Adjusting Challenge-Skill Balance to Improve Quality of Life in Older Adults: A Randomized Controlled Trial

Adjusting Challenge–Skill Balance to Improve Quality of
       Life in Older Adults: A Randomized Controlled Trial

                                                                Ippei Yoshida, Kazuki Hirao, Tetsushi Nonaka

                                                                OBJECTIVE. We sought to investigate whether occupational therapy that includes adjusting the challenge–
                                                                skill balance improves health-related quality of life (HRQOL) for older adults in comparison with standard
                                                                occupational therapy.
                                                                METHOD. In this single-blind, randomized controlled trial, 56 older adults were assigned to two groups
                                                                that received 10 sessions of occupational therapy with and without adjustment of challenge–skill balance.
                                                                The primary outcome was change in HRQOL after 10 sessions of occupational therapy.
                                                                RESULTS. Significant differences were observed in HRQOL using the EuroQol–5 Dimension score (p 5
                                                                .022, d 5 0.76) and the eight-item Short-Form Health Survey scores for general health (p 5 .001, d 5
                                                                0.99) and in flow experience using the Flow State Scale for Occupational Tasks (p 5 .008, d 5 0.82).
                                                                CONCLUSION. Assessment and adjustment of the challenge–skill balance of activities may effectively
                                                                improve older adults’ HRQOL.

                                                                Yoshida, I., Hirao, K., & Nonaka, T. (2018). Adjusting challenge–skill balance to improve quality of life in older adults: A
                                                                      randomized controlled trial. American Journal of Occupational Therapy, 72, 7201205030.

                                                                O    ccupational therapy is a client-centered health profession concerned with
       Ippei Yoshida, MS, OTR, is Assistant Section Manager,
       Harue Hospital, Fukui, Japan; and Doctoral Candidate,
                                                                     promoting health and well-being through occupation (World Federation of
       Department of Occupational Therapy, Graduate School of
       Human Health Sciences, Tokyo Metropolitan University,    Occupational Therapists, 2010). Its primary goal is to enable people to par-
       Tokyo, Japan;                     ticipate in the activities of everyday life. Underlying occupational therapy
                                                                theory and practice is the reported relationship between occupation and health
       Kazuki Hirao, PhD, OTR, is Assistant Professor,
       Department of Occupational Therapy, Kibi International
                                                                and well-being (Townsend, 1997; Wilcock, 1993). A deeper understanding of
       University, Okayama, Japan.                              how occupations pertain to health and well-being can enable the provision of
                                                                more efficient occupational therapy services.
       Tetsushi Nonaka, PhD, is Associate Professor,                 Client-centered practice, which embraces a philosophy of respect for, and
       Graduate School of Human Development and
       Environment, Kobe University, Hyogo, Japan.
                                                                partnership with, the people receiving services, is increasingly advocated to support
                                                                the realization of meaningful occupation for clients (Falardeau & Durand, 2002;
                                                                Law, Baptiste, & Mills, 1995; Palmadottir, 2003; Sumsion & Smyth, 2000;
                                                                Taylor, 2003). Its success depends on the desire and ability of clients to take part
                                                                in the decision-making process and the ability of occupational therapy practi-
                                                                tioners to include clients in this process. However, inclusion of clients in decision
                                                                making tends to depend on practitioners’ experience and values; Maitra and Erway
                                                                (2006) reported a gap between occupational therapists and their clients in their
                                                                perceptions of client-centered practice. Moreover, when clients do not appro-
                                                                priately convey a demand for a given occupation, the practitioner may not
                                                                properly recognize clients’ subjective evaluation related to the occupation.
                                                                Therefore, for practitioners to realize the occupation the client desires, it is
                                                                necessary to facilitate sharing of the meaning of the occupation between practi-
                                                                tioner and client. In other words, we think that practitioners are required to
                                                                capture a subjective evaluation of their clients’ occupations.

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One concept that captures the psychological state for                 using GpPower (Version 3.1.7; Erdfelder, Faul, & Buchner,
       an activity is flow, defined as “the state in which people                 1996) and determined that a total sample size of 54 clients
       are so involved in an activity that nothing else seems to                  (27 in each of two groups) would provide 80% power
       matter; the experience itself is so enjoyable that people                  for detecting a difference with an effect size of 0.80 in
       will do it even at great cost, for the sheer sake of doing it”             HRQOL scores using a two-tailed test and an a level of
       (Csikszentmihalyi, 1990, p. 4). Flow can contribute to                     .05. To compensate for possible attrition, we decided to
       increased levels of happiness, self-esteem, work productivity,             enroll 63 clients. All provided written informed consent
       and joy in life (Csikszentmihalyi & Csikszentmihalyi,                      before participation.
       1992; Haworth & Evans, 1995; Nielsen & Cleal, 2010).
       Studies have described the relationship between the                        Procedure
       experience of flow and occupation in everyday life (Larson                 The study was designed as a single-blind RCT and re-
       & von Eye, 2010; Rebeiro & Polgar, 1999; Wright, Sadlo,                    ported in accordance with the CONSORT guidelines
       & Stew, 2007).                                                             for reporting clinical trials (Schulz, Altman, & Moher,
            Jackson and Csikszentmihalyi (1999) stated that the                   2010). Clients were randomly assigned by blocked ran-
       most important characteristic of flow is the challenge–skill               domization (block size 5 4) either to the experimental
       balance: Flow is expected to occur when the perceived                      group, who received occupational therapy that included
       level of challenge provided by the activity and the per-                   assessment and adjustment of the challenge–skill balance
       son’s perceived level of skill are balanced. Activities in                 of the activities, or to the control group, who received
       which the person’s skill is perceived to be high relative to               occupational therapy as typically conducted at the adult
       the challenge provided would lead to boredom. Likewise,                    day program.
       low-perceived skill and high-perceived challenge would                          Because the factors affecting the outcomes were ho-
       produce anxiety, whereas low-perceived skill and low-                      mogeneous between the experimental and control groups,
       perceived challenge would result in apathy. For exam-                      randomization was stratified by sex and EuroQol visual
       ple, Hirao, Kobayashi, Okishima, and Tomokuni (2012)                       analog scale (EQ–VAS) scores for the self-assessment of
       reported that the physical health of older adults was                      general health in the EuroQol–5 Dimension scale (EQ–
       significantly better in groups who experienced flow dur-                   5D; EuroQol Group, 1990; high–low boundary 5 50),
       ing important everyday activities than in a group who                      resulting in four layers: (1) male and high EQ–VAS
       experienced apathy.                                                        scores, (2) male and low EQ–VAS scores, (3) female and
            Therefore, we think that careful attention to the                     high EQ–VAS scores, and (4) female and low EQ–VAS
       challenge–skill balance in client occupations, applying the                scores. Order of blocks was randomly assigned by R
       concept of flow, can be useful in occupational therapy                     software (Version 3.2.1; R Foundation, Vienna).
       intervention. However, few studies have addressed chal-                         The clients were blinded to group allocation, but the
       lenge–skill balance for clients in clinical occupational                   therapists were aware of the treatment assigned. Occu-
       therapy. The purpose of this study was to investigate                      pational therapy for both groups consisted of 10 sessions
       whether occupational therapy that includes adjusting                       of 20 min each held over about 10 wk (once a week); after
       the challenge–skill balance significantly improves health-                 this, the outcomes were reevaluated, and clients were asked
       related quality of life (HRQOL) for older adults in com-                   whether they knew which group they were allocated to.
       parison with standard occupational therapy.                                Criteria for withdrawal from the study were admission to
                                                                                  hospital, absenteeism, or death. The study protocol was
                                                                                  approved by the ethics committee of Kibi International
       Method                                                                     University, Okayama, Japan.
                                                                                       Experimental Group. The intervention was imple-
       Participants                                                               mented by occupational therapists with >5 yr experience
       Participants were recruited between December 2013 and                      in geriatric occupational therapy; the therapists had pre-
       March 2014 at an adult day program in Japan. Inclusion                     viously performed a trial study with several clients. The
       criteria were age >60 yr and participation in occupational                 intervention program focused on the occupational per-
       therapy at the center for >3 mo. Exclusion criteria were                   formance of activities and was conducted individually.
       dementia and visual impairment. In reference to the re-                    In both the intervention and control groups, the in-
       sults of a randomized controlled trial (RCT) in the field                  tervention was consistent with the Occupational Therapy
       of occupational therapy, in which the effect size for QOL                  Practice Framework: Domain and Process (3rd ed.; Ameri-
       was 1.30 (Graff et al., 2007), we conducted a powerx analysis              can Occupational Therapy Association [AOTA], 2014). The

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difference between the groups was in whether the evaluation                5D defines health in five dimensions: mobility, self-care,
       and intervention were conducted on the basis of the chal-                  usual activities, pain and discomfort, and anxiety or de-
       lenge–skill balance.                                                       pression. The EQ–5D includes the EQ–VAS, which
            In the first session of occupational therapy, the                     clients use to self-assess their health on a scale from
       therapist assessed the client’s problems in daily living                   0 (worst possible health) to 100 (best possible health). The
       using the Canadian Occupational Performance Measure                        SF–8 encompasses eight domains: General Health,
       (COPM; Law et al., 1990). An activity that could be                        Physical Functioning, Role Physical, Bodily Pain, Vital-
       supported in the adult day program was selected from                       ity, Social Functioning, Role Emotional, and Mental
       the problems identified.                                                   Health. The domains can be combined to yield a physical
            In the second session, the client performed the selected              component summary score and a mental component
       activity and then evaluated the activity using the challenge               summary score, whose reliability and validity have been
       and skill levels, which the therapist confirmed. Challenge                 confirmed (Fukuhara & Suzukamo, 2004).
       level was defined as the “challenges of the activity” and                       Flow experience was assessed using the Flow State
       was rated from 1 (very simple) to 7 (very difficult). Skill                Scale for Occupational Tasks (Yoshida et al., 2013), de-
       level was defined as “your skills in the activity” rated from              veloped for clinical situations, which consists of 14 items
       1 (not at all skillful) to 7 (very skillful; Csikszentmihalyi &            and three factors (scores range from 7 to 98). Its reli-
       Larson, 1984; Engeser & Rheinberg, 2008). At that time,                    ability and validity have been confirmed (Yoshida et al.,
       the therapist explored the client’s reasons for his or her                 2013). The client’s self-perceived occupational perfor-
       ratings of the challenge level and skill level.                            mance was assessed using the COPM, which involves a
            On the basis of the client’s and therapist’s evaluation,              semistructured interview format and structured scoring.
       the factors that made the occupational performance dif-                    Clients were rated on a scale from 1 to 10 for perceived
       ficult (challenge components; e.g., environment, execu-                    performance capacity and for level of satisfaction with
       tion time, size of the place for the activity) and factors                 performance.
       that improved the occupational performance (skill com-                          Information collected at pretest included the client’s
       ponents) were determined. Adjustment of the challenge–                     age, sex, diagnosis, FIM® score (Granger, Hamilton,
       skill balance in the activity was initiated on the basis of                Keith, Zielezny, & Sherwin, 1986), and Frenchay
       these components.                                                          Activities Index (FAI) score (Holbrook & Skilbeck,
            After the client performed the adjusted activity, the                 1983). The FIM is an 18-item, 7-level scale that uni-
       challenge and skill levels were reevaluated. If the challenge              formly assesses the severity of the client’s disability and
       and skill levels were not balanced, the activity was read-                 medical rehabilitation functional outcome (overall scores
       justed in the next session. The intervention aimed at im-                  range from 7 to 126). The FAI is a 15-item self-report
       proving the skill level for the activity until the challenge               scale that provides an index of a client’s capacity to
       and skill levels were balanced.                                            perform instrumental activities of daily living (overall
            Control Group. The first and second sessions were                     scores range from 0 to 45).
       conducted in the same way as for the experimental group,
       except that the therapists did not address the client’s                    Statistical Analysis
       subjective perception of the challenge and skill levels for                The primary outcome was the difference between pretest
       the activity. From the third session, the therapists simply                and posttest scores for HRQOL (EQ–5D and SF–8).
       assessed the client’s performance and conducted the                        The secondary outcomes were the differences between
       therapy in the typical manner for the adult day program,                   pretest and posttest scores on the Flow State Scale for
       following the general guidelines for occupational therapy                  Occupational Tasks and COPM. All data were analyzed
       practice.                                                                  on the basis of intention-to-treat analysis, applying the
                                                                                  last-observation-carried-forward method for withdrawals.
       Outcome Assessments                                                        Using Graff et al.’s (2007) method, we evaluated pretest–
       Clients were assessed before the intervention (pretest)                    posttest differences using analysis of covariance, with the
       and after the 10th session (posttest). The outcome measures,               pretest scores for the EQ–5D, the SF–8, and the Flow
       all self-reported by the clients, were HRQOL, flow expe-                   State Scale for Occupational Tasks as covariates. More-
       rience, and self-perception of occupational performance.                   over, 1,000 bootstrap replicates were performed.
            HRQOL was assessed using the EQ–5D and the                                 The Mann2Whitney U test was used to evaluate
       Japanese version of the eight-item Short-Form Health                       changes in COPM scores (two-tailed, a 5 .05). We also
       Survey (SF–8; Fukuhara & Suzukamo, 2004). The EQ–                          reported the significance according to Benjamini and

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Hochberg’s (1995) method for adjusting the overall score                   did not consent to the study, leaving 56 clients for the
       controlling for the false discovery rate. The proportion of                analysis. Four clients left the study. In the experimental
       clients achieving a clinically relevant improvement, de-                   group, 1 died and 1 was admitted to the hospital before
       fined as an improvement of .05 points in the EQ–5D                         assessment. In the control group, 1 was admitted to
       score (Robinson et al., 2013), and the numbers needed to                   the hospital immediately after randomization, and 1 was
       treat with 95% confidence intervals (CIs) were calculated.                 withdrawn from the study because he was not func-
       Per protocol analysis was also carried out. Effect sizes                   tioning well. Consequently, the per protocol analyses
       (Cohen’s d ) were calculated to assess the practical sig-                  included 52 clients.
       nificance of the interventions relative to the control                          The pretest characteristics of the clients were well
       condition. Statistical analysis was performed with IBM                     matched between the two groups (Table 1). The occu-
       SPSS Statistics (Version 22.0; IBM Corp., Armonk, NY).                     pations determined using the COPM were classified as
                                                                                  follows: in the experimental group, hobbies (6), house-
                                                                                  work (5), personal care (4), walking (6), basic movement
       Results                                                                    (4), physical function (2), and learning (1), and in the
       Sixty-three consecutive clients who received occupational                  control group, hobbies (5), housework (3), personal care
       therapy at the adult day program were evaluated for eli-                   (5), walking (8), basic movement (3), and physical func-
       gibility (see Figure 1). Of these, 5 were excluded and 2                   tion (3).

       Figure 1. Flow diagram of participant allocation.
       Note. ITT 5 intention to treat.

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Table 1. Participant Characteristics at Pretest
       Characteristic                                              Experimental Group (n 5 28)                       Control Group (n 5 27)                    p
       Mean (SD) age, yr                                                  80.9     (8.36)                                  81.2   (6.51)                      .89
       Male, n                                                            14                                               13                                 .89
       Disease, n                                                                                                                                             .71
         Cerebral vascular disease                                        11                                               10
         Orthopedic disease                                                 9                                              13
         Neurodegenerative disease                                          3                                               1
         Spinal cord disease                                                2                                               0
         Internal disease                                                   3                                               3
       Mean (SD) scores
         FIM                                                              95.4 (12.0)                                      93.4 (17.1)                        .62
         FAI                                                               9.5 (5.4)                                        9.2 (5.7)                         .87
         EQ–VAS                                                           47.2 (25.3)                                      44.9 (27.4)                        .72
       Mean (SD) duration of service use, days                           993.8 (874.7)                                  1,066.5 (995.5)                       .77
       Note. EQ–VAS 5 EuroQol–5 Dimension visual analog scale; FAI 5 Frenchay Activities Index; SD 5 standard deviation.

            The results analyzed by analysis of covariance using                            which was not statistically significant, 95% CI [221.74,
       the bootstrap method and the changes pretest to posttest                             3.06]. The effect sizes and 95% CIs are shown in Table 3.
       are shown in Tables 2 and 3. For the primary outcomes,                               The per protocol analyses showed the following effect sizes
       statistically significant differences were observed between                          and 95% CIs: EQ–5D, d 5 0.78 [0.22, 1.34]; SF–8
       the two groups in EQ–5D scores and SF–8 scores for                                   General Health, d 5 1.01 [0.45, 1.61]; SF–8 Physical
       general health. However, no difference between groups                                Functioning, d 5 0.66 [0.10, 1.22]; SF–8 Vitality, d 5
       was found in the SF–8 physical or mental component                                   0.69 [0.13, 1.25]; and Flow State Scale for Occupational
       summary scores. For the secondary outcomes, significant                              Tasks, d 5 0.80 [0.23, 1.37]. In addition, the blinding of
       differences were observed between the two groups in                                  the clients was checked; 13 (25.0%) of the clients knew
       Flow State Scale for Occupational Tasks scores. Although                             their treatment allocation.
       the COPM Satisfaction and Performance scores both
       showed a trend toward improvement in favor of the
       experimental group, the difference was not significant                               Discussion
       (Tables 2 and 3).                                                                    In this study, older adults who received occupational
            A clinically relevant improvement was achieved by 11                            therapy that focused on the adjustment of challenge–skill
       (39%) experimental participants and 5 (19%) control par-                             balance had significantly better EQ–5D and SF–8 QOL
       ticipants. The EQ–5D number needed to treat was 4.82,                                scores. This intervention was demonstrated to be highly

       Table 2. Comparison of Primary Outcomes Postintervention, by Group
                                                 Observed M (SD)
       Primary Outcome Measure        Experimental Group    Control Group        Covariate-Adjusted Treatment Difference [95% CI]         p   Effect Size [95% CI]
       EQ–5D                              0.58 (0.12)        0.49 (0.15)                       0.08   [0.03, 0.14]                    .022    0.76   [0.21, 1.31]
       EQ–VAS                            47.18 (25.31)      43.36 (16.98)                      4.85 [23.76, 13.41]                    .260    0.31 [20.22, 0.84]
         General Health                  46.47 (5.75)       40.70 (7.67)                       5.80   [2.37, 8.76]                    .001    0.99   [0.43, 1.55]
         Physical Functioning            39.99 (8.09)       34.27 (9.78)                       4.99   [0.32, 9.79]                    .045    0.56   [0.02, 1.10]
         Role Physical                   38.31 (10.06)      36.27 (10.29)                      1.15 [23.69, 6.03]                     .640    0.13 [20.40, 0.66]
         Bodily Pain                     41.92 (6.69)       40.09 (8.25)                       0.69 [22.63, 3.94]                     .690    0.10 [20.43, 0.63]
         Vitality                        45.93 (6.60)       41.94 (6.58)                       3.54 [0.27, 6.67]                      .044    0.59 [0.05, 1.13]
         Social Functioning              42.30 (8.37)       36.70 (7.60)                       4.09   [0.13, 8.10]                    .052    0.57   [0.03, 1.11]
         Mental Health                   45.20 (6.83)       44.14 (7.13)                       0.29 [23.07, 3.23]                     .870    0.05 [20.48, 0.58]
         Role Emotional                  43.63 (6.42)       39.76 (8.23)                       3.00 [20.61, 6.61]                     .110    0.45 [20.09, 0.99]
         Physical component score        38.97 (6.61)       34.60 (7.90)                       3.50 [20.07, 6.90]                     .064    0.53 [20.01, 1.07]
         Mental component score          46.30 (5.63)       43.81 (6.76)                       1.25 [21.89, 4.23]                     .420    0.22 [20.31, 0.75]
       Note. CI 5 confidence interval; EQ–5D 5 EuroQol–5 Dimension; EQ–VAS 5 EQ–5D visual analog scale; M 5 mean; SD 5 standard deviation; SF–8 5 8-item
       Short-Form Health Survey.

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Table 3. Comparison of Secondary Outcomes Postintervention, by Group
                                                         Observed M (SD)
       Secondary Outcome Measure                 Experimental Group Control Group Covariate-Adjusted Treatment Difference [95% CI]    p     Effect Size [95% CI]
       Flow State Scale for Occupational Tasks     63.74 (11.56)     54.46 (18.82)                8.11 [2.74, 13.15]                 .008    0.82 [0.27, 1.37]
       COPM Satisfactiona                           5.71 (1.96)       5.36 (2.45)                         —                          .580           —
       COPM Performancea                            5.75 (2.17)       5.33 (2.48)                        —                           .340           —
       Note. — 5 not applicable; CI 5 confidence interval; COPM 5 Canadian Occupational Performance Measure; M 5 mean; SD 5 standard deviation.
        Mann2Whitney U test.

       effective for improving HRQOL, with a large effect size                          HRQOL were sustained after completion of the inter-
       for the improvement in SF–8 General Health scores                                vention. In addition, blinding of therapists regarding
       and medium effect sizes for the improvements in EQ–5D                            the intervention method was difficult because the thera-
       scores.                                                                          pists themselves performed the intervention. Nevertheless,
            According to the Framework (AOTA, 2014), to help                            only a quarter of the clients were able to identify their
       clients achieve their desired outcomes, occupational                             group assignment, suggesting that measurement bias on
       therapy practitioners facilitate interactions between the                        the client side did not strongly influence the outcomes. In
       client and his or her environments and contexts and the                          the future, we want to do blinding of outcome assessors
       occupations in which he or she engages. However, this                            and implement a study of a multicenter RCT to reduce the
       process tends to depend on practitioners’ experiences and                        potential for bias.
       values (Maitra & Erway, 2006). In previous research
       (Yoshida, Mima, Nonaka, Kobayashi, & Hirao, 2016) it
                                                                                        Implications for Occupational
       became clear that therapists could not properly evaluate
       the challenge and skill levels of activities for older adults
                                                                                        Therapy Practice
       unless the therapists checked with the clients; therefore,                       The results of this study suggest the following implications
       the client’s subjective evaluation using the perceived                           for occupational therapy practice:
       challenge level and skill level can facilitate the therapist’s                   • Adjustment of the challenge–skill balance of activities
       understanding of the client’s perceptions of the occupa-                            in occupational therapy practice can positively influ-
       tion. Consequently, occupational therapy that includes                              ence older adults’ HRQOL.
       adjustments to the challenge–skill balance can be one strat-                     • Assessment and adjustment of challenge–skill balance
       egy to improve HRQOL and help ensure the quality of                                 may be a helpful method for understanding older adults’
       occupational therapy.                                                               perceptions of their occupations and can assist the oc-
            The results also showed improvement in flow expe-                              cupational therapy process.
       riences for occupational tasks with the adjusted challenge–
       skill balance. Csikszentmihalyi (1990) reported that flow
       occurs when a person perceives a balance between the
       challenge of the activity and his or her own skill. Thus,                        In examining the effects of an occupational therapy in-
       adjustment of the challenge–skill balance in the intervention                    tervention using a focus on challenge–skill balance, we
       group may have helped result in flow. In addition, because                       found that assessment and adjustment of the challenge–
       these participants’ flow state increased, the method of the                      skill balance for activities of older adults positively
       present intervention appears to be appropriate. Further re-                      influenced their HRQOL. This intervention approach
       search could address issues regarding the relationship be-                       may be a helpful method for understanding clients’ per-
       tween occupational therapy and flow experiences.                                 ceptions of their occupations. The present findings in-
            No significant differences were found with respect to                       dicate that using a challenge–skill balance approach is
       the COPM Satisfaction and Performance scores. We                                 a promising tool for occupational therapy with older
       considered that improvement of the COPM score was                                adults. s
       small, because this study focused on partial activity that the
       client could achieve at that time regarding the occupation.                      Acknowledgments
                                                                                        This study is registered at (No.
       Limitations                                                                      NCT00232934). We acknowledge Harue Hospital, Kalmia
       A limitation of our study was the lack of follow-up data;                        Harue; Graduate School of Health Science Studies, Kibi
       we were unable to assess whether the observed changes in                         International University; and Graduate School of Human

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Health Sciences, Tokyo Metropolitan University, as well                    Hirao, K., Kobayashi, R., Okishima, K., & Tomokuni, Y.
       as all the participants who took part in this study. We                         (2012). Flow experience and health-related quality of
       declare no conflict of interest.                                                life in community dwelling elderly Japanese. Nursing
                                                                                       and Health Sciences, 14, 52–57.
       References                                                                 Holbrook, M., & Skilbeck, C. E. (1983). An activities index
       American Occupational Therapy Association. (2014). Occupa-                      for use with stroke patients. Age and Ageing, 12, 166–170.
            tional therapy practice framework: Domain and process (3rd       
            ed.). American Journal of Occupational Therapy, 68(Suppl. 1),         Jackson, S. A., & Csikszentmihalyi, M. (1999). Flow in sports.
            S1–S48.                           Champaign, IL: Human Kinetics.
       Benjamini, Y., & Hochberg, Y. (1995). Controlling the false                Larson, E., & von Eye, A. (2010). Beyond flow: Temporality
            discovery rate: A practical and powerful approach to mul-                  and participation in everyday activities. American Journal
            tiple testing. Journal of the Royal Statistical Society, Series B,         of Occupational Therapy, 64, 152–163.
            57, 289–300.                                                               10.5014/ajot.64.1.152
       Csikszentmihalyi, M. (1990). Flow: The psychology of optimal               Law, M., Baptiste, S., McColl, M., Opzoomer, A., Polatajko, H.,
            experience. New York: Harper Perennial.                                    & Pollock, N. (1990). The Canadian Occupational Perfor-
       Csikszentmihalyi, M., & Csikszentmihalyi, I. S. (Eds.). (1992).                 mance Measure: An outcome measure for occupational
            Optimal experience: Psychological studies of flow in conscious-            therapy. Canadian Journal of Occupational Therapy, 57,
            ness. Cambridge, England: Cambridge University Press.                      82–87.
       Csikszentmihalyi, M., & Larson, R. (1984). Being adolescent:               Law, M., Baptiste, S., & Mills, J. (1995). Client-centred prac-
            Conflict and growth in the teenage years. New York: Basic                  tice: What does it mean and does it make a difference?
            Books.                                                                     Canadian Journal of Occupational Therapy, 62, 250–257.
       Engeser, S., & Rheinberg, F. (2008). Flow, performance and            
            moderators of challenge–skill balance. Motivation and                 Maitra, K. K., & Erway, F. (2006). Perception of client-
            Emotion, 32, 158–172.                      centered practice in occupational therapists and their clients.
            008-9102-4                                                                 American Journal of Occupational Therapy, 60, 298–310.
       Erdfelder, E., Faul, F., & Buchner, A. (1996). GPOWER: A              
            general power analysis program. Behavior Research Meth-               Nielsen, K., & Cleal, B. (2010). Predicting flow at work: In-
            ods, Instruments, and Computers, 28, 1–11.                vestigating the activities and job characteristics that predict
            10.3758/BF03203630                                                         flow states at work. Journal of Occupational Health Psychol-
       EuroQol Group. (1990). EuroQol—A new facility for the                           ogy, 15, 180–190.
            measurement of health-related quality of life. Health Pol-            Palmadottir, G. (2003). Client perspectives on occupational
            icy, 16, 199–208.                    therapy in rehabilitation services. Scandinavian Journal
            90421-9                                                                    of Occupational Therapy, 10, 157–166.
       Falardeau, M., & Durand, M. J. (2002). Negotiation-centred                      10.1080/11038120310017318
            versus client-centred: Which approach should be used?                 Rebeiro, K. L., & Polgar, J. M. (1999). Enabling occupational
            Canadian Journal of Occupational Therapy, 69, 135–142.                     performance: Optimal experiences in therapy. Canadian
                                   Journal of Occupational Therapy, 66, 14–22. https://doi.
       Fukuhara, S., & Suzukamo, Y. (2004). Manual of the SF–8                         org/10.1177/000841749906600102
            Japanese version. Kyoto, Japan: Institute for Health Out-             Robinson, A., Gyrd-Hansen, D., Bacon, P., Baker, R.,
            comes & Process Evaluation Research.                                       Pennington, M., & Donaldson, C.; EuroVaQ Team. (2013).
       Graff, M. J., Vernooij-Dassen, M. J., Thijssen, M., Dekker, J.,                 Estimating a WTP-based value of a QALY: The “chained”
            Hoefnagels, W. H., & OldeRikkert, M. G. (2007). Ef-                        approach. Social Science and Medicine, 92, 92–104. https://
            fects of community occupational therapy on quality of            
            life, mood, and health status in dementia patients and                Schulz, K. F., Altman, D. G., & Moher, D.; CONSORT
            their caregivers: A randomized controlled trial. Journals of               Group. (2010). CONSORT 2010 statement: Updated
            Gerontology, Series A: Biological Sciences and Medical Sci-                guidelines for reporting parallel group randomized trials.
            ences, 62, 1002–1009.                   Annals of Internal Medicine, 152, 726–732. https://doi.
            9.1002                                                                     org/10.7326/0003-4819-152-11-201006010-00232
       Granger, C. V., Hamilton, B. B., Keith, R. A., Zielezny, M.,               Sumsion, T., & Smyth, G. (2000). Barriers to client-
            & Sherwin, F. S. (1986). Advances in functional as-                        centredness and their resolution. Canadian Journal of Oc-
            sessment for medical rehabilitation. Topics in Geriatric                   cupational Therapy, 67, 15–21.
            Rehabilitation, 1, 59–74.                000841740006700104
            198604000-00007                                                       Taylor, R. R. (2003). Extending client-centered practice:
       Haworth, J., & Evans, S. (1995). Challenge, skill and posi-                     The use of participatory methods to empower clients. Oc-
            tive subjective states in the daily life of a sample of YTS                cupational Therapy in Mental Health, 19(2), 57–75. https://
            students. Journal of Occupational and Organizational             
            Psychology, 68, 109–121.              Townsend, E. A. (1997). Enabling occupation: An occupational
            8325.1995.tb00576.x                                                        therapy perspective. Ottawa: CAOT Publications.

       The American Journal of Occupational Therapy                                                                                      7201205030p7
Downloaded From: on 03/09/2018 Terms of Use:
Wilcock, A. (1993). A theory of the human need for occupa-                 Yoshida, K., Asakawa, K., Yamauchi, T., Sakuraba, S.,
           tion. Journal of Occupational Science, 1, 17–24. https://doi.              Sawamura, D., Murakami, Y., & Sakai, S. (2013).
           org/10.1080/14427591.1993.9686375                                          The Flow State Scale for Occupational Tasks: Develop-
       World Federation of Occupational Therapists. (2010). Statement on              ment, reliability, and validity. Hong Kong Journal of
           occupational therapy. Retrieved from                  Occupational Therapy, 23, 54–61.
           ResourceCentre.aspx                                                        j.hkjot.2013.09.002
       Wright, J. J., Sadlo, G., & Stew, G. (2007). Further explora-              Yoshida, I., Mima, H., Nonaka, T., Kobayashi, R., & Hirao, K.
           tions into the conundrum of flow process. Journal of Oc-                   (2016). Analysis of subjective evaluation in occupations
           cupational Science, 14, 136–144.                  of the elderly: A study based on the flow model. Japanese
           14427591.2007.9686594                                                      Occupational Therapy Research, 35, 70–79.

       7201205030p8                                                                                      January/February 2018, Volume 72, Number 1
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