers had nearly intact shape (Fig. 2, left). Thosehung to dry with pinch hangers had marks and werestretched where clothespins were placed (Fig. 2 middle,
circled). Those dried using bath towel racks had a markof the bar where folded (Fig. 2 right, arrow). Sweatshirts
dried using backrest hangers were deemed comfortable
to wear and go out by the majority of participants (Table
1A).
Hanging operation time. The median (interquartile
range) of hanging operation time were 18.1 (14.8–20.2)
sec, 57.0 (38.4–79.7) sec, and 35.7 (26.6–39.5) sec,
respectively (Table 1A). Shortest duration was required
to complete the hanging task using the backrest hanger,
followed by the bath towel rack, and then the pinch
hanger ( p < .01).
The most commonly used way of hanging. Figure
3 displays the most commonly used way of hanging
backrest hangers (a), pinch hangers (b), and bath towel
racks (c). The methods shown in the figure were usedby 12, 20, and 7 participants, respectively. The mostcommonly used way of hanging sweatshirt using abackrest hanger was as follows: The arm is inserted into
the neck hole of the sweatshirt to reach the hem andthe sweatshirt is lifted up; then the hanging side of thehem is placed on the backrest to start covering the sideipsilateral to the arm being used; while retaining thearm in the sweatshirt, the arm is moved on the backrest

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UTILITY OF CHAIR BACKREST TO HANG GARMENTS

Table 1. The responses of healthy volunteers and patients with hemiplegia to different tools.

A. Experiment 1 (healthy volunteers)
Assessment of ease of hanging (number of subjects)
Very easy
Somewhat easy
Neither easy nor difficult
Somewhat difficult
Very difficult
Clothes were comfortable to wear and go out in?
Yes
No
I do not know
Hanging operation time (seconds)
Overall subject population
Subjects who hung the tool to dry according to the
instructions provided to the patients with hemiplegia
Drying time (hours)
B. Experiment 2 (patients with hemiplegia)
Assessment of ease of hanging (number of subjects)
Very easy
Somewhat easy
Neither easy nor difficult
Somewhat difficult
Very difficult
Clothes were comfortable to wear and go out in?
Yes
No
I do not know
Number of subjects who completed the hanging task
Hanging operation time (seconds)

Backrest hanger

Pinch hanger

Bath towel rack

14
6
0
0
0

0
0
1
2
17

7
7
6
0
0

20
0
0

0
20
0

12
8
0

18.1 (14.8–20.2)

57.0 (38.4–79.7)

35.7 (26.6–39.5)

16.9 (14.5–19.2)

57.0 (38.4–79.7)

32.4 (25.2–38.4)

8

8

12

13
3
0
0
0

0
0
0
0
16

0
11
5
0
0

2
0
14
16
16.9 (15.1–28.6)

0
2
14
12
48.4 (34.0–62.3)

0
2
14
16
28.7 (19.5–54.3)

P value*< 0.01*< 0.01*

The hanging operation time lengths for all healthy volunteers are shown in mean form (standard deviation). The hanging operation time
lengths for healthy volunteers who hung a sweatshirt to dry according to the instructions provided to the patients with hemiplegia and thehanging operation time lengths for patients with hemiplegia are shown in median form (interquartile range).
* Wilcoxon’s signed rank test ( p < .016): Backrest hanger < Pinch hanger, Bath towel rack < Pinch hanger, Backrest hanger < Bath towel rack

Fig. 2. Appearance of dried sweatshirts.
Sweatshirts dried using a backrest hanger (left), pinch hanger (center), and bath towel rack (right). Circles in the center panel
indicate hem areas of the pinch hanger-dried sweatshirt where clothespin marks and stretches were observed. The arrow in theright panel denotes the mark of a rod of the bath towel rack.

Asian J Occup Ther 16: 95−101, 2020

Tachibana H et al.

99

Fig. 3. Most commonly used methods of hanging with different tools
Methods of hanging with backrest hanger (a), pinch hanger (b), and bath towel rack (c). Photographs in column (1) in (a) and (b)were taken from the side of the hand being used. Photographs in columns (2)–(6) in (a) and (b) and those in columns (1)–(2) in (c)were taken from diagonally behind the opposite side of the hand being used.
(a) Method of hanging with a backrest hanger.
(b) Method of hanging with a pinch hanger. A sweatshirt is placed on the thigh; the left or right hem is held with the ring finger,
little finger, and palm; the hem was pinched with a clothespin attached to the pinch hanger using the thumb and index finger.
At this stage, the pinch hanger rotates and tilts as the clothespin is not at the center position of the pinch hanger. The otherside of the hem is identified, held with the ring finger, little finger, and palm; the direction and height of the pinch hanger isadjusted using the thumb and index finger, and then the hem is pinched with another clothespin to complete the hanging task.
(c) Method of hanging with a bath towel rack. A sweatshirt is placed on a bath towel rack. The neck hole of the sweatshirt is held
and inserted into the space between one rod and another. Arms of the sweatshirt are then inserted between the rods and pulledleft and right to stretch. Finally, the hem is inserted between the rods to complete the hanging task.

first horizontally to the other side, then downward sothat the sweatshirt covers the entire backrest, including
the opposite surface; then the hanger is pulled up to
detach it with the sweatshirt from the backrest; and thiscompletes the hanging operation with a backrest hanger.
Operations with other tools are shown in lower tiers in
the figure. Patients with hemiplegia were instructed touse these ways of hanging in Experiment 2.
Drying time. The total drying time when using
backrest hangers was comparable with that of pinch
hangers, and 30% shorter than that of bath towel racks(Table 1A).

Experiment 2 (Patients with Hemiplegia)
Subjective assessment of ease of hanging. The
backrest hanger was rated as the easiest tool to use.
Finish and acceptability of sweatshirts to be worn
outside. Finished sweatshirts after drying were characterized similarly as in Experiment 1. Fourteen patientssaid, “I do not know because I do not usually wear
sweatshirts.” The remaining two patients answered OK
for the backrest hanger, but not OK for other tools.
Hanging operation time. Four patients could notcomplete the hanging task using a pinch hanger. The
median (interquartile range) of hanging operation time
were 16.9 (15.1–28.6) sec, 48.4 (34.0–62.3) sec, and28.7 (19.5–54.3) sec, respectively (Table 1B). The

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UTILITY OF CHAIR BACKREST TO HANG GARMENTS

duration required to complete the hanging task using
a backrest hanger was significantly shorter than that
required using either of other two tools ( p < .01). In addition, there were no significant differences in hanging
operation time between patients with hemiplegia andhealthy participants who used the same ways of hanging
for respective tools.

4. Discussion
Results from these experiments demonstrated that,among the three tools, the backrest hanger was theeasiest and quickest one to hang a sweatshirt to dry for
healthy volunteers. They reported that they would be
comfortable going out wearing the sweatshirts driedusing backrest hangers. The backrest hanger was theeasiest tool to hang a sweatshirt to dry also for patientswith hemiplegia. When pinch hangers were used, four
patients could not complete the hanging task, indicatingthat the pinch hanger may not always be suitable forpatients with hemiplegia. Moreover, even in the comparison that excluded these patients, the backrest hanger
had the shortest drying operation time among the three
tools. These findings suggest that backrest hangers are
more practically useful to hang pullover garments to dry
than pinch hangers or bath towel racks for both healthy
individuals and patients with hemiplegia.
When using a pinch hanger, the participants had
to correct its position during the task (Fig. 3b). With
respect to the bath towel rack, participants had to horizontally pull both sides of the sweatshirt hung on a rod
several times to prevent wrinkle formation (Fig. 3c).
The backrest hanger did not require any of these actions. Relatively simple series of actions were required
to cover the backrest with a pullover garment, so theparticipants did not fail often. This is presumably why
the backrest hanger was considered easy to use andrequired a shorter duration to complete the hanging task.
For pinch hangers, several methods to solve difficulties
in the hanging operation were reported, including amethod of placing a pinch hanger on the table thenstarting the hanging operation [5], the use of a pinch
hanger designed for one-hand users [6], and a method of
attaching a curtain hook to each clothespin, putting suchclothespins on a garment on the table, and hanging thegarment over a pinch hanger through the curtain hooks[7]. However, irrespective of the methods used, the dried
garment had marks and stretched where a clothespin
was put, as shown in the center of Fig. 2. Consequently,
we consider the use of a backrest hanger to be favorable
than any of the previously reported methods.
As a pullover garment, we did not use a sweater orundershirt that is often worn by individuals in the agegroup of hemiplegic patients in this study. In addition,
we did not directly ask with which method the finishedgarments were most preferable. As a result, we wereuncertain about how the patients with hemiplegia felt
regarding the finish with different tools. Nevertheless,sweaters and undershirts hung to dry using respective
tools are expected to have similar characteristics to thoseseen in this study. The use of backrest hangers is likely
to be most preferred as it does not leave any pinch mark,stretch, or folding line.
No significant differences were observed between
heathy participants and patients with hemiplegia interms of the time required to complete the hanging task
for all the tools. In other words, patients with hemiplegia could complete the task in the same amount of timeas the healthy participants albeit the backrest hanger
method being new to them.
Limitations and Future Directions
In this study, participants with hemiplegia werelimited to chronic-phase patients capable of attending a
daycare service facility. In addition, patients with severe
higher brain dysfunction were not included. Therefore,
it remains unclear whether the backrest hanger method
has a similar level of usefulness in acute-phase patientsor patients with severe higher brain dysfunction. For
example, the method may be difficult for patients withamnesia because they have to remember how to use
the backrest and hanger they have never used before. It
is conceivable that the method is similarly effective inpatients who are forced to use the unilateral upper limb
due to orthopedic diseases; however, this has not been
demonstrated. In the future, the practical usefulness of
this method should be tested in other patient populations, such as acute-phase patients, patients with higher
brain dysfunction, and patients with orthopedic diseases.
In the present study, we studied one part of the wholeprocess of washing clothes. Thus, in the future study,
it should be important to focus on the whole process of
washing clothes as daily activity.

5. Summary and Conclusions
We requested healthy volunteers and patients withhemiplegia to hang a sweatshirt to dry by using only one
hand to operate three tools: a backrest hanger, a pinch
hanger, and a bath towel rack. Next, the participants
were requested to rate their level of ease in hanging thesweatshirts, and the time they took to complete the task
was measured. Both healthy volunteers and patientswith hemiplegia reported that the backrest hanger was
the easiest tool to use for hanging sweatshirts, and it required a significantly shorter amount of time comparedAsian J Occup Ther 16: 95−101, 2020

to the other two tools. The study findings thus indicatedthe high practical usefulness of the backrest hanger
method.

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

Acknowledgments
We are grateful to Keiko Endo for her constantsupport and insightful comments.

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