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Revised: 8 January 2021

DOI: 10.1002/1348-9585.12201

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Accepted: 15 January 2021

CA S E ST U DY

Fitting the task to a person with disabilities: A case of
return-to-work support for a patient due to left-sided poststroke
hemiplegia using tailor-made jigs-and-tools
Naomichi Tani1,2
Susumu Oda2

| Fumiko Ichikawa2 | Risa Mitani2 | Junichi Akatsu1,3 |

1

The association for preventive medicine of
Japan, Tokyo, Japan
2

Fukuoka occupational health support
center, Japan Organization of Occupational
Health and Safety, Fukuoka, Japan
3

University of Occupational and
Environmental Health, Kitakyushu, Japan
Correspondence
Naomichi Tani, The association for
preventive medicine of Japan, 3-19-5,
Hakataekimae, Hakataku, Fukuokashi,
Fukuoka, Japan.
Email: [email-masked]

Abstract
Background: A 45-
year-
old Japanese male pharmacist developed a stroke in
December 2018; hence, he had left-sided hemiplegia due to the after-effects of cerebral stroke. This paper reports the return-to-work (RTW) and after RTW support
for poststroke patients from a combined ergonomic and rehabilitation perspective.
Methods: From April 2019 to July 2020, we visited hospitals and workplaces multiple times, making various preparations for workplace accommodation and exchanging information as follows: allowing staggered working hours; securing the flow
routes in the back room; equipping a cane holder on his working desk; and adjusting
the position of the work tablet. In August 2020, after RTW, we conducted a brief
evaluation of residual motor function and an on-site task analysis, and we subsequently made a support tool.
Results: In July 2020, his RTW was eventually realized. Moreover, as a result of introducing the tailor-made support tool, the duration of certain tasks that he had been
claiming to be difficult was reduced when compared to that before support-tool use,
and the average task duration before and after support-tool use was 32.8 s and 10 s,
respectively (reduced by approximately 69.5%).
Conclusion: To augment our efforts, hospital staff, support staff in his workplace,
and his employer collaborated to make various workplace accommodations for the
smooth realization of RTW before and after RTW. In the present case, the ergonomic
and rehabilitation approach after RTW might have contributed to ease of task, work
efficiency, and the potential for future job retention.
KEYWORDS

ergonomic and rehabilitation, poststroke, return to work, task analysis

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited and is not used for commercial purposes.
© 2021 The Authors. Journal of Occupational Health published by John Wiley & Sons Australia, Ltd on behalf of The Japan Society for Occupational Health
J Occup Health. 2021;63:e12201.		
https://doi.org/10.1002/1348-9585.12201

wileyonlinelibrary.com/journal/joh2

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IN TRO D U C T ION

According to the World Health Organization (WHO), with
the aging of the global population, the occurrence of cardiovascular disease (heart disease and stroke) has become an
important health problem.1 In particular, if a working-age
person suffers a stroke, the poststroke effects may reduce
work performance.2 Recently in Japan, Saeki et al reported
that the proportion of stroke survivors who have had a successful return-to-work (RTW) experience has remained static
at 45% for the past 20 years.3 According to previous studies, important factors associated with RTW and stroke are
gender, age, enterprise size, education level, stroke severity,
and comorbidity.2,4,5 In addition, the potentiality of RTW
after hospital discharge was reported to be influenced by
impairments and occupation.6 In particular, poststroke survivors have residual impairments in the upper and lower limbs
(hemiparesis), which are important factors related to RTW.6,7
Consequently, hemiparesis affects work ability and productivity after RTW; hence, it is important to make an effort in
workplace accommodation—fitting the task to the person
with disabilities—within each workplace.8
The WHO recommends assessing the capacity to work
of persons with disabilities and thereby setting up disability management programs to support RTW.1 Published
in February 2016, the Japanese Guideline for Assisting
Treatment-Work Balance clearly states that the occupational health support centers nationwide owned by the
Japan Organization of Occupational Health and Safety
(JOHAS) will RTW support and advise for companies and
workers.8 Therefore, in order to provide RTW support from
various aspects, occupational health support centers nationwide have not only occupational health physicians, public
health nurses, and ergonomists but also other specialists
(eg, nurse, lawyer, labor and social security attorney, medical social worker, and physical therapist) were assigned
in recent years. Moreover, the Japanese guidelines also
recommend creating an RTW support plan that includes
workplace accommodation for persons with disabilities.8
Additionally, it was indicated that in specific cases of persons with disabilities, environmental factors hindered optimal performance; thus, it is important to increase RTW
rates through workplace accommodation.1 According to
previous studies, the importance of workplace accommodation for persons with disabilities through the use of ergonomic principles is emphasized.9,10 Moreover, previous
studies have shown that evaluation from an ergonomic and
rehabilitation perspective is important for workplace design for persons with disabilities.11 Therefore, in order to
increase the RTW rate, it seems necessary to accumulate
useful case reports on workplace accommodation from ergonomic and rehabilitation perspectives.

TANI et al

In this paper, we report on RTW support for a poststroke
patient. The Fukuoka Occupational Health Support Center
(FOHSC), which is one of centers owned by the JOHAS,
provides RTW support and advise free of charge to companies and workers who have requested. The role and aim
of FOHSC in the present case study was to gather opinions
from patients, hospital staff, employers, and support staff in
the workplace regarding the adjustments necessary for establishing optimal working environments for patients and
workplace staff. Hence, we visited hospitals and workplaces,
making various preparations and exchanging information. In
particular, we considered it important to publish detailed information from an ergonomic and rehabilitation perspective
in this case study.

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CASE PRESENTATION

The present case was one of 423 consultations received by
FOHSC in 2019. A 45-year-old Japanese male worker, who
was employed as a pharmacist at a pharmacy, developed a
stroke in December 2018. Subsequently, he was diagnosed
with left-sided spastic hemiplegia. Although he lived alone,
he returned to his hometown and was transferred to a hospital near his parents' house in January 2019. He was eager
to return to work, and thus, his manager in the pharmacy requested RTW support from FOHSC in April 2019. Hence,
we began collaborating with hospital staff (eg, physicians,
nurses, physical therapists, occupational therapists, and
medical social workers) and support staff in his workplace
to support his RTW. Furthermore, we occasionally visited
the pharmacy because it was important to understand the interaction between the patient's functions and the workplace's
environment and work system so as to fit the task and environment to his condition. When it comes to occupational
medicine in Japan, any company with over 50 employees is
required to hire an occupational physician under the Japanese
Industrial Safety and Health Law. The pharmacy was small-
sized enterprise with a few employees, so it did not have a
contract with any occupational health physician or public
health nurse.
On March 6, 2020, we visited the workplace for the first
time to conduct a preliminary workplace evaluation at the
time he was making RTW plans. We assessed the working
desk he planned to use for the task and the routes he was
likely to take within the back room. We recommended the
employer to implement the following to protect him from
trips and falls and avoid reducing productivity: allow staggered working hours, ensure secure flow routes in the back
room (eg, relocate the trash), equip his working desk with
a cane holder, and place the work tablet on the right side
of his working desk. Workplace preparation was conducted

  

TANI et al

concurrently with the patient's discharge preparation. On July
8, 2020, his RTW was realized.
Evaluation of motor function, including anthropometry,
is important to work environment design for persons with
disabilities.1,9,12 Therefore, on August 25, 2020, we made
a second visit to his workplace for a brief evaluation of residual motor function, on-site task analysis using the work
sampling and time-and-motion methods,10,12 and interviews.
The results of the brief evaluation of motor function involved
the following variables: (a) active range of motion (AROM)
of upper limbs, (b) Brunnstrom Stage13 of upper limbs, (c)
grip strength measurement, and (d) check-up gait patterns.
The AROM of his left upper limb was 140° of shoulder joint
flexion and almost normal for left elbow joint flexion and extension, left forearm supination and pronation, and left wrist
joint flexion and extension. Brunnstrom Stage is a motor function test that evaluates the recovery stage of hemiplegia.13 It
is categorized according to Stage I-VI. There is no voluntary
movement in Stage I. In Stage VI, various coordinated movement is possible. His left hand was capable of both cylindrical
and spherical grasps. Furthermore, all his left fingers could
be actively extended. These finger movements are the criteria
for Brunnstrom Stage V. Therefore, his left hand seemed to
correspond to Brunnstrom Stage V. However, when he moved
his right hand and/or finger, a certain associated movement of
his left hand and fingers occurred. Furthermore, we checked
the grasping power of his hands, which had powers of 29.5 kg
and 8.5 kg for the right and left hands, respectively. Although
his gait pattern was affected by the leg circumduction due to
extensor hypertonia in the lower limb, his gait performance
was self-sufficient with a short leg brace and T-cane. The
results of the hierarchical task analysis are shown in Figure 1.
The main tasks assigned to him were “prepare medicine” and
“prescribed medicine guidance to patient.” Although he had
to work with both hands in the “Put prescribed medicine in
pharmacy bag” task, he was able to press down the pharmacy
bag with his left hand and put the medicine in the pharmacy
bag with his right hand. However, he complained in an interview that “tie the press through pack sheets (PTPs) up with a
Providing medicine to
patient

1. Take patient
prescription

2. Collate with past
medication records

3. Prepare medicine

3.1. Dispensing task

3.2. Picking task

3.2.1. Picking the press
through pack sheets
needed

: Assigned task
: Unassigned task

FIGURE 1
tasks in Japan

4. Prescription and
medicine double-check

5. Prescribed medicine
guidance to patient

rubber band” work was difficult. Thus, we performed a micromotion analysis to identify the problem associated with
“tie the PTPs up with a rubber band” (Table 1). The “tie the
PTPs up with a rubber band” task consisted of six elements
and required a fair amount of seconds for the following motions: “hold the PTPs, tie the PTPs up with a rubber band”
and “tie the PTPs up with a rubber band” for the right and left
hands, respectively. In this micromotion, his left hand was not
holding a rubber band. Due to the impairments in dexterity of
the left hand after stroke, he could barely hook a rubber band
on his finger. However, we applied his left hand to “Grasp”
for convenience in this micromotion. Furthermore, in this micromotion, he made two and three mistakes on the third and
fourth time, respectively. In addition, he broke PTPs in the
fourth task. As the number of tasks increased, the dexterity
of the left hand gradually decreased. Moreover, commercially
available fingers and/or hand splints did not seem to match
his task. Based on the results of this analysis, we proposed
to him and his employer that we make tailor-made jigs-and-
tools to support his task. Additionally, from the perspective
of rehabilitation, it was recommended to actively use the left
hand for other assigned tasks that do not require dexterity.
On our third visit to the workplace on September 4, 2020,
we gave him jigs-and-tools (Figure 2). This support tool is a
device for wrapping a rubber band around four pillars. The
PTPs in the expanded rubber band were set, and the rubber
band and PTPs were subsequently removed together. With
this support tool and operation, it was envisioned that he
could perform the traditional task of “tie the PTPs up with
a rubber band” with the right hand only (Figure 3). It was
made based on the size of his right hand, size of the PTPs
to be handled, and operability with only the right hand in
mind. Although we made support tools, the cost was very
low. Furthermore, we performed micromotion analysis again
to compare the differences between before and after support
tool use. As shown in Table 2, after using the support tool, the
micromotion consisted of six elements. Therefore, there was
the same number of motion elements than before support tool
use. However, the average number of seconds for five-time
measurements showed a decreasing trend compared to that
before support tool use, and the number of seconds before
and after support tool use was 32.8 s and 10 s, respectively
(reduced by approximately 69.5%). According to the patient
himself, the usability of the support tools was beneficial.

3 | DISCUSSION AND
CONCLUSION

3.2.2. Tie the press
through pack sheets up
with a rubber band

5.1. Explain the effect
and precautions relevant
to medicines

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5.2. Put prescribed
medicine in pharmacy
bag

Hierarchical task analysis for particular pharmacy

In the present case, a male pharmacist had left-sided hemiplegia due to poststroke sequelae, and shortly after RTW,
he complained of difficulty in certain tasks. It was difficult
to work on “wrap a rubber band twice over multiple PTPs”

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TABLE 1

TANI et al

The micromotion analysis of medicine handling before using support tools
Measured time (sec)

No

Left hand description

Therblig

First

Second

Third

Fourth

Fifth

Therblig

Right hand

1

—

—

1

1

1

1

1

G

Grasp a rubber
band

2

—

—

1

1

1

1

1

TE

Reach for PTPs

3

—

—

2

2

1

2

3

G

Grasp PTPs

4

Grasp a rubber band

G

1

1

2

1

1

H

Hold the PTPs

5

Tie the PTPs up with a
rubber band

U

8

6

45

59

15

H, U

Hold the PTPs,
Tie the PTPs
up with a
rubber band

6

—

—

1

1

1

1

1

TL, RL

Put in the
designated box

Abbreviations: G, grasp; H, hold; No, number; PTPs, press through pack sheets; RL, release Load; sec, seconds; TE, transport empty; TL, transport loaded; U, use.

FIGURE 2

A support tool to assist specific micromotion

developed a support tool to fill the gap between him and the
difficult task. As a result, the number of seconds required for
the task was reduced.
According to a previous study, more supportive social
and work environments and professional jobs had a higher
probability of RTW.7 Similarly, this case of RTW was realized in a situation where good conditions (eg, occupation, job requirements, personal work motivation, and the
employer's effort) were met without a glitch, in line with
the Japanese guidelines.8 For example, he was allowed
staggered working hours. Moreover, he was able to walk
alone using a T-cane and short leg brace; however, it was
difficult to maintain a standing position for a long time.
For that reason, the work assigned to him involved tasks
that could be done while sitting. Furthermore, support staff
in the workplace secured the flow routes in the back room
to prevent trips and falls. A T-cane holder was attached
F I G U R E 3 Changes in the process
before (A-C) and after (D-F) using the
support tool. He used it with a weight (about
1 kg) placed so that the support tool became
stable

because his left hand could not grasp the PTPs due to the
associated movement. Additionally, a commercially available brace did not seem to match his task. Therefore, we

to his work desk, and the tools on his desk were arranged
such that they would be easy to use, despite motor impairment of the left upper limb. However, he complained of

  

TANI et al

TABLE 2

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The micromotion analysis of medicine handling after using support tools
Measured time (sec)

No

Left hand
description

Therblig

First

Second

Third

Fourth

Fifth

Therblig

Right hand

1

—

—

1

1

1

1

1

G

Grasp a rubber
band

2

—

—

4

4

5

6

4

U

Wrap a rubber
band around a
tool

3

—

—

1

1

1

1

1

TE

Reach for PTPs

4

—

—

2

1

1

1

1

G, TL

Grasp PTPs and
put them on the
tool

5

—

—

2

1

1

1

1

G

Grasp the PTPs
and rubber band

6

—

—

1

1

1

1

1

TL, RL

Put in the
designated box

Abbreviations: G, grasp; No, number; PTPs, press through pack sheets; RL, release load; sec, seconds; TE, transport empty; TL, transport loaded; U, use.

difficulty in certain tasks shortly after RTW. As a result
of the evaluation of residual motor function and the on-
site task analysis, there was clearly a mismatch between
the motor function required for the task with his residual
motor function. As a result of micromotion analysis, we
identify the problem associated with “tie the PTPs up with
a rubber band.” Because the dexterity of left hand after a
stroke was impaired, he could barely hook a rubber band
on his finger. Therefore, we considered the process to carry
out the work of “tie the PTPs up with a rubber band” with
only one hand. Normally, we recognize that the task of “tie
the PTPs up with a rubber band” is the work of tying up
“PTPs” with “rubber bands.” However, we considered how
to put “PTPs” in “rubber bands.” Additionally, we made
a support tool consisting of struts to fix the rubber bands.
The support tool eliminated the mismatch between him and
his task.
It has been reported that if workplace environments include tasks that do not accommodate persons with disabilities, it may make a person less productive and eligible for
a lower market wage.1 It has also been suggested that a mismatch between a task and its implementer becomes psychologically stressful.12 In addition, a person with disabilities
may leave their job as a result of mental health and psychosocial problems and be offered a lower wage.1,8 In order to prevent the above, it is important to fit the task to a person with
disabilities; hence, evaluation of residual motor function and
task analysis are essential. It is likely that this will contribute
to the retention of jobs for persons with disabilities through
continued workplace accommodation, even after RTW. For
this reason, workplace accommodation using the ergonomic
and rehabilitation approach14 is important not only in contributing to RTW after disease but also in improving after RTW

job retention for people with disabilities. Furthermore, in the
present case, the patient was grateful to all staff who supported his RTW. In addition, he began to voluntarily improve
his diet to prevent stroke recurrence. The sincere support of
those around him might have prompted behavior change.
In conclusion, it seems that the use of support tools reduces task mistakes and task duration. Hence, it might
have had a positive effect on physical and mental health.
Consequently, in the present case, the ergonomic and rehabilitation approach might have contributed to the potential for
future job retention. Additionally, task analysis is essential to
fit the task to people with disabilities. Micromotion analysis
may be useful, especially if the worker has motor impairment
due to sequelae caused by diseases. This is because motor
impairment affects micromotion and also affects tasks that
consist of micromotion components. Furthermore, in order
to retain a person with disabilities, it is considered necessary to select the preferred method for “fitting the task to a
person with disabilities” after motor impairment and work
environment evaluation (eg, compensate with compensatory
movement, increase the number of motions, use a brace and/
or make tailor-made jigs-and-tools, etc). In other words, ergonomics and rehabilitation are essential perspectives for
workplace accommodation for persons with disabilities after
RTW.9,14

4 | APPROVAL OF THE
RESEARCH PROTOCOL
The ethical committee of the Association for Preventive
Medicine of Japan (Approval Number: 2020006) approved
this study.

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TANI et al

IN FO R ME D CON SE N T

Written informed consent was obtained from the patient and
employer for publication of this case report.

6 | R EG ISTRY A N D
RE G IST R AT IO N NO . O F T HE
ST U DY / TR A IL
N/A.

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A N IM A L ST U D IE S

N/A.
ACKNOWLEDGMENT
We are grateful to the patient, fellow employees of the company he works for, and his employer for their participation.
We would also like to thank Editage for English language
editing.
CONFLICTS OF INTEREST
Authors declare no conflicts of interest for this article.
AUTHORS’ CONTRIBUTIONS
NT, FI, RM, and SO contributed to study design. NT and FI
collected the data. NT and JA analyzed the data and drafted
the manuscript. All the authors contributed to the writing of
the manuscript, critical revision, and agreed with the final
version.
ORCID
Naomichi Tani

https://orcid.org/0000-0002-8317-5273

R E F E R E NC E S

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return to work after stroke. Work. 2014;47(4):553-559.
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Work
Balance.
https://www.mhlw.go.jp/content/​
11200000/000621298.pdf. Published March 2020. Accessed
October 5, 2020.
9. de Guimarães BM. Ergonomics and workplace adaptation to people with disabilities. Work. 2015;50(4):607-609.
10. Chi C-
F, Dewi RS, Jang Y, et al. Workplace accommodation
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How to cite this article: Tani N, Ichikawa F, Mitani
R, Akatsu J, Oda S. Fitting the task to a person with
disabilities: A case of return-to-work support for a
patient due to left-sided poststroke hemiplegia using
tailor-made jigs-and-tools. J Occup Health.
2021;63:e12201. https://doi.org/10.1002/13489585.12201