1 Work xx (20xx) x–xx DOI:10.3233/WOR-162338 IOS Press The effects of gardening on quality of life in people with stroke Fen-Ling Kuoa , Sui-Hua Hoa,b,∗ and Chiuhsiang Joe Linb a Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan b Department of Industrial Management, National Taiwan University of Science and Technology, Taipei, Taiwan Au tho rP roo f Received 20 November 2014 Accepted 15 June 2015 23 Keywords: Occupational therapy, cerebrovascular accident, horticultural activity, 2k factorial design, occupation 24 Introduction 25 1.1 Background 14 15 16 17 18 19 20 21 26 27 28 rre 13 co 12 Un 11 cte d 22 Abstract BACKGROUND: Compared with traditional rehabilitation, gardening has been viewed as a more occupation-based intervention to help patients improve functional performance However, there is still a need for evidence-based research into what factors interact to create the beneficial effects of gardening for people who have sustained a cerebral vascular accident (CVA) OBJECTIVE: To explore how plant, gender, and the time after stroke onset influenced improvements in the quality of life of patients in a gardening program METHODS: One treatment of tending short-term plants, and another treatment of tending long-term plants were compared Quality of life improvement was evaluated according to three factors: plant, gender, and the time after stroke onset The data were analyzed with 2k replicated factorial designs RESULTS: The 2k factorial design with replication indicated significant effects on both the social role and the family role For the social role, the interaction of plant and gender difference was significant For the family role, the significant effects were found on interaction of plant with both gender and the time after stroke onset CONCLUSIONS: Tending plants with different life cycles has varied effects on the quality of life of people who have sustained a CVA Factors related to gender and the time after stroke onset influenced role competency in this sample 10 A cerebral vascular accident (CVA) usually results in a decline in physical, mental, and/or cognitive abilities, those influence functional performance out∗ Address for correspondence: Sui-Hua Ho, Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, No 291, Zhongzheng Rd., Zhonghe, Taipei 23561, Taiwan Tel.: +886 22490088 ext 1624; Fax: +886 22490088 ext 1634 E-mail: D10101001@mail.ntust.edu.tw, shh283@nyu.edu comes The physical changes after the disease [1] and the psychosocial changes within the working environment [2] in turn brought the occupational stress and influenced the work engagement of people [3] Wang, Kapellusch [4] mentioned that the CVA recovery, especially in perceptive, speech, and cognitive domains, was a critical factor of returning to work Alcˆantara, Sampaio [5] also found that health condition would influence work ability profoundly The consequences after CVA can impact the quality of life (QoL) of not only patients [6] but also caregivers [7] Traditional rehabilitation has provided patients with many opportunities to improve their sensorimo- 1051-9815/16/$35.00 © 2016 – IOS Press and the authors All rights reserved 29 30 31 32 33 34 35 36 37 38 39 40 41 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 roo f 46 ate gardening activities for each gender Although some evidence strongly supports the gender disparity in stroke functional progress and QoL, no studies to date have described the gender differences in QoL improvement related to gardening with this disability group Besides gender differences, issues such as severity and time after stroke onset, may also affect the functional recovery of people with stroke In a recent study using a modified Rankin Scale as a measure of functional performance, Liou and Lin [28] found that rather than stroke severity, onset time was the more significant indicator of functional status for people who have sustained a CVA Regarding the association between time after stroke onset and the future recovery, Skilbeck, Wade [29] found that although most recovery took place within months in areas of basic activities of daily living, arm function, and language, there were still some non-significant improvement in speech and language after 18 months rehabilitation in their stroke unit Hochstenbach, den Otter [30] also mentioned the long-term improvement in cognitive function still occurred up to years after stroke onset by some of their participants, and the most obvious recovery was in the attention-related domains In addition, G Broeks, Lankhorst [31] found that although most improvement happened within 16 weeks, some arm motor functional recovery still took place after years after stroke onset No studies were found in the current review of the literature exploring the influence of onset time on the quality of life of patients after therapeutic gardening activities Other authors have discussed the benefits of gardening in rehabilitation in general for patients [32–34] Through the therapeutic use of gardening as a form of occupation [32, 33], therapists consider the benefits in the process of nurturing the plants, to select the horticultural activities, which meet the special needs of the participants [34] The horticultural activities may include sowing seeds, tending seedlings, adding water, pulling weed, and harvesting plants finally Participants are benefited through the active involvement of nurturing the living plants [34] It should also be noted that different kinds of plants, such as plants with different life cycles and characteristics, may have different effects on patients The plant life cycle usually starts from a seed, and the seed will sprout to become an immature seedling The seedling will grow continuously to be a mature plant Then, the mature plant will grow flowers After pollination, the fertilization allows flowers to develop cte d 45 rre 44 tor, cognitive, and mental health However, the use of repetitive and long-term rehabilitative programs may discourage patients from consistently and continuously returning for follow-up care The therapeutic garden has been viewed as a natural and pleasant intervention setting for improving quality of life (QoL) in the elderly [8] Gardening has been utilized for healing since ancient times Evidence dated to 2000 BCE in Mesopotamia shows that gardening activities have long been used for sensory modulation [9] The beneficial effects of gardening on veterans from World War I have also been noted [10] Although previous researchers have tried to explore the effects of the gardening setting on CVA survivors [9, 11, 12], these studies have mostly focused on a single or just a few cases, providing exploratory results of variable effects There is still a need for evidence-based research into the effects of therapeutic gardening quantitatively [8] Furthermore, several preliminary studies of the gardening setting have reported positive therapeutic effects, including pain relief [13], improvement in attention [14–16], stress management [17], agitation reduction [18], and fall prevention [19] The above positive effects are vital in the further improvement of QoL [8] However, insufficient evidence remains about the beneficial effects of gardening activities for people who have sustained a CVA Several studies have demonstrated gender disparities in stroke recovery [20–24] In an investigation of retrospective cohort data, Boehme and Siegler [20] found poorer functional outcomes for female patients with stroke than for their male counterparts Additionally, using the Barthel Index [25] and Rankin Scale [26], Di Carlo and Lamassa [23] collected data across countries, including England, France, Germany, Hungary, Italy, Portugal, and Spain, and found a significant gender effect on activities of daily living (ADL) and handicap predictors of people with stroke In that study, male gender was still shown as a better predictor of functional recovery A similar effect was indicated in a two-year follow-up study employing Health-Related Quality of Life (HRQoL) Sturm and Donnan [24] indicated that female gender was a determiner for lower quality of life than male gender Das [27] found the gender differences on ergonomic risk factors among farmers Therefore, there might be some gender differences on musculoskeletal influences for people performing gardening activities Understanding gender differences in recovery from CVA with various gardening programs may provide practitioners with guidelines for designing appropri- co 43 Un 42 F.-L Kuo et al / The effects of gardening on quality Au tho rP 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 F.-L Kuo et al / The effects of gardening on quality Several pilot studies [9, 17] have supported the effects of gardening for patients with stroke and related diseases However, those preliminary studies lacked well-designed experiments and sufficiently representative sampling Due to the limited scientific evidence of the effects of gardening on people with stroke, we explored these effects on combinations (2 levels of gender X levels of stroke stage X levels of plants) with replications and analyzed the results following the principles of experimental design [35] No exploratory pilot test was run in this research 158 1.2 Objective and Hypotheses Methodology 206 This study explored the effects of gardening on the quality of life of patients with cerebral vascular accidents The effects of plants with different duration of life cycles on patients’ QoL were analyzed In this research, long-term plants were plants with life cycle longer than months (tomato and string bean were adopted in this design) Short-term plants were life cycle shorter than months (water spinach and lettuce were adopted in this design) In addition, the amount of variance in the beneficial gardening effects on gender and the time after stroke onset was also examined Based on the previous findings, although the majority of recovery took place within to months after stroke onset for acute patients, there was still some speech recovery after 18 months [29], and arm motor improvement after years for chronic patients [31] In this research, the chronic patients who had sustained a CVA over months were recruited to have a stable condition to perform the gardening activities Therefore, 18 months after stroke onset was chosen as the cut point to classify the participants into two groups: stage (6 to 18 months after stroke onset) and stage (>18 months after stroke onset) The study was developed to test three major hypotheses 2.1 Experimental design 207 152 153 154 155 156 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 Au tho rP 151 This research explored how three factors (plant, gender, and stroke stage) would influence improvement in the quality of life of patients who have sustained a CVA following their participation in a gardening program The 2k factorial design, where k equals 3, was applied to test the hypotheses in this research Two kinds of plants, those with shortterm life cycles (short-term plants) and long-term life cycles (long-term plants), were used Males and females in stage1 and stage of recovery from CVA were recruited cte d 150 rre 149 co 148 1) After gardening activities, males who have sustained a CVA will demonstrate greater improvement in their quality of life than females 2) After gardening activities, people in the CVA stage of recovery will demonstrate greater improvement in their quality of life than people in the CVA stage of recovery 3) Tending plants with short-term life cycles will have greater impact on quality of life than tending plants with long-term life cycles Un 147 roo f 157 seeds to restart a new life cycle of the plant The duration of the entire life cycle may vary from several weeks to years depending on different types of plants Therefore, tending for plants with different duration of life cycles might bring about different physical and also psychological influences to people For example, participants tending plants with shorter life cycle will harvest and get the feedbacks of collecting fruit earlier than tending plants with longer life cycle It is still unclear whether tending plants with different duration of life cycle would have the same effects on participants 146 2.2 Participants Before this research started, the leader of this research project contacted with the clinical occupational therapists in the Taipei Medical University-Shuang Ho Hospital, Ministry of Health and Welfare The major purpose of this project was told to the occupational therapists, and they were asked to consider appropriate participants who met the inclusion criteria from their clients at that time The inclusion criteria were (1) diagnosis of CVA by a medical specialist, including ischemia and hemorrhage, and onset time over months; (2) ability to communicate normally and clearly express feelings; (3) no other injuries, musculoskeletal disorders, or mental illness which could interfere with participating in gardening activities; (4) agreement to sign a participant consent form Then, the leader of this research project invited the participants from the list given by the occupational therapists, to join the research After knowing all the risks/benefits after joining this project and the right of dropping out 194 195 196 197 198 199 200 201 202 203 204 205 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 F.-L Kuo et al / The effects of gardening on quality 258 2.3 Dependent variable 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 281 2.4 Independent variables 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 282 283 284 285 286 287 rre 262 co 261 Un 260 2.5 Held constant variables The factors that were held constant were the therapist and the gardening environment The entire gardening program was conducted by one registered occupational therapist In addition, evaluation and intervention were conducted in the same clinical setting 2.6 Nuisance factors Each participant had their own speed of recovery, and differences in this speed could possibly influence the improvement in their quality of life Caregiver attitudes and patient motivation could also affect the rate of recovery The strategy we used was to select cases with similar features We recruited cases only from New Taipei City in an attempt to reduce the impact of nuisance factors However, since people from the same place might still show different amounts of improvement, once the variables of gender and CVA level were confirmed, participants were randomly assigned to either tending long-term plants or tending short-term plants After three months, the treatment exchanged People who tended long-term plants changed to tend short-term plants, and vice versa cte d 280 The response variable in this study was improvement in quality of life Quality of life was measured with the Chinese version of the Stroke Specific Quality of Life scale (SSQOL), which had been previously translated following standard translation procedures [36] and validated by Hsueh and Jeng [37] in Taiwan The SSQOL is an evaluation tool developed for patients with cerebral vascular accident (CVA) It consists of 49 items that focus on 12 areas of healthrelated quality of life The items are scored on a 5-point Likert-type scale; the higher the score the better the quality of life The reliability and validity of the SSQOL for various kinds of people with stroke have been reported previously [38] The reliability and validity of the Danish version of the SSQOL has been examined in patients with intracerebral hemorrhage [39] Ewert and Stucki [40] also validated the German version of the SSQOL for patients with hemorrhagic and ischemic stroke, and Boosman and Passier [41] validated the scale for patients with aneurysmal subarachnoid hemorrhage Measures of reliability and validity were found to be acceptable 259 (6–18 months after stroke onset) and stage (>18 months after stroke onset) roo f 257 this experiment at any time, all invited people agreed to join and signed the participant consent form Thirteen participants meeting the inclusion criteria were invited to join this research Initially, it was aimed as within subject design, that was each participant must complete both treatment (tending long-term plant and short-term plant) Finally, there were participants completed both treatment Five participants joined only in the short-term plant treatment, and two joined only long-term plant treatment During the study, the participants dropped out due to either decreased physical condition (expressed too tired to perform outdoor activities) or stopped insurance benefits Thus, for the short-term plant treatment, there were 11 data points For the longterm plant treatment, there were data points Eventually, the data collected were analyzed using imbalanced factorial design 240 Au tho rP The three controlled variables were gender, life cycle of plants, and time after stroke onset The different effects on male and female patients were tested The life cycles of plants consisted of two categories: long-term (>3 months) and short-term ([...]... 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