Adjusting Challenge-Skill Balance to Improve Quality of Life in Older Adults: A Randomized Controlled Trial
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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. https://doi.org/10.5014/
ajot.2018.020982
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; ippe.i.yoshi@gmail.com 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.
The American Journal of Occupational Therapy 7201205030p1
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/936623/ on 03/09/2018 Terms of Use: http://AOTA.org/termsOne 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
7201205030p2 January/February 2018, Volume 72, Number 1
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/936623/ on 03/09/2018 Terms of Use: http://AOTA.org/termsdifference 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
The American Journal of Occupational Therapy 7201205030p3
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/936623/ on 03/09/2018 Terms of Use: http://AOTA.org/termsHochberg’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.
7201205030p4 January/February 2018, Volume 72, Number 1
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/936623/ on 03/09/2018 Terms of Use: http://AOTA.org/termsTable 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]
SF–8
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.
The American Journal of Occupational Therapy 7201205030p5
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/936623/ on 03/09/2018 Terms of Use: http://AOTA.org/termsTable 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.
a
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
Conclusion
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 ClinicalTrials.gov (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
7201205030p6 January/February 2018, Volume 72, Number 1
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/936623/ on 03/09/2018 Terms of Use: http://AOTA.org/termsHealth 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. https://doi.org/10.1111/
j.1442-2018.2011.00663.x
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