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1 Work xx (20xx) x–xx DOI:10.3233/WOR-162338 IOS Press 2 The effects of gardening on quality of life in people with stroke 3 Fen-Ling Kuoa , Sui-Hua Hoa,b,∗ and Chiuhsiang Joe Linb 4 a Division 5 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 8 Au tho rP 6 7 roo f 1 Received 20 November 2014 Accepted 15 June 2015 23 Keywords: Occupational therapy, cerebrovascular accident, horticultural activity, 2k factorial design, occupation 24 1. 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. 9 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 2 22490088 ext. 1624; Fax: +886 2 22490088 ext. 1634. E-mail: [email protected], [email protected]. 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. Alcântara, 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 6 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 2 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 4 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 7 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 2 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 3 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 8 combinations (2 levels of gender X 2 levels of stroke stage X 2 levels of plants) with 3 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 2. 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 3 months (tomato and string bean were adopted in this design). Short-term plants were life cycle shorter than 3 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 4 to 6 months after stroke onset for acute patients, there was still some speech recovery after 18 months [29], and arm motor improvement after 4 years for chronic patients [31]. In this research, the chronic patients who had sustained a CVA over 6 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 1 (6 to 18 months after stroke onset) and stage 2 (>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 2 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 1 of recovery will demonstrate greater improvement in their quality of life than people in the CVA stage 2 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 6 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 1 (6–18 months after stroke onset) and stage 2 (>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 6 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 8 data points. Eventually, the data collected were analyzed using imbalanced factorial design. 240 Au tho rP 4 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 (<3 months). The time after stroke onset were classified into stage 2.7. Ethics statement Before the data collection, the experimental protocol and participant consent procedure were approved by the Taipei Medical University-Joint Institutional Review Board (case No. 201204015). The written informed consent, in accordance with institutional guidelines, was completed by each participant before the data collection. 2.8. Procedure All participants attended the gardening program once a week, for one hour in each session. Participants were guided to tend different plants by a registered occupational therapist in a garden located within Taipei Medical University-Shuang Ho Hospital, Ministry of Health and Welfare. For the long-term plant condition, participants tended tomato and string beans, which were not harvested by the end of the gardening program. Participants in the short-term plant 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 351 2.9. Data analysis 337 338 339 340 341 342 343 344 345 346 347 348 349 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 The response was defined as the change in score on quality of life between the before and after measures, the higher the response the greater the improvement. Thus, a total of 13 responses, including score changes in 12 areas and one total score, were collected for each participant. Additionally, 3 factors, each at 2 levels, were analyzed using the 23 factorial design. Minitab (16th edition) was used as the statistical software. For gender, male was marked as 1 and female marked as -1. For time after stroke onset, stage 1 was marked as 1 and stage 2 was marked as –1. For plant life cycle, long-term life cycle was marked as –1 and short-term life cycle was marked as 1. Due to the fact that some participants could not complete all experimental conditions, the data were analyzed using imbalanced 23 factorial design with replication (number of available participants). Fig. 1. Pareto chart for social role. Plant: factor A, Gender: factor B, Time after stroke onset: factor C. cte d 336 rre 335 3. Results co 334 Un 333 Au tho rP 350 condition tended water spinach and lettuce. At the end of the gardening program, all short-term plants were harvested by the patients themselves. For each plant condition, the duration of the gardening program was 3 months. Quality of life was evaluated before and after the gardening program by two registered occupational therapists. These two therapists were familiar with the instruments and used the same scoring guidelines. In addition, they were blind to the research hypotheses. Twelve areas were evaluated including: energy level, family roles, language, mobility, mood, personality, self-care, social roles, thinking, vision, upper-extremity function and work productivity. The score for each area was obtained by summing the scores on all items in each of these areas. The total quality of life score for each participant was obtained by summing the results from the 12 areas to obtain a health-related quality of life score. 332 5 roo f F.-L. Kuo et al. / The effects of gardening on quality The significant results of social role and family role as determined by 23 replicated factorial analyses are presented as follows. 3.1. Social role 23 According to the analysis for the factorial design, the Pareto chart (Fig. 1), Normal plot (Fig. 2), and Half normal plot (Fig. 3) showed significant Fig. 2. Normal plot for social role. Plant: factor A, Gender: factor B, Time after stroke onset: factor C. effects of variable A (plant) (F = 8.22, p = 0.015) and AB interaction (plant and gender) (F = 8.8, p = 0.013) on improvement of the social role area. Based on further analysis of the main effect (Fig. 4), participants tending short-term plants demonstrated greater improvement in the social role area than those who tended long-term plants. The interaction plot (Fig. 5) showed that females demonstrated more improvement than males when tending short-term plants. Based on the cube plot (Fig. 6), the optimal level combination of the social role response was found in female participants in the stage 2 tending shortterm plants. Based on the correlation coefficients in Table 1, the regression function is as follows: 377 378 379 380 381 382 383 384 385 386 387 388 389 390 F.-L. Kuo et al. / The effects of gardening on quality Fig. 3. Half normal plot for social role. Plant: factor A, Gender: factor B, Time after stroke onset: factor C. Au tho rP roo f 6 Fig. 6. The design for the social role area shown geometrically in the cube plot. Optimal level combination appeared on plant (1), gender (–1), and onset time (–1). Table 1 The estimated effects and coefficients for the social role area Factor cte d Constant Plant Gender stroke plantXgender plantXstroke genderXstroke plantXgenderXstroke Un co rre Fig. 4. Main effects plot for social role. Plant: factor A (1, shortterm; –1, long-term), gender: factor B (1, male; –1, female), time after stroke onset: factor C (1, stage 1; –1, stage 2). Fig. 5. Interaction plot for social role. Plant: factor A (1, shortterm; –1, long-term), gender: factor B (1, male; –1, female), time after stroke onset: factor C (1, stage 1; –1, stage 2). Effect Coef SE Coef T P 1.4333 0.6167 0.5667 –1.4833 –0.2333 –0.0500 0.4500 0.0167 0.7167 0.3083 0.2833 –0.7417 –0.1167 –0.0250 0.2250 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.07 2.87 1.23 1.13 –2.97 –0.47 –0.10 0.90 0.948 0.015 0.243 0.281 0.013 0.650 0.922 0.387 ŷ = 0.0167 + 0.7167x1+ 0.3083x2+ 0.2833x3 + (–0.7417)x1 x2 + (–0.1167)x1 x3 + (–0.0250) x2 x3+ 0.225 x1 x2 x3 . . . r2 = 0.5781 where ŷ is the predicted quality of life improvement, x1 is the variable representing factor A (plant), x2 is the variable representing factor B (gender), and x3 is the variable representing factor C (time after stroke onset). The x1 x2 , x1 x3 , and x2 x3 represent the two-way interactions. The three-way interaction is represented by x1 x2 x3 . In this fitted regression model, x1 , x2 , and x3 were all defined on a coded scale from -1 to 1. 3.2. Family role According to the analysis with the 23 factorial design, the significant effects of variable AB interaction (plant and gender) (F = 13.57, p = 0.004) and AC interaction (plant and time after stroke onset) (F = 6.08, p = 0.031) on improvement in the family role area were revealed in the Pareto chart (Fig. 7), Normal plot (Fig. 8), and Half normal plot 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 7 Fig. 9. Half normal plot for family role. Plant: factor A, Gender: factor B, Time after stroke onset: factor C. cte d Fig. 7. Pareto chart for family role. Plant: factor A, Gender: factor B, Time after stroke onset: factor C. Au tho rP roo f F.-L. Kuo et al. / The effects of gardening on quality 413 414 415 416 417 418 419 420 421 422 423 424 425 426 (Fig. 9). The main effects of three factors are shown in Fig. 10. The interaction plot (Fig. 11) showed that males demonstrated greater improvement than females while tending long-term plants. Additionally, patients in the stage 1 tending long-term plants demonstrated greater improvement than those in the stage 2. The cube plot for the design of family roles in Fig. 12 revealed that the optimal level combination of family role area appeared in two situations: female patients in the stage 2 tending short-term pants and male patients in the stage 1 tending long-term plants. Based on the correlation coefficients shown in Table 2, the regression function was as follows: co 412 Un 411 rre Fig. 8. Normal plot for family role. Plant: factor A, Gender: factor B, Time after stroke onset: factor C. ŷ = (–0.1208) + (–0.0708)x1 + (–0.0542)x2 + (–0.0375)x3 + (–0.5042)x1 x2 + (–0.3375)x1 x3 + (–0.2208) x2 x3 + (–0.0208) x1 x2 x3 r2 = 0.6966 Fig. 10. Main effects plot for family role. Plant: factor A (1, shortterm; –1, long-term), gender: factor B (1, male; –1, female), time after stroke onset: factor C (1, stage 1; –1, stage 2). where ŷ is the predicted quality of life improvement, x1 is the variable representing factor A (plant), x2 is the variable representing factor B (gender), and x3 is the variable representing factor C (time after stroke). In this fitted regression model, x1 x2 represents the interactions between x1 and x2 , x1 x3 represents the interaction between x1 and x3 , and x2 x3 represents the two-way interaction between x2 and x3 . The three-way interaction is represented by x1 x2 x3 . The variables of x1 , x2 , and x3 were all defined on a coded scale from –1 to 1. 427 428 429 430 431 432 433 434 435 436 437 438 8 F.-L. Kuo et al. / The effects of gardening on quality Table 2 The estimated effects and coefficients for the family role area Constant plant gender stroke plantXgender plantXstroke genderXstroke plantXgenderXstroke Coef SE Coef T P –0.1417 –0.1083 –0.0750 –1.0083 –0.6750 –0.4417 –0.0417 –0.1208 –0.0708 –0.0542 –0.0375 –0.5042 –0.3375 –0.2208 –0.0208 0.1369 0.1369 0.1369 0.1369 0.1369 0.1369 0.1369 0.1369 –0.88 –0.52 –0.40 –0.27 –3.68 –2.47 –1.61 –0.15 0.396 0.615 0.700 0.789 0.004 0.031 0.135 0.882 lettuce) were harvested by the participants at the end of the gardening program. This harvest could provide participants with a chance to share the vegetables with friends and thereby enhance their social interactions. However, it still needs further investigation to explore the reason of gender differences on the improvement in social role. Au tho rP Fig. 11. Interaction plot for family role. Plant: factor A (1, shortterm; –1, long-term), gender: factor B (1, male; –1, female), time after stroke onset: factor C (1, stage 1; –1, stage 2). Effect roo f Factor 4.2. Family role cte d The significant interaction of plant and gender using the 2k replicated factorial design showed that while tending long-term plants, males tended to show greater improvement in the family role than females. This might be explained by the features of tomatoes and string beans, the long-term plants adopted in this research. Although at the end of the gardening program, these two plants had not been harvested, fruit had begun growing on the stems. It is possible that the tomatoes and string beans were more likely to give people obvious visual feedback stimuli than the short-term plants (water spinach and lettuce). Rosenblitt and Soler [42] observed more sensation seeking behavior, especially for visual sensation, in men than in women. Therefore, we speculated that the obvious appearance of fruit could give male participants more confidence that they could be productive gardeners and be less of a burden on their families. The significant interaction of plant and time after stroke onset showed that when tending long-term plants, participants in the CVA stage 1 tended to show greater improvement in their quality of life scores than those in the stage 2. As reported in several previous studies, acute stage CVA patients are more likely to suffer feelings of depression than chronic stage patients [43–45] due to the sudden impact of stroke on their lives. The feelings of depression may cause acute patients to see themselves as a burden on their families. In this study, after tending long-term plants, participants with stroke less than 18 months showed that their perception of family burden decreased more 4. Discussion 440 4.1. Social role 442 443 444 445 446 447 448 449 450 Significant effects of plant type and gender/plant interaction were found for improvement in quality of life under social role. For all participants, the care of short-term plants was linked to improved social role. This difference between short and long term plant care could be due to the shorter harvest period of short-term plants. However, when gender was considered simultaneously, females showed better responses than males to short-term plants. In our observation, the short-term plants (water spinach and Un 441 co 439 rre Fig. 12. The design for family role shown geometrically in the cube plot. Optimal level combination appeared in two situations: plant (1), gender (–1), onset time (–1), plant (–1), gender (1), onset time (1) 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 F.-L. Kuo et al. / The effects of gardening on quality 4.3. Limitations 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 1) Baseline condition: Each participant had a different baseline condition, which may have resulted in different speeds of improvement. However, it is hard to control the baseline condition. Therefore, we measured the difference between the pre-test and the post-test to reflect improvement from the onset to the end of gardening program for each participant. 2) Natural disease progression: The variables we measured may have been affected by the variation of natural disease progression, particularly in the areas of physical, mental, and functional performance, which could cause variation in quality of life improvement. Using a large number of participants may reduce the effect of natural disease progression, because it is unlikely that all participants develop this progression during measurement period. Due to the availability of participants qualifying the selection criteria of the study, the study results were obtained based on a relatively small number of participants. It is recommended to increase the number of participants in the future. 3) Limits to randomization: cte d 497 In interpreting the findings, it is important to consider the following limitations: rre 496 Once a case was selected, the variables of gender and disease severity were defined. The only variable we could select for this case was the plant life cycle. Randomly arranging the participants into different groups tending long-term and short-term plants could further reduce the errors. However, the ideal condition should be the full randomization of all factors. co 493 5. Conclusion Un 492 in Fig. 12). Additionally, the optimal level of social role improvement was seen in female participants sustained a CVA over 18 months tending short-term plants. It should be noticed that the effects of plant features and gender-related differences enhanced the social role of participants in this sample. In addition, based on our analysis, in the future to improve the quality of life for people with CVA, especially in the family role, practitioners are recommended to consider plant features, gender differences, and the time after CVA onset when arranging gardening programs. Although sample size in this research was small, significant results were obtained. This study shows that tending different types of plants resulted in significant differences in the beneficial effects of gardening on quality of life for people with CVA. Gender-related differences and the time after CVA onset need to be taken into consideration in future studies. Based on this finding, we think that further experiments examining factors related to participants’ preferences would be useful in identifying the key factors in motivation enhancement. It is also suggested that future studies employ longer periods of gardening to further examine whether the visual effect of the appearance of fruit is significant. There are factors in the gardening process that can influence the quality of life of people who have sustained a CVA. The current findings provide future researchers with directions for further investigation in this area. roo f 495 491 Au tho rP 494 significantly than people sustained a CVA over 18 months. Based on our findings, the visually obvious fruit, tomatoes and string beans, may increase the confidence of participants and improve their quality of life in the family role area. 490 9 This research provides further evidence for the use of gardening programs with people who are recovering from CVA. Higher levels of quality of life were shown by female participants sustained a CVA over 18 months tended short-term plants (see cube plot Acknowledgments The funding was supported by Shuang Ho Hospital, Taipei Medical University. The number of this research project is 101SHH-HCP-04. Conflict of interest None to declare. References [1] [2] [3] Andersen G, Christensen D, Kirkevold M, Johnsen S. Poststroke fatigue and return to work: A 2-year follow-up. Acta Neurologica Scandinavica 2012;125(4):248-53. Hackett ML, Glozier N, Jan S, Lindley R. Returning to paid employment after stroke: The Psychosocial Outcomes In StrokE (POISE) cohort study. PloS one 2012;7(7):e41795. Padula RS, Chiavegato LD, Cabral CMN, Almeid T, Ortiz T, Carregaro RL. 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