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Influenceofanimalassistedtherapyusingdogforpatientswithstrokeandexaminationofnursingcare.pdf

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126 International Medical Journal Vol. 26, No. 2, pp. 126 - 134 , April 2019

ANIMAL ASSISTED THERAPY

Influence of Animal Assisted Therapy Using Dog for Patients with Stroke and Examination of Nursing Care

Hiroko Fujisawa0, Takayuki Kumasaka”, Mikako Arakida2)

ABSTRACT

Purpose: Japan's ageing society exhibits high rates of cerebrovascular disease. Animal Assisted Therapy (AAT) for patients with stroke may be an effective means by previous research. The objective of this study was to examine the nursing care effects of AAT, using dogs handled by nurses, with patients following stroke.

Method: 23 patients underwent mood examinations before and after AAT. Additionally, we measured changes in physical function, the total time required for each behaviour during AAT, and nursing outcomes over the 4-week experimental period.

Results: At baseline, between weeks 1 and 4, and post-AAT we observed no statistically significant between-group differences in 'change in mood' and 'behaviour during AAT'd Both the AAT group and the waiting group exhibited significant change in FIM and S1AS scores between weeks 1 and 4. The AAT group exhibited a significant change over the study period, compared with the waiting group on the Nursing outcomes Classification (NOC) index.

Conclusion: There was a significant improvement in nursing outcomes as assessed by NOC indices. AAT is an effective means of delivering nursing care for patients with stroke.

KEY WORDS

animal assisted therapy, stroke, nursing care, dog, alternative therapy

INTRODUCTION

Animal-assisted therapy (AAT) is an adjunctive therapy and alterna tive therapy, carried out by medical staff, involving contact between ani mals and patients in medical settings. AAT seeks to improve patient independence and adaptation, emotional stability, sense of autonomy and motivation and socialisation while helping patients acquire social and daily routine skills. A key component of AAT is recovery of the patient’s basic life rhythm by utilising his or her relationship with living things* 1 2'3'.

AAT is practised throughout Europe and the United States, in hospi tals and other medical facilities, with patients ranging in age from very young to elderly, with acute to chronic disease profiles. Current esti mates indicate that AAT reduces medical costs by approximately 3 to 7 million dollars4'”. In contrast, animal-assisted activity (AAA) is used in Japan. The results of these programmes are occasionally reported as AAT in Japan: however, the Companion Animal Partnership Program and AAA differ from AAT and, in actuality, AAT (as it occurs in Europe and the United States) is not used in Japan1"'20'. In Japan, For people who enjoy the company of animals, AAT may serve as an effective adjuvant/ alternative therapy, with more an emphasis on sustained patient activity, continuous physical improvement and psychological or social change compared with AAA.

Among Japanese citizens aged 65 and older, rates of cerebrovascu lar disease requiring hospitalisation are high. Consequently, the costs of treating cerebrovascular diseases are considerable and pose a major bur den on Japan’s long-term care insurance system21'. Internationally, the World Health Organization (WHO) reported that the second leading cause of death worldwide in 2015 was stroke. Over the past 15 years,

stroke has continued to be a leading cause of death in the world22’. AAT may be able to improve mood in patients with cerebrovascular

disease and mental sequelae due to disorders such as paralysis. Additionally, AAT may help improve patient communication, emotional stability and social engagement. From a standpoint of physical rehabili tation, it may possible to improve daily living skills and patient motiva tion via AAT. Because AAT seeks to enhance autonomy and facilitate patient adaptation, it may also be able to restore physical function. Because nurses are intimately involved in the daily and psychological lives of patients, nursing may be able to effectively implement AAT within medical settings.

AAT is recognised by the Nursing Interventions Classification (NIC) of the North American Nursing Diagnosis Association (NANDA)23', but there are no studies investigating which evaluation items in the Nursing Outcomes Classification (NOC) index are affected. AAT is not currently practised as a form of nursing care in Japan; hence, Japanese nurses do not recognise AAT. Therefore, the purpose of this research was to verify the nursing care effects on patients attributable to AAT. Here AAT was delivered by nurses and dogs in medical settings, to patients following stroke.

MATERIALS AND METHODS

Study design and setting

This was a quasi-experimental research study (non-randomised con trolled trial) conducted from May to November, 2007. Participants were

Received on September 5, 2018 and accepted on November 23, 2018 1) Japan University of Health Sciences

1961-2 Satte, Satte-City, Saitama, Japan 2) International University of Health and Welfare

1-2-25 Shiroyania, Odawara-City, Kanagawa, Japan Correspondence to: Hiroko Fujisawa (e-mail: [email protected])

((3) 2019 Japan Health Sciences University & Japan International Cultural Exchange Foundation

mailto:[email protected]

Fujisawa H. et al. 127

Table 1. Change in mood (VAS) of patients in AAT 1-4 weeks (cm)

Before AAT After AAT Difference before and

after AAT

Percentile Percentile Percentile

Week 25 50 75 25 50 75 25 50 75

(Median) (Median) (Median)

1 4.7 5.0 6.3 6.4 7.2 8.5 1.5 2.3 3.2

2 5.1 5.4 6.7 5.9 7.8 8.9 0.2 1.2 3.0 3 3.6 4.5 5.6 6.3 8.3 9.1 0.8 2.6 4.6 4 4.3 5.2 5.8 7.6 8.4 8.8 1.0 3.5 4.4

P 0.363 0.921 0.408

Table 2. Change in behavior in AAT 1-4 weeks (second)

Talking (Handler) Talking (Therapy dog) Watching Touching

Percentile Percentile Percentile Percentile

week 25 50

(Median)

75 25 50

(Median)

75 25 50

(Median)

75 25 50

(Median)

1 14.0 36.4 158.1 0.0 0.0 0.2 22.5 84.5 120.3 0.0 2.5 15.4 2 13.4 42.2 128.0 0.0 0.0 4.8 12.1 67.3 90.4 0.0 0.0 27.7 3 2.5 37.1 186.7 0.0 0.0 2.3 56.5 95.3 197.8 0.0 2.2 32.0 4 7.3 75.2 121.8 0.0 1.7 8.2 20.1 100.2 169.3 0.0 4.8 54.0

P 0.840 0.038a 0.525 0.694

a: Significant difference talking (Therapy dog) between 2nd and 4th week (Wilcoxon test)

randomly assigned to either the AAT intervention group or the waiting/ control group. Criteria for inclusion were 1) history of stroke, presently in good (stable) condition; 2) physician determination that AAT inter vention was appropriate; 3) favourable opinion of dogs; 4) patients agreeable to taking part in AAT; 5) functional communication skills; 6) residing in hospital during the study period; and 7) provision of informed consent to participate in research.

A ssignm ent o f in te rven tio n g ro u p a n d w a itin g g ro u p

This was a single-site study, involving one ward of a general hospi tal with 340 beds and a recovery ward with 40 beds. The patients who agreed to participate were randomly assigned to either the AAT or wait ing group. Assignment was carried out according to order of presenta tion, alternately assigned to the AAT or waiting group. All participants in the waiting group were offered AAT following the study period.

Prescription of AAT b y d o c to r

A nurse who also handled the therapy dog provided AAT to patients after a physician’s prescription. These prescriptions were directed at improvement of 1) watching, 2) touching (manual contact with dog), 3) brushing or 4) walking.

Nursing AAT In terven tio n

Nurses drafted a nursing care plan, which was implemented and evaluated using nursing diagnoses based on NANDA-NIC-NOC linkag- esJ4>. The primary nurse drafted and evaluated the nursing plans for both groups. For the AAT group, the observation and the aid items included AAT. The waiting group was not exposed to AAT during the study peri od. The nursing AAT records were recorded by the nurse who was also the dog handler.

AAT

The handler nurse performed AAT on weekday afternoons, involv ing approximately 10 min of one-on-one contact between a therapy dog and patient. The 10-min duration was determined on the basis of the average duration of therapy dogs' concentration, limited opportunities for AAT activities in the afternoon and a preliminary survey of patient involvement with AAT. The handler nurse took a therapy dog and went to the patient’s room where AAT was performed with the patient in bed.

or seated at bedside. The handler nurse performed AAT in accordance with NIC procedures, with goals directed as per the physician order. AAT was conducted using the same therapy dog every time. The handler completed all tasks related to therapy dog excretion, daily training, cleansing and oral care prior to AAT administration each day.

T h era p y D og a n d H an d le r

The therapy dog had passed the Yamanashi Therapy Dog Club ther apy dog certification programme and was disease free and current on all vaccinations. The dog used was an English Cocker Spaniel named Orb, aged 2 y and 5 months.

The handler was hired by the hospital to work as both a handler and nurse. She possessed 5 y of nursing experience and typically completed her nursing work in the ward during the mornings and performed AAT on weekday afternoons. The handler was trained in implementation of AAT activities and was certified by the Yamanashi Therapy Dog Club.

Survey

The following (1) to (4) surveys were conducted with participants over the 4-week study period. In the AAT group, all four surveys were administered, and two surveys [(3) and (4)] were administered to the waiting group. Only the intervention group was administered (1) and (2) once per week, with the psychological aspect evaluated by AAT. (3) and (4) conducted an investigation in both groups, (3) evaluated the physical aspect and (4) conducted a survey on nursing outcomes. We comprehen sively investigated the effects of AAT from 2 perspectives: those of patients and nursing.

M o o d c h a n g e s

Changes in patient mood, before and after AAT, were evaluated using visual analogue scales (VAS). We standardised the response stim ulus as, 'Please tell us your mood at the present time'i and were careful not to influence the patient's response at any time. VAS measures were taken eight times per patient, for 4 weeks, once per week involving one assessment before and another after AAT. We specifically focused on mood changes before and after AAT in the AAT group.

B ehaviour during AAT

We analysed participant behaviours during AAT via video analysis.

128 Influence of Animal Assisted Therapy for Patients with Stroke

Table 3. Changes in motor function and cognitive function by FIM at the start and end of AAT in inter vention group and waiting group

B efore AAT A fter AAT D ifference

before

and after

P ercentile P ercentile P ercentile p

25 50 75 25 50 75 25 50 75

(M edian) (M edian) (M edian)

meal 1.0 5.0 5.0 1.0 5.0 5.0 0.0 0.0 0.0 0.317

cosm etic 1.0 4.0 5.0 1.0 4.0 5.0 0.0 0.0 1.0 0.102

cleansing 1.0 3.0 4.0 1.0 3.0 4.0 0.0 0.0 0.0 0.317

dressing / upper body 1.0 3.0 3.0 1.0 3.0 4.0 0.0 0.0 1.0 0.102

dressing / L ow er body 1.0 1.0 3.0 1.0 2.0 4.0 0.0 0.0 1.0 0.102

to ilet action 1.0 1.0 5.0 1.0 1.0 5.0 0.0 0.0 1.0 1.000

m otor function urination m anagem ent 1.0 3.0 6.0 1.0 5.0 7.0 0.0 0.0 0.0 0.180

defecation m anagem ent 1.0 5.0 6.0 1.0 6.0 6.0 0.0 0.0 0.0 0.317

bed /chair/w heelchair 1.0 4.0 5.0 2.0 4.0 5.0 0.0 1.0 1.0 0.024

in terven-tion group to ilet 1.0 1.0 4.0 1.0 4.0 5.0 0.0 0.0 1.0 0.059

bath tub/show er 1.0 1.0 4.0 1.0 2.0 4.0 0.0 0.0 0.0 0.414

w alking 0.0 1.0 1.0 0.0 1.0 1.0 0.0 0.0 0.0 0.157

w heelchair 0.0 1.0 1.0 0.0 1.0 1.0 0.0 0.0 0.0 1.000

stairs 1.0 1.0 1.0 1.0 1.0 1.0 0.0 0.0 0.0 0.180

understanding 3.0 4.0 5.0 3.0 5.0 6.0 0.0 0.0 2.0 0.059

expressing 3.0 5.0 6.0 3.0 5.0 6.0 0.0 0.0 1.0 0.066

cogn itive function social exchange 3.0 4.0 5.0 4.0 4.0 6.0 0.0 0.0 0.0 0.157

problem solution 1.0 1.0 5.0 1.0 2.0 5.0 0.0 0.0 0.0 0.180

m em ory 1.0 2.0 3.0 1.0 3.0 4.0 0.0 0.0 2.0 0.034

m eal 4.0 5.5 6.0 4.3 6.0 6.0 0.0 0.0 0.0 0.157

cosm etic 2.0 5.0 5.8 2.0 5.0 7.0 0.0 0.0 1.0 0.059

cleansing 1.0 4.0 5.0 1.0 5.0 6.0 0.0 0.0 1.0 0.063

d ressing / upper body 2.3 5.0 6.8 2.3 5.0 7.0 0.0 0.0 0.0 0.157

d ressing / L ow er body 2.0 4.0 6.8 2.0 5.0 7.0 0.0 0.0 1.0 0.059

to ilet action 1.3 4.5 6.8 2.0 5.0 6.8 0.0 0.0 0.8 0.102

m otor function urination m anagem ent 1.0 5.0 7.0 1.0 5.5 7.0 0.0 0.0 0.0 0.317

defecation m anagem ent 1.0 4.5 6.8 1.0 6.0 6.8 0.0 0.0 0.0 0.180

w aiting group bed /chair/w heelchair 1.8 5.0 5.8 2.8 5.0 7.0 0.0 0.5 1.0 0 .020

to ilet 1.8 5.0 5.8 2.8 5.0 6.8 0.0 0.0 1.0 0.034

bath tub/show er 1.0 3.0 5.0 2.5 4.5 6.0 0.0 1.0 1.8 0.010

w alking 0.0 1.0 4.8 2.5 4.5 6.0 1.0 1.5 3.8 0.005

w heelchair 0.0 0.0 1.0 0.0 0.0 1.0 0.0 0.0 0.0 0.655

stairs 1.0 1.0 1.0 1.0 1.0 5.0 0.0 0.0 1.8 0.041

cogn itive function understanding 2.3 5.0 6.0 3.3 5.0 6.0 0.0 0.0 0.0 0.180

expressing 2.5 5.0 6.0 4.0 5.0 6.8 0.0 0.0 0.8 0.102

socia l exchange 4.3 5.5 7.0 4.3 6.0 7.0 0.0 0.0 0.0 0.317

problem solution 1.0 3.0 5.8 1.3 3.0 5.8 0.0 0.0 0.0 0.317

m em ory 1.3 2.5 4.5 2.3 3.0 5.8 0.0 0.0 1.0 0.038

We specifically coded four voluntary participant behaviours including 'talking (to the handler)', 'talking (to the therapy dog)', 'watching (the ther apy dog)' and 'touching (the therapy dog)'. One patient was videotaped once weekly for 4 weeks, and a total of four surveys were conducted.

P h y s ic a l fu n c tio n m e a s u re s

The F unc tiona l Independence M easure (FIM ) and S troke Impairment Assessment Set (SIAS) were used to evaluate body function changes in both the AAT and waiting groups. A total o f 2 surveys were conducted for on patient at the beginning of the survey and 4 weeks later. These data were evaluated by the treating physiotherapists.

N u rs in g O u tc o m e s

NOC evaluations were completed four times per week for 4 weeks

to examine changes in the various indices. NOC measures were deter mined for two items: 'psychomotor energy' and 'participation in leisure ac tiv ities 'c . Psychom otor energy was evaluated by nine item s. Participation in leisure activities was evaluated by 10 items.

S ta tis t ic a l a n a ly s is

M o o d c h a n g e s

VAS values were measured before AAT, after AAT, and the differ ence in measured VAS values were determined before and after AAT from week 1 through 4. The median o f the percentile was calculated using non-parametric methods. Differences in the measured VAS values were compared using the Friedman test.

Fujisawa H. et al. 129

Table 4. Changes in the NANDA-NOC index at 1-4 weeks -NOC: psychomotor energy, participation in leisure activities-

1st week 2nd week 3rd week 4th week pa pb

score n % n % n % n %

0 0 0.0 0 0.0 0 0.0 0 0.0 =ro 3

1 2 33.3 1 16.7 0 0.0 0 0.0 o 2 1 16.7 1 16.7 0 0.0 0 0.0

intervention group 0.001

3 3 3 50.0 3 50.0 2 33.3 0 0.0

to 4 0 0.0 1 16.7 2 33.3 2 33.3 601: showing a love fit for the 5 0 0.0 0 0.0 2 33.3 4 66.7

0.025 situation 0 1 12.5 1 12.5 1 12.5 1 12.5

1 6 75.0 5 62.5 3 37.5 2 25.0

2 1 12.5 2 25.0 3 37.5 4 50.0

waiting group 3 0 0.0 0 0.0 1 12.5 1 12.5 0.010

4 0 0.0 0 0.0 0 0.0 0 0.0

5 0 0.0 0 0.0 0 0.0 0 0.0

0 0 0.0 0 0.0 0 0.0 0 0.0

1 2 33.3 1 16.7 0 0.0 0 0.0

intervention group

2 1 16.7 1 16.7 0 0.0 0 0.0 0.004

3 3 50.0 1 16.7 4 66.7 1 16.7 4 0 0.0 3 50.0 2 33.3 4 66.7

602: indicating concentration 5 0 0.0 1 16.7 0 0.0 i 16.7

0.014 0 0 0.0 0 0.0 0 0.0 0 0.0

1 6 75.0 5 62.5 3 37.5 2 25.0

waiting group

2 2 25.0 2 25.0 3 37.5 4 50.0 0.005

3 0 0.0 1 12.5 2 25.0 2 25.0

4 0 0.0 0 0.0 0 0.0 0 0.0

5 0 0.0 0 0.0 0 0.0 0 0.0

0 5 83.3 5 83.3 5 83.3 5 83.3

1 0 0.0 0 0.0 0 0.0 0 0.0 2 0 0.0 0 0.0 0 0.0 0 0.0

intervention group 3 0 0.0 0 0.0 0 0.0 0 0.0

4 1 16.7 1 16.7 1 16.7 1 16.7 603: indicating appropriate 5 0 0.0 0 0.0 0 0.0 0 0.0

0.157 adjustment and hygiene 0 6 75.0 6 75.0 6 75.0 6 75.0

1 0 0.0 0 0.0 0 0.0 0 0.0

2 1 12.5 1 12.5 1 12.5 0 0.0 0.112

waiting group 3 1 12.5 1 12.5 1 12.5 1 12.5

4 0 0.0 0 0.0 0 0.0 1 12.5

5 0 0.0 0 0.0 0 0.0 0 0.0

0 3 50.0 3 50.0 3 50.0 3 50.0

1 1 16.7 1 16.7 0 0.0 0 0.0

intervention group

2 0 0.0 0 0.0 0 0.0 0 0.0 0.194

3 0 0.0 0 0.0 1 16.7 1 16.7

4 2 33.3 2 33.3 2 33.3 1 16.7

604: indicating normal appetite 5 0 0.0 0 0.0 0 0.0 1 16.7

0.157 0 4 50.0 4 50.0 4 50.0 4 50.0

1 2 25.0 1 12.5 i 12.5 I 12.5

waiting group

2 0 0.0 1 12.5 0 0.0 0 0.0 0.129

3 1 12.5 1 12.5 1 12.5 1 12.5

4 0 0.0 0 0.0 1 12.5 0 0.0

5 1 12.5 1 12.5 1 12.5 2 25.0

0 5 83.3 5 83.3 5 83.3 5 83.3

1 0 0.0 0 0.0 0 0.0 0 0.0

2 0 0.0 0 0.0 0 0.0 0 0.0

intervention group 3 0 0.0 0 0.0 0 0.0 0 0.0

4 1 16.7 1 16.7 1 16.7 1 16.7 613 protecting the indicated 5 0 0.0 0 0.0 0 0.0 0 0.0

1.000 drug 0 7 87.5 7 87.5 7 87.5 7 87.5

1 1 12.5 1 12.5 1 12.5 1 12.5

waiting group 2 0 0.0 0 0.0 0 0.0 0 0.0 -

130 Influence of Animal Assisted Therapy for Patients with Stroke

waiting group

intervention group

614 : Protect instructed therapy

waiting group

intervention group

606: Pay attention to

surroundings

waiting group

intervention group

608: Show appropriate

energy level

waiting group

intervention group

609: Ability to achieve

daily routine

waiting group

“•or5a

160401: Participate in

activities other than

regular work

intervention group

3 0 0.0 0 0.0 0 0.0 0 0.0

4 0 0.0 0 0.0 0 0.0 0 0.0

5 0 0.0 0 0.0 0 0.0 0 0.0

0 5 83.3 5 83.3 5 83.3 5 83.3

1 0 0.0 0 0.0 0 0.0 0 0.0

2 0 0.0 0 0.0 0 0.0 0 0.0

3 0 0.0 0 0.0 0 0.0 0 0.0

4 1 16.7 1 16.7 1 16.7 1 16.7

5 0 0.0 0 0.0 0 0.0 0 0.0

0 6 75.0 6 75.0 6 75.0 6 75.0

1 2 25.0 2 25.0 1 12.5 1 12.5

2 0 0.0 0 0.0 1 12.5 1 12.5

3 0 0.0 0 0.0 0 0.0 0 0.0

4 0 0.0 0 0.0 0 0.0 0 0.0

5 0 0.0 0 0.0 0 0.0 0 0.0

0 0 0.0 0 0.0 0 0.0 0 0.0

1 2 33.3 1 16.7 0 0.0 0 0.0

2 1 16.7 1 16.7 0 0.0 0 0.0

3 3 50.0 3 50.0 2 33.3 0 0.0

4 0 0.0 1 16.7 4 66.7 4 66.7

5 0 0.0 0 0.0 0 0.0 2 33.3

0 0 0.0 0 0.0 0 0.0 0 0.0

1 7 87.5 6 75.0 3 37.5 2 25.0

2 1 12.5 2 25.0 4 50.0 5 62.5

3 0 0.0 0 0.0 1 12.5 1 12.5

4 0 0.0 0 0.0 0 0.0 0 0.0

5 0 0.0 0 0.0 0 0.0 0 0.0

0 2 33.3 2 33.3 2 33.3 2 33.3

1 2 33.3 1 16.7 0 0.0 0 0.0

2 0 0.0 0 0.0 0 0.0 0 0.0

3 2 33.3 2 33.3 2 33.3 1 16.7

4 0 0.0 1 16.7 2 33.3 2 33.3

5 0 0.0 0 0.0 0 0.0 1 16.7

0 0 0.0 0 0.0 0 0.0 0 0.0

1 6 75.0 6 75.0 4 50.0 4 50.0

2 0 0.0 0 0.0 2 25.0 2 25.0

3 2 25.0 2 25.0 1 12.5 0 0.0

4 0 0.0 0 0.0 1 12.5 1 12.5

5 0 0.0 0 0.0 0 0.0 1 12.5

0 6 100.0 6 100.0 6 100.0 6 100.0

1 0 0.0 0 0.0 0 0.0 0 0.0

2 0 0.0 0 0.0 0 0.0 0 0.0

3 0 0.0 0 0.0 0 0.0 0 0.0

4 0 0.0 0 0.0 0 0.0 0 0.0 5 0 0.0 0 0.0 0 0.0 0 0.0

0 2 25.0 2 25.0 2 25.0 2 25.0

1 4 50.0 4 50.0 4 50.0 3 37.5 2 0 0.0 0 0.0 0 0.0 1 12.5

3 2 25.0 2 25.0 0 0.0 0 0.0

4 0 0.0 0 0.0 2 25.0 1 12.5

5 0 0.0 0 0.0 0 0.0 1 12.5

0 0 0.0 0 0.0 0 0.0 0 0.0

1 1 25.0 0 0.0 0 0.0 0 0.0

2 2 50.0 3 75.0 1 25.0 0 0.0

3 0 0.0 0 0.0 2 50.0 3 75.0 4 1 25.0 1 25.0 1 25.0 1 25.0

5 0 0.0 0 0.0 0 0.0 0 0.0

0 0 0.0 0 0.0 0 0.0 0 0.0 1 0 0.0 0 0.0 0 0.0 0 0.0 2 1 25.0 1 25.0 0 0.0 0 0.0

0.392

0.002

0.003

0.022

0.016

0.121

0.047

0.724

0.005

0.282

0.491

0.200

waiting group 3 75.0 3 75.0 4 100.0 4 100.0

0.392

Fujisawa H. et al. 131

160410: physical exercise

participates in advanced

leisure activities

160411: participate in leisure activities with low

physical activity

160412: Interest of Select a

certain leisure activity

160402: express

satisfaction in

leisure activities

160403: use appropriate

skills of social interaction

4 0 0.0 0 0.0 0 0.0 0 0.0

5 0 0.0 0 0.0 0 0.0 0 0.0

0 4 100.0 3 75.0 3 75.0 0 0.0

1 0 0.0 1 25.0 1 25.0 0 0.0

intervention group 2

0.0

0.0 -

4 0 0.0 0 0.0 0 0.0 0 0.0

5 0 0.0 0 0.0 0 0.0 0 0.0 1.000

0 0 0.0 0 0.0 0 0.0 0 0.0 1 4 100.0 4 100.0 4 100.0 4 100.0

waiting group 2

0 0.0

0.0

0.0 -

4 0 0.0 0 0.0 0 0.0 0 0.0 5 0 0.0 0 0.0 0 0.0 0 0.0

0 4 100.0 3 75.0 3 75.0 4 100.0 1 0 0.0 0 0.0 0 0.0 0 0.0

intervention group 2

0.0

25.0

0.0

0.0 0.392

4 0 0.0 0 0.0 1 25.0 0 0.0 5 0 0.0 0 0.0 0 0.0 0 0.0

0.886 0 0 0.0 0 0.0 0 0.0 0 0.0 1 0 0.0 0 0.0 0 0.0 0 0.0

waiting group 2

75.0

25.0

75.0

25.0

75.0

25.0

75.0 0.112

4 0 0.0 0 0.0 0 0.0 0 0.0 5 0 0.0 0 0.0 0 0.0 0 0.0

0 0 0.0 0 0.0 0 0.0 0 0.0 1 3 75.0 0 0.0 0 0.0 0 0.0

intervention group 2 3

0 0

0.0 0.0

2 1

50.0 25.0

2 1

50.0 25.0

0 3

0.0 75.0

0.019

4 1 25.0 i 25.0 i 25.0 0 0.0 5 0 0.0 0 0.0 0 0.0 1 25.0

0.200 0 0 0.0 0 0.0 0 0.0 0 0.0 1 0 0.0 0 0.0 0 0.0 0 0.0

waiting group 2

75.0

25.0

75.0

25.0

0.0

100.0

0.0

100.0 0.029

4 0 0.0 0 0.0 0 0.0 0 0.0 5 0 0.0 0 0.0 0 0.0 0 0.0

0 0 0.0 0 0.0 0 0.0 0 0.0 1 1 25.0 1 25.0 0 0.0 0 0.0

intervention group 2

50.0

0.0

50.0

0.0

50.0

25.0

0.0

50.0 0.013

4 1 25.0 1 25.0 I 25.0 1 25.0 5 0 0.0 0 0.0 0 0.0 1 25.0

0.343 0 0 0.0 0 0.0 0 0.0 0 0.0 1 0 0.0 0 0.0 0 0.0 0 0.0

waiting group 2

1 75.0

25.0

4 0.0

100.0

0.0

75.0

0.0

75.0 0.019

4 0 0.0 0 0.0 1 25.0 1 25.0 5 0 0.0 0 0.0 0 0.0 0 0.0

0 0 0.0 0 0.0 0 0.0 0 0.0 1 1 25.0 1 25.0 1 25.0 0 0.0

intervention group 2

50.0

0.0

50.0

0.0

0 50.0

0.0

2 0.0

50.0 0.043

4 1 25.0 1 25.0 i 25.0 1 25.0 5 0 0.0 0 0.0 0 0.0 1 25.0

0.114 0 0 0.0 0 0.0 0 0.0 0 0.0 1 4 100.0 4 100.0 4 100.0 4 100.0

waiting group 2

0.0

0.0 -

4 0 0.0 0 0.0 0 0.0 0 0.0

132 Influence of Animal Assisted Therapy for Patients with Stroke

5 0 0.0 0 0.0 0 0.0 0 0.0

0 0 0.0 0 0.0 0 0.0 0 0.0

1 1 25.0 0 0.0 0 0.0 0 0.0

intervention group 2

50.0

0.0

75.0

0.0

25.0

0.0

75.0 0.022

4 1 25.0 1 25.0 2 50.0 0 0.0

160404: relax by 5 0 0.0 0 0.0 0 0.0 1 25.0 0.343

leisure activities 0 0 0.0 0 0.0 0 0.0 0 0.0

1 0 0.0 0 0.0 0 0.0 0 0.0

waiting group 2

75.0

25.0

75.0

0.0

75.0

0.0

75.0 0.024

4 0 0.0 0 0.0 1 25.0 1 25.0

5 0 0.0 0 0.0 0 0.0 0 0.0

0 0 0.0 0 0.0 0 0.0 0 0.0

1 1 25.0 0 0.0 0 0.0 0 0.0

intervention group 2

50.0

0.0

75.0

0.0

25.0

0.0

50.0 0.022

4 1 25.0 1 25.0 2 50.0 1 25.0

160413: enjoy leisure 5 0 0.0 0 0.0 0 0.0 1 25.0 0.343

activities 0 0 0.0 0 0.0 0 0.0 0 0.0

1 0 0.0 0 0.0 0 0.0 0 0.0

waiting group 2

75.0

25.0

75.0

0.0

75.0

0.0

75.0 0.024

4 0 0.0 0 0.0 1 25.0 1 25.0

5 0 0.0 0 0.0 0 0.0 0 0.0

0 0 0.0 0 0.0 0 0.0 0 0.0

1 1 25.0 0 0.0 0 0.0 0 0.0

intervention group 2

50.0

25.0

75.0

25.0

50.0

75.0

0.0

100.0 0.022

160405: to demonstrate 4

0.0

25.0 0.114

leisure activities 0

0.0

waiting group 2

75.0

25.0

75.0

25.0

75.0

25.0

75.0 0.112

4 0 0.0 0 0.0 0 0.0 0 0.0

5 0 0.0 0 0.0 0 0.0 0 0.0

0 0 0.0 0 0.0 0 0.0 0 0.0

1 1 25.0 0 0.0 0 0.0 0 0.0

intervention group 2

50.0

0.0

75.0

0.0

50.0

25.0

0.0

75.0 0.067

160407: consider 4

25.0

0.0

25.0

0.0

25.0

0.0

25.0

0.0 0.686

activities 0

0.0

waiting group 2

75.0

25.0

75.0

25.0

0.0

100.0

0.0

100.0 0.029

4 0 0.0 0 0.0 0 0.0 0 0.0

5 0 0.0 0 0.0 0 0.0 0 0.0

a: Significance probability of changes in scores of 1-4 weeks in intervention group and waiting group (Friedman test)

b: Significance probability of changes in scores on week 1 and week 4 of intervention group and waiting group (Wilcoxon test)

B ehaviour during AAT

The median of the percentile was calculated using non-parametric methods. Differences in the number of appearances for each of the 4 actions, from week 1 to 4, were compared by Friedman test. Items with significant differences were further subjected to non-parametric testing and compared by Wilcoxon test. In addition, the median for the self-care and non-self-care groups of FIM was calculated using a non-parametric test. The differences in the number of times the four actions appeared were compared using the Friedman test. The obtained video was sub

jected to behaviour analysis and statistical processing using a behaviour coding system (DKH beco version 3.2). The Kappa coefficient was used to determine validity. Analysts were trained by DKH Co., Ltd., on behaviour analysis procedures and software operation to ensure reliabil ity. There were two analysers and one supervisor.

Physical Function M easu res

The median was calculated by performing a non-parametric test on the change in FIM scores between the AAT group and the waiting group

Fujisawa H. et al. 133

pre-AAT, post-AAT and before and after execution of AAT for motor function and cognitive function items. Trends before and after AAT were compared by Friedman test. The median was calculated by non-parametric test for changes in 'pain' and 'language function' on the SIAS pre-AAT and post-AAT. Changes between pre- and post-AAT were compared by Wilcoxon test.

Nursing Outcomes

Non-parametric tests were conducted separately for the AAT and waiting groups, and changes in the five points of the NOC index items between weeks 1 and 4 were compared by Friedman test. All statistical operations were completed using IBM SPSS Statistics Version 24.

Ethics

All participants provided consent for participation following oral and written explanations about the objectives, methods, freedom to par ticipate (or not), risks/benefits and privacy concerns. All information was encrypted so that individuals and hospitals were not identified and stored securely.

We considered the possibility of both physical and psychological fatigue for the therapy dog, and all possible precautions were taken to insure maximum animal welfare. This research was conducted with the ethical review of the hospital and approval of the Research Ethics Review Committee of the International Medical and Welfare University.

RESULTS

Patient Overview

A total of 30 participants, including 15 in the AAT group and 15 in the waiting group were planned, but several people dropped out. As a result of attrition, there were 23 surveys. Ultimately, 11 patients were included in the intervention group [five women and six men, average age 78.6 (SD: 15.09), and 12 patients in the waiting group [seven women and five men, average age 79.0 (SD: 10.78).

In the ATT group, four patients were diagnosed with cerebral haem orrhage (36.4%) and seven with cerebral infarction (63.6%). In the wait ing group, four patients (33.3%) were diagnosed with cerebral haemor rhage and eight (66.7%) with cerebral infarction. The groups were sta tistically homogeneous regarding age, gender and disease.

Mood changes

Change in VAS between week 1 and 4 was measured to investigate mood changes. There were no statistically significant differences in any measure between week 1 and 4 (Table 1).

Behaviour during AAT

We measured the duration (in seconds) of the four behaviours during AAT between weeks 1 and 4. The only significant difference (P < 0.05) was with 'talking (to the therapy dog)' (P < 0.05) and there was a significant difference between week 2 and 4 during multiple compari son (P < 0.05) (Table 2).

Among patients who demonstrated independence on FIMs, we mea sured the behaviour durations (in seconds) during AAT at weeks 1 to 4. The median of'talking (to the handler)' 97.9-132.0, 'talking (to the ther apy dog)' 0.52-4.4, 'watching' 57.9-88.1, and 'touching1 2.39-16.22 in 4 weeks. There were no significant differences noted in the four actions.

Among patients who were not independent on FIMs, the median duration for 'talking (to the handler)' 5.7-23.5, 'talking (to the therapy dog)' 0.0, 'watching' 84.5- 152.3, and 'touching' 0.0- 19.1 in 4 weeks. There were no significant differences in the durations of the four actions.

Physical function

The median values of items of exercise function and cognitive func tion by FIM were calculated before and after the AAT of the interven tion group. There was a significant difference between the AAT before and after the item of'bed/chair/wheelchair' of motor function (p < 0.05). There was a significant difference in 'memory' in cognitive function {p <

0.05). The median values of items of exercise function and cognitive func

tion by FIM were calculated at the start and end of survey of the waiting group. There was a significant difference in the difference in scores before and after the AAT for 'bed/chair/wheelchair' (p < 0.05), 'toilet' (p < 0.05), 'bathtub/shower' (p < 0.01), 'walk' (p < 0.01), and 'stairway' (p < 0.05). (Table 3)

Median values of SIAS items in the AAT group were 'pain' 2.0, 'lan guage function' 2.0 before AAT and 'pain' 2.0, ’language function' 2.0 after AAT. In the waiting group, scores were ’pain' 3.0, 'language func tion' 3.0 before the AAT, and 'pain' 2.5, 'language function' 3.0 after the AAT. There was no statistically significant difference between pre- and post-test measures for any item.

Nursing Outcomes

The indicators of the selected NOC were 'psychomotor energy' (AAT group 6, and waiting group 8), 'participation in leisure activities' (AAT group 4, and waiting group 4) and 'severity of loneliness' (AAT group 1).

"Psychomotor energy") There was a significant difference in three items, '601: showing a love appropriate for the situation', '602: indicat ing concentration' and '606: paying attention to surroundings', between week 1 and 4 for both groups.

"Participation in leisure activities") There were significant between- group differences between week 1 and 4 for six evaluation items: '160401: participate in non-regular work activities', '160412: choose interesting leisure activities', '160402: express satisfaction with leisure activities', '160404: relax by leisure activities', '160413: enjoy leisure activities' and T 60407: to consider various leisure activities as indices of'participation in leisure activities'. There were significant differences in two items: '160403: use appropriate skills for social interaction' and '160405: demonstrate creativity through leisure activities' in the waiting group.

There were no statistically significant between-group differences between weeks 1 and 4 for all evaluation items (Table 4).

DISCUSSION

This study investigated the effects of AAT using a dog and a nurse as a handler, and the nursing care effects for patients following stroke. Although AAT has been conducted in medical institutions and elder care facilities, we evaluated AAT as a component of nursing care.

The effect of AAT on patients with stroke

We evaluated the effect of AAT on physical function, mood, behaviour and nursing outcome classifications in patients following stroke. Physical changes were evaluated by motor function and cogni tive function by FIM and SIAS. There was a significant change in the motor function indicator for 'bed/chair/wheelchair' and in the 'memory' indicator for cognitive function in the AAT group. However, these items also changed significantly in the waiting group. In addition, there were significant differences in four items including 'exercise function', 'toilet' 'bathtub/shower', 'walk' and 'stairway' in the waiting group. Improvements in FIM scores are presumed to occur secondary to reha bilitation procedures commonly performed for the purpose of restoring function, yet FIM scores changed significantly in the waiting group. It is possible that 4 weeks of AAT was insufficient for recovery of physical functions because the items 'pain' and ’language function1 (by SIAS) did not differ significantly in either group. However, In the present study, the position and degree of paralysis were different among the patients. Thus, the impact of paralysis on physical function could act as the com mon denominator.

There was no statistically significant change in mood for either group; therefore, it is unclear whether AAT affected mood in patients following stroke. Additionally, we could not clarify the effect of AAT on physical function changes. On the basis of previous research25’ it is pos sible that our results were different because the number of subjects and the number instances of AAT exposure were small.

We predicted that the action time spent talking to the therapy dogs during AAT would gradually increase, because patients would gradually become attached to the animal used for AAT26’. Therefore, the four actions involving the patient voluntary 'talking (to the handler)', 'talking (to the therapy dog)', 'watching' and 'touching' were analysed. We antici pated that the time spent engaging in these actions would increase over

134 Influence of Animal Assisted Therapy for Patients with Stroke

time. However, we did not identify such a trend. There was no signifi cant difference in the time spent engaging in the 4 actions, even when patients were divided into those who were independent, or not indepen dent, carrying out ADLs (as indicated by FIM score).There was a signif icant difference in time spent 'talking (to the therapy dog)', between week 2 and 4, but we were unable to clarify the effect of AAT on patients with histories of stroke. In this study, patients only interacted with the dogs or nurse handlers. Also, we did not consider conversation al content as a variable of interest. To examine the emotional effects of AAT, it would be necessary to more deeply investigate the content of patient discourse, as in previous research2”.

Nursing Outcomes

AAT may have contributed to achieving nursing outcomes as nurs ing care, because there was a significant difference between the AAT group and the waiting group in the 'emotion', 'concentration' and 'inter est' items of 'mental kinetic energy' as NOC indices. Depression is a common sequela of stroke that often occurs starting in the acute phase, and into the second-year post-onset, regardless of age. Approximately, 30% of individuals who suffer a stroke will have depression by three months post-onset2*’. Depression can be accompanied by pain and suf fering and may also impair QOL and affect the family unit. For patients who have sustained a stroke, AAT may be an effective nursing care method for preventing depression after stroke.

We noted significant improvement on the six NOC indices includ ing 'participation in leisure activities', but there was also a significant improvement in the waiting group. It is highly probable that AAT was not effective as a nursing care intervention for this outcome. This study allowed for direct comparison of the AAT and waiting group, thereby providing a better way of quantifying the effects of AAT. As a result, we believe that AAT can improve variables related to mental activity such as affection, concentration, and attention, although the effect of AAT was unclear for physical and functional variables.

Limitations

This study was limited by our relative small study cohort and short investigation period. We cannot draw conclusions about how AAT may affect physical functions in stroke patients, and further investigations are needed. Information gleaned from future studies will assist our efforts to restore physical and mental functionality in patients who have sustained strokes via effective application of AAT in Japan. We also seek to establish a system for formally implementing AAT as a form of nursing care.

C O N C L U S IO N

We investigated the effects of AAT in a cohort of patients following stroke, and nursing care variables, using a dog handled by a nurse. Our results did not clearly indicate whether 4 weeks of AAT affected physi cal functional or mood variables following stroke. Observed behavioural changes in patients who participated in AAT included increased 'talking (to the therapy dog)', but these changes were not clearly attributable to AAT alone. As a nursing care modality, AAT may be an effective means of achieving nursing outcomes regarding 'emo tion' 'concentration' and 'interest' as per the NOC. Future studies are needed to further verify the effects of AAT, including those with longer observation periods and with greater numbers of subjects.

A C K N O W L E D G E M E N T S

We appreciate the patients, their families, the hospital director, the ward nurses, and the teachers of the rehabilitation department who cooperated in this research, and we thank therapy dog Orb. We would like to thank Enago (www.enago.jp) for the English language review.

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http://www8.cao.go.jp/

http://www.who.int/

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