A Study on Creative Activities for Enhancing Manual Dexterity and Visual- Motor Integration in Older Adults: Focus on Bamboo Weaving

doi:10.21203/rs.3.rs-7240362/v1

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A Study on Creative Activities for Enhancing Manual Dexterity and Visual- Motor Integration in Older Adults: Focus on Bamboo Weaving

https://doi.org/10.21203/rs.3.rs-7240362/v1

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Objective In the face of a rapidly aging society and the consequent rise in healthcare costs, maintaining the health of older adults and delaying functional decline to preserve their independence in daily living has become a critical issue in long-term care and healthcare development. This study examines the effects of creative activities on enhancing manual dexterity and visual-motor integration (VMI) in elderly individuals, with bamboo weaving selected as the intervention.

Methods A total of 87 participants aged 60 to 75 were assigned to three groups (A, B, and C) based on varying levels of course difficulty. Pre- and post-intervention assessments were conducted using the Purdue Pegboard Test (PPT), VMI test, Visual Perception (VP), and Motor Coordination (MC) tests to evaluate the intervention outcomes. Findings indicated that participants across all levels demonstrated significant improvements post-intervention. Further analysis revealed that participants in the lower-difficulty courses showed better performance in the PPT assembly task as well as in the VMI and MC assessments. Full name of the registry：International Standard Randomised Controlled Trial Number registry.Trial registration number and the date of registration：ISRCTN19035046. 03/09/2025. “Retrospectively registered”

Conclusion These results partially support the study’s hypotheses and provide valuable evidence for designing occupational therapy interventions that incorporate creative activities to enhance fine motor and visuomotor abilities in older adults.

Older Adults

Hand Dexterity

Visual-Motor Integration (VMI)

Bamboo Weaving

Creative Activities

Occupational Therapy

Taiwan officially became an ageing society in 2018 and is expected to become an super-aged society by 2025 As individuals grow older[1], the decline in musculoskeletal ability might result in a reduction in exercise capacity, mobility, and walking ability [2, 3]. Additionally, there is a decline in physical sensory function [4, 5], which affects an individual's ability to maintain balance [6, 7], dexterity [8], and can affect not only quality of life [9], but also, for example, can cause falls [10], and a variety of other extended risks due to unresponsive mobility. In addition to musculoskeletal abilities, researchers have identified deterioration of cognitive abilities and multisensory integration as risk factors associated with ageing [11, 12, 13]. The decline in postural control observed in older adults can be attributed to a deterioration in sensory signal coordination [14] as well as movement coordination and control [15, 16, 17]. Unfortunately, as the elderly confront their physical dysfunction and deterioration, which results in feelings of powerlessness, frustration, and loss in daily life [11], the elderly are left with a sense of inner disarray. Cour et al. [18], which gives rise to a gradual decline in social functioning [2], a proclivity towards loneliness, anxiety, and a tendency to become isolated, anxious, and depressed. They are prone to experiencing loneliness, anxiety, and depression [19, 20].

In light of the challenges associated with the ageing process, the World Health Organisation (WHO) put forth the Global Strategy and Plan of Action on Ageing and Health at the 69th World Health Assembly in 2016. The Taiwanese government has correspondingly launched the ‘Ten-Year Plan for Long-Term Care 2.0’, which emphasizes the ‘aging-in-place’ mindset [21], and builds a system of care services by supporting multiple and continuous services in the family, at home, and in the community. The caring community, which is based in the district, provides seniors with group life and mental and physical services after retirement. Till 2024, the number of senior learning centers in Taiwan reached the number of 367 [22], and the average number of creative activities per center is estimated at 375 per year [23].

As a matter of fact, several researchers have suggested that promoting physical activity in the elderly [24, 25], such as maintaining a consistent daily work and rest routine, keeping them muscularly functional, and cardiorespiratory endurance healthy [26], will result in a better outcome than those who are sedentary for a long period of time, sedentary older adults will achieve better Tasks that appear as part of everyday life, for example, baking, cooking, gardening, textiles, ceramics, painting, clay, music, reading aloud, playing cards, crossword puzzles, and even walking, travelling, and visiting museums [31, 24, 18], have an important role in the functional training of occupational abilities and are seen as a preparation for older people to return to normal daily life and occupations [32, 33, 34, 35].

A previous study from Sweden examined the practice of 304 occupational therapists using creative activities in their clinical work [31].Their study found that more than two thirds of respondents had used creative activities as an intervention, including 48% who used creative activities one or more times a week. Similarly, Craik, et al.'s [36] study in the UK found that at least 80% of occupational therapists in the UK used creative activities in occupational therapy at least once a week. In fact, it was interesting for the purposes of this study that the results of Müllersdorf and Ivarsson's survey showed similarities with the current situation in Taiwan, where more than 89.6% of occupational therapists in various creative activities chose craft and art activities such as textiles, ceramics, leather, etc. as occupational therapy interventions [31, 37].

Several researchers have also found that older adults' participation in these craft activities contributes to their mental health. These activities have been found to contribute to the mental health domain of older adults by increasing not only dopamine, but also theta and delta brainwave activity in the brain, helping them to achieve a sense of well-being and contentment similar to that experienced through meditation [38, 39], mindfulness [40, 41], happiness and contentment [24], as well as emotional relief in the field of musculoskeletal rehabilitation [31, 42, 43]. In a study by Leonard et al. [44] using knitting as an occupational therapy intervention, 37 participants (18 in the control group and 19 in the intervention group) were invited to take part in an eight-week programme consisting of a single 20-minute knitting session once a week and a 20-minute independent knitting activity on the remaining five weekdays. As Leonard et al. [44] suggested that craft activities could be considered as a form of physiotherapy, their findings showed that knitting activities were effective in relieving symptoms associated with osteoarthritis of the hands, while at the same time being a much anticipated pleasurable process for the intervention group. In another study from South Korea, Kim [2] invited 28 older adults over the age of 65 to participate in an eight-week, twice-weekly programme that combined activities such as arts and crafts, physical activities, and recreational activities. The results showed a significant increase in activities of daily living (ADLs) in these older adults, both men and women. This contributed to the release of positive and happy emotions, the restoration of self-confidence and a significant reduction in depression, and was consistent with other studies which found that these older adults had significant increases in fine motor skills, cognitive function and concentration [45, 46, 24].

In addition, previous studies have shown that manual dexterity involves a number of complex cognitive processes, including visual perception, attention, planning, judgment, proprioception, working memory, reaction speed and decision-making ability [47, 48, 49, 50, 51], a positive relationship between manual dexterity and cognitive function has been demonstrated [52, 53, 54]. In fact, manual dexterity can even be used as an effective tool to screen for mild cognitive impairment [55]. Furthermore, these manual dexterity training activities have been found to be effective in activating and recruiting a wide range of brain networks, including Prefrontal Cortex integrating cognitive learning, control and locomotion [52, 56, 57]; Parietal Cortex, which integrates perceptual-motor coordination, spatial cognition [58, 59]; Integration of advanced visual perception, the Temporal Cortex, which integrates advanced visual perception, long-term working memory, and the Ventral-Temporal Cortex [60, 61, 62, 63].The pleasure that people experience in the process of making things, which arises from the mesocorticolimbic system in the brain, brings feelings of satisfaction, well-being and emotional balance [24, 64, 65, 66].

The elderly learning centers in Taiwan offered a fairly diverse range of arts and crafts courses, also characterized by their distinctive local cultures, such as plant dyeing, bamboo weaving, rattan weaving, wood carving, stone carving, ceramics, printmaking, leather, weaving, paper making, metal working, etc., which are generally recognized as having the potential to relax and reward left and right brain functioning and help maintain cognitive function [45, 24]. Kim's [2] findings explain the positive

therapeutic benefits of crafting, such as exquisite movement, self-awareness, creativity, concentration, camaraderie and self-esteem. However, due to the diverse nature of the craft program in terms of procedures, tools, materials and creative environments, we find that the efficacy of craft activities as occupational therapy has been questioned to a considerable extent in previous studies [67, 68]. As a result, previous research on the therapeutic effects of arts and crafts has opted for more qualitative discussions in the form of exploratory and case-descriptive studies [32, 69, 70]. This study, however, indicates that the diverse nature of handicrafts provides a greater opportunity for quantitative research in occupational therapy, given that the majority of handicrafts are characterized by the repetition of the same motions. For instance, the training of cognition and logic can be reflected in the handicrafts of weaving, bamboo weaving, and rattan weaving, which are defined by mathematical calculations, spatial logic, and structural qualities[27]. The training in grip strength, for instance, can be reflected in various crafts that necessitate a considerable degree of exertion and manipulation of the palms and fingers, including ceramics, plant dyeing, printmaking, woodcarving, stone carving, and other similar pursuits. These crafts even engage the training of the wrists and arms. An additional example is the training of fine movements, which can be reflected in the crafts of weaving, bamboo weaving, metalworking, paper craft, leatherwork, and other crafts that necessitate a considerable degree of concentration, fine movements, and repetitive finger movements. This provides an indication of the potential outcomes of the rehabilitation process [27].

The present study has selected bamboo weaving, a common form of handicraft, as the focus of this project. This decision was based on the findings of numerous studies which have highlighted the crucial role of hand dexterity in the upper limb. Furthermore, hand function is a significant determinant of the quality of daily life for the elderly, influencing activities such as self-care, writing, typing on computers and mobile phones, cooking, sewing, gardening, undoing of buttons, and grasping of any objects with various precise movements [71, 72, 73, 75]. All mentioned movement rely on sensory processes of vision, kinesthesia, touch, hand muscles, and cognition to form coordinated hand movements [47, 76, 77, 78]. As we age, however, the efficacy of performing these precise hand movements declines [52, 54, 79]. The positive aspect of the ageing process is that despite the impact it may have on manual capability, such deterioration is not definitive but rather selective [78]. As previously mentioned, these functional declines are always relatively more severe in older adults who are less physically active [17, 52, 80]. Studies have demonstrated that hand exercise can mitigate age-related deterioration; with Wishart et al. [81] claiming that moderate hand exercise can bring benefits to hand abilities and visual feedback. Furthermore, Pelosin et al.[82] suggested that hand performance could be effectively enhanced by training in a finger exercise experiment. The characteristics of the bamboo weaving process are that each step requires the same repeated actions, and to finish a complete weave, participants must constantly make visual and tactile judgments and hand coordination, which is a comprehensive challenge and training for the sensory integration and movement planning ability of the elderly. It also provides an opportunity for quantitative design. As a result, this study believes with confidence that a considerable amount of bamboo weaving activities will have the opportunity to bring about some degree of benefits to the elderly in terms of hand skills.

For a better understanding of the benefits of handicrafts for the elderly, we selected bamboo weaving courses of differing difficulty levels and divided the participants into three groups to observe the changes in manual dexterity and visual-motor integration of the elderly before and after participating in the courses.

The present study was designed to initiate a preliminary investigation of the potential effects of handicraft interventions on the abilities of elderly people in performing precision movements and visual-motor integration. Bamboo weaving, which is characterized by a high-repetition of movements, continuous judgment, and delicate manipulation, was chosen as the subject of the study. For the purpose of evaluating the effectiveness of the courses at different levels of difficulty, we invited several experts in the related fields to design three bamboo weaving courses at different levels of difficulty, with a total duration of 8 weeks with a total of 48 hours, aiming at establishing a set of reproducible and systematic craft intervention model. Through this study, we hope to provide an empirical basis and program design reference for further investigation of the therapeutic and functional enhancement effects of craft activities in the elderly population.

Interference Design

In addition to considering the complexity of the work process, the ease of thinking and the use of materials in the course design, the study also focused on how the content of the course could stimulate interest and a sense of achievement in older people [83, 84]. The study invited a nationally certified custodian of the intangible cultural asset 'bamboo weaving' to design and teach the course.

This study attempts to quantify the range and number of muscles used in the craft process as a means of obtaining meaningful data from these difficult to control crafts [27]. In the production of small bamboo weavings, the Thumb Interphalangeal Joint and Metacarpophalangeal Joint (MCP), Distal Interphalangeal Joint (DIP), Proximal Interphalangeal Joint(PIP, PIP), and Metacarpophalangeal Joint (MCP) are all frequently mobilized. It is also a familiar area for precision finger movements, and the simultaneous use of both hands in the production process is inevitable, while the wrists and arms may be used occasionally for material handling. Most of the time the production process took place in a sitting position, and only during the observation of the movements guided by the instructor did the participants stand up and walk around. Therefore, we focused on the number of finger movements in the recordings. Table 1 lists three groups of intervention courses with different levels of complexity, the techniques of which are referred to as Group A: 'cross weave', Group B: 'hexagonal weave' and Group C: 'windmill weave'. The materials used were all "shan mieh" (bamboo strips), made from the flesh of the bamboo after removing the skin from the gabions, and hand planed to a thickness of about 0.08 cm, with the length and width varying depending on the object being made. All three groups of participants were different, but the instructor was the same. The teacher gradually guides the students, starting with the basic techniques of flat surfaces and then moving on to the production of three-dimensional objects that are common in everyday life. Each intervention group has a series of production projects to be completed one after the other. The main consideration is that familiarity with the techniques must be built up gradually, and that objectives that are easier to achieve will prevent students from giving up in the middle of the course, while the production of useful objects with aesthetic design will encourage students to be motivated to actively complete the course objectives. Each group of courses was designed to be completed once a week for 6 hours each time, for a total of 48 hours over a period of 8 weeks. To meet the requirements of the total number of hours in the experimental design, we can see that there is a slight difference in the production content of the three groups. For example, there are more items of 'cross knitting' in group A than in groups B and C. This is because the technique of 'cross knitting' in group A is simpler and the speed of production is also higher. This is because Group A:'cross knitting' is simpler and faster. This course design is the better course content proposal after continuous testing and evaluation by craftsmen and experimenters.

Table 1. Basic Techniques and Projects For The Three Groups Programmes

Participants

This study was conducted in a learning classroom in the Central Taiwan Cultural Heritage Park. The program was divided into three groups, A, B, and C, and each group recruited 30 healthy seniors who volunteered to participate, for a total of 90 participants. The recruitment of participants included newspaper advertisements, online announcements, flyers posted at long-term care centers and community gathering places, and preliminary screening by telephone. The selection criteria were as follows:

Aged 60 or above;
Possess basic self-care skills and be able to perform activities of daily living independently;
No physician-imposed restrictions on major physical activity (Seol et al., 2023 [52]);
No history of major neurologic disease (e.g., dementia, Parkinson's disease, post-stroke, etc.);
No hand movement disorder or visual impairment (e.g., color blindness);
Understanding of the objectives of this study and consent to participate.

All participants provided written informed consent. No monetary compensation was offered; however, participants were allowed to keep the bamboo weaving products they created during the course as a token of appreciation.The Edinburgh Handedness Inventory [85] was used to assess hand dominance, confirming that all participants were right-handed (mean score = 84 ± 12).Group assignments were based on participants’ expressed interest in the course content of each group. Gender and age distributions across groups are presented in Table 2.To maintain research integrity, participants were informed that this study was a meaningful and structured scientific investigation. While the atmosphere was designed to be pleasant and supportive, participants were instructed to complete their bamboo weaving projects independently, without excessive reliance on instructors or peers, to ensure the validity of individual intervention effects.

The intervention was conducted from August to December 2023. Of the 90 participants who completed the pretest, 87 completed the full 8-week program and posttest assessments, resulting in a dropout rate of 3.33%. Two participants withdrew due to health issues, and one withdrew for family-related reasons. None of the dropouts were attributed to dissatisfaction with the intervention itself.

Table 2

Participants Gender and Age
Group	Gender	N(%)	Mean age(SD)
Group A	Male Female	5(17.2) 24 (82.8)	68.0 (1.6) 66.0 (3.0)
Group B	Male Female	3 (10.3) 26 (89.7)	65.7 (6.0) 66.2 (4.2)
Group C	Male Female	4 (14.0) 25 (86.0)	64.3 (3.9) 66.6 (3.7)

Ethical Considerations

The procedures of this study were conducted in accordance with the principles of the Declaration of Helsinki and were approved by the China Medical University & Hospital Research Ethics Center Central Regional Research Ethics Committee for Human Research/Human Studies with consent code CRREC-112-048. (Date of Approval: Jun. 28, 2023) All participants gave informed consent before the study and signed an informed consent form after being informed of their rights and interests. All participants were informed prior to the test and were informed of their rights and signed a consent form.

Data collection

To provide empirical evidence of the benefits of bamboo weaving on the manual dexterity and cognitive abilities of the elderly, a series of tests were conducted on all participants, including the Purdue Pegboard Test and the Beery-Buktenica Developmental Test of Visual-Motor Integration. These tests were administered one week before and one week after the intervention programme, allowing for the analysis of the changes brought about by the intervention.

Purdue Pegboard Test

The hypothesis of this study was that increased training of manual dexterity in the fingers would result in improved performance of tasks requiring fine finger control [78]. Bamboo weaving necessitates the coordination of numerous motor skills, which are continuous, repetitive, and require logical reasoning. The Purdue Pegboard Test (PPT) has been a prevalent assessment tool in research and clinical studies, as it provides a reliable and standardised method for evaluating manual dexterity, encompassing both unilateral and bilateral hand movements [86, 91]. Additionally, the PPT exhibits excellent retesting reliability [92, 93]. The PPT task was deemed to necessitate cognitive control [94].

Several studies have demonstrated that the PPT exhibits strong test-retest reliability, particularly among older populations without hand impairments. In Desrosiers et al. (1995), for example, high reliability was observed in adults aged 60 to 89 over a one-week test interval. To reinforce the validity of using the PPT in the current study, Table 3 summarizes the key findings of the PPT retest reliability from the announcement data of the official website of the Purdue Plug and Play (2023) [95], highlighting its relevance for assessing fine-motor competence in the aging population.

Table 3

PPT Retest Reliability Analysis Result
Subtests	Tiffin & Asher [86]	Bass & Stucki [87]	Tiffin [88]	Reddon, Gill, Gauk & Maerz [89]	Desrosiers, Bravo & Dutil [90]
Right Hand	0.63	0.67	0.68	0.63/0.76	0.66
Left Hand	0.60	0.66	0.65	0.64/0.79	0.66
Two Hands	0.68	0.71	0.73	0.67/0.81	0.81
Assembly Tasks	0.68	0.72	0.67	0.81/0.83	0.84

The Purdue pegboard employed in this study was designed by the Lafayette Instrument Company (Model No. 32020). The model comprises pins, washers, and collars, in addition to a test plate featuring two rows of holes. The testing board size is 30 cm in length, 45 cm in width, and 2 cm in height. The upper surface of the test board incorporates four grooved cups, each containing 25 pins, 40 washers, 20 collars, and 25 pins, arranged from left to right. There are two vertical rows of 25 small holes in the centre of the test board. This study was conducted in accordance with the recommendations set forth by the official website of the Purdue Pegboard Test (2023) [96]. Prior to administering the test, the researcher provided a detailed explanation of the study's procedure, the number of times it would be conducted, and the estimated time it would take to complete.

Additionally, the researcher reconfirmed the participant's identity, age, gender, and confirmation of their willingness to participate in the study. Then, in order, complete the four tasks, including: The first two tasks require you to use your dominant hand to place a staple in the hole of a pegboard as quickly as possible within 30 seconds, and then perform the same task with your non-dominant hand. The third task is to use both hands to place pins in the holes of the test board as quickly as possible within 30 seconds. The fourth task consists of assembling the four components (pin, washer, collar, washer in sequential order) as quickly as possible with both hands within 60 seconds and placing the assembly in the hole of the test board [97]. These tasks were repeated twice in this study and the average result was used as the subject's task performance [98]. The PPT is an assessment of dexterity based on the quality and speed of the subject's hand performance in completing the four tasks [47].

Berry-Buktenica Developmental Test of Visual-Motor Integration (VMI)

Sensory integration has been defined as the physiological

process by which the body processes information about the external environment and transmits it to the brain so that the information can be organised, analysed, compared, integrated and responded to appropriately [99]. Visual-motor integration (VMI) describes the coordination and integration of information received by the visual receptors with motor skills through the transformation of mental operations. Visual-motor integration can be understood as 'eye-hand coordination', which refers to the ability to perform tasks by coordinating visual stimuli with physiological functions that respond to motor skills [100]. It has also been defined as the coordination of fine scale movements and visual perception [101]. It also includes both physiological reflexes outside of motor coordination and stimulus response speed or psychomotor speed [102]. With appropriate learning and training tasks, older people can be provided with some visual and manual movement training, which is beneficial for promoting their visual motor coordination.

Some common instruments for measuring visual-motor integration include the Berry-Buktenica Developmental Test of Visual-Motor Integration (VMI) [103], the Bruininks-Oseretsky Test of Motor Proficiency [104], the Test of Visual Motor Skills, the Test of Visual Perceptual Skills [105], and the Test of Visual Analysis Skills. In this study, the Berry-Buktenica Developmental Test of Visual-Motor Integration was chosen as the instrument for this study. The instrument has been shown to be culturally neutral [106]; however, this study takes into account the potential research bias that may be introduced by administering the test in different languages. The instrument was adapted from The Berry-Buktenica Developmental Test of Visual-Motor Integration (Forth Edition) compiled by Beery in 1996 by Profs. L. Lu and H. X. Liu and L. Lu (1997)[107] in Taiwan. The Berry-Buktenica Developmental Test of Visual-Motor Integration (Forth Edition), which was translated into Chinese and published by Taiwan Psychological Publishing Co. It is suitable for measuring visual movements from 2 years old to adults.

Before the formal test, the researchers demonstrated how to complete the first three questions and provided relevant instructions to ensure participants fully understood the testing process. The main test involved copying and drawing 27 figures of varying difficulty using the dominant hand. This included 24 copying tasks and 3 imitation drawing tasks, with no time limit. One point was awarded for each correct answer, but the test was discontinued after three consecutive mistakes. The maximum possible score was 27. The VMI measures visual perception and motor integration abilities and can identify the degree of difficulty experienced by individuals with finger and hand movement challenges. In addition to the main test, two supplementary tests were included: Visual Perception (VP) and Motor Coordination (MC). In the VP test, participants identified 27 matching figures sequentially. The test ended after three consecutive errors or when the three-minute time limit expired. The MC test required participants to trace geometric figures within the designated contour area while avoiding going outside the lines. This test also ended after three consecutive errors or when the five-minute time limit was reached [107].

At the end of each test, the same occupational therapist administered the test and scores were calculated according to the criteria in the guidelines manual to ensure the consistency of the scores. The raw scores were converted to standardized scores according to the Beery-VMI manual, with a mean of 100 and a standard deviation of 15. As the sample size was relatively small, comparisons of raw scores were used to increase the sensitivity of the study in detecting short-term changes [108, 109]

Data analysis method

The present study aimed to elucidate the discrepancies between the pre-test and post-test outcomes of the intervention program. All analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 22.0. In addition to the mean and standard deviation of the raw scores and standardized scores, ANOVA (analysis of variance) and t-test were conducted to compare the differences between the pre-test and post-test within groups A, B, and C, as well as to assess the magnitude of improvement between groups A, B, and C. The aim was to determine whether the observed differences reached a statistically significant level.

PPT Performance

Table 4 presents the means and standard deviations of participants’ performance on the Purdue Pegboard Test (PPT) tasks before and after the intervention. It shows that for the four tasks—right hand, left hand, both hands, and assembly—the post-test scores were higher than the pre-test scores. Paired sample t-tests in Table 5 confirm that the differences between pre- and post-test scores for each task were statistically significant(p < .05), and this result was consistent across Groups A, B, and C. However, when comparing the differences in pre-test and post-test score improvements among Groups A, B, and C using ANOVA, the results indicated that these improvements did not reach a statistically significant level (Table 6). This suggests that interventions of varying difficulty levels did not produce significant differences in enhancing hand dexterity (p > .05). Moreover, a closer examination reveals additional details. For instance, as shown in Table 5, improvements in right-hand tasks were greater than those in left-hand tasks (an average increase of 2.6 for the right hand versus 2.2 for the left hand). Observations from Table 6 further show that across the four task categories, Group C demonstrated the greatest improvements in right-hand, left-hand, and bilateral tasks, followed by Group B, and lastly Group A. Interestingly, the pattern was reversed in the assembly task, where Group A showed the largest improvement, followed by Group B, and finally Group C.

Table 4

Summary Table of PPT Pre-test and Post-tests
M (SD)
Group	Pretest Right Hand	Posttest Right Hand	Pretest Left Hand	Posttest Left Hand	Pretest Two Hands	Posttest Two Hands	Pretest Assembly Tasks	Posttest Assemble Tasks
Group A	14.3 (1.7)	16.4 (1.5)	13.5 (2.1)	15.3 (1.6)	11.3 (2.0)	12.8 (1.7)	29.3 (5.7)	36.5 (4.9)
Case Observation(N)	Progress 25; No Change 2; Decline 2		Progress 23; No Change 2; Decline 4		Progress 23; No Change 4; Decline 2		Progress 28; No Change 1; Decline 0
Group B	13.8 (2.1)	16.3 (1.9)	13.0 (1.6)	15.2 (1.8)	11.3 (1.4)	13.0 (1.3)	28.4 (6.3)	34.4 (6.2)
Case Observation(N)	Progress 26; No Change 0; Decline 3		Progress 26; No Change 0; Decline 3		Progress 26; No Change 3; Decline 0		Progress 27; No Change 2; Decline 0
Group C	14.4 (1.7)	17.5 (1.1)	13.3 (1.9)	15.9 (1.4)	11.6 (1.4)	13.7 (1.1)	30.7 (5.3)	35.5 (5.3)
Case Observation(N)	Progress 29; No Change 0; Decline 0		Progress 29; No Change 0; Decline 0		Progress 29; No Change 0; Decline 0		Progress 27; No Change 2; Decline 0
Note: Case observations are categorized as “Progress” (posttest score > pretest score), “No Change” (posttest score = pretest score), or “Decline” (posttest score < pretest score) to represent the individual outcomes across tasks.

Table 5

Summary of PPT pre-test and post-test for paired samples of T-test
		Pairwise Variables Correlation		Paired Variable Differences
Group		Correlation Coefficient	p	Mean	Standard Deviation	T	p
Group A	Right Hand Pretest-Posttest	.39	.037	2.07	1.81	6.15	.000
	Left Hand Pretest-Posttest	.65	.000	1.81	1.61	6.05	.000
	Two Hands Pretest-Posttest	.82	.000	1.50	1.14	7.12	.000
	Assembly Tasks Pretest-Posttest	.72	.000	7.19	4.03	9.60	.000
Group B	Right Hand Pretest-Posttest	.55	.002	2.47	1.88	7.08	.000
	Left Hand Pretest-Posttest	.67	.000	2.22	1.37	8.76	.000
	Two Hands Pretest-Posttest	.77	.000	1.67	.93	9.70	.000
	Assembly Tasks Pretest-Posttest	.83	.000	5.99	3.63	8.83	.000
Group C	Right Hand Pretest-Posttest	.55	.002	3.03	1.45	11.26	.000
	Left Hand Pretest-Posttest	.71	.000	2.60	1.35	10.42	.000
	Two Hands Pretest-Posttest	.74	.000	2.03	.94	11.60	.000
	Assembly Tasks Pretest-Posttest	.76	.000	4.83	3.67	7.07	.000

Table 6

Variance Analysis of PPT Post-test Score Increase
		Descriptive Statistics			Analysis of Variance
Tasks	Group	N	Mean	Standard Deviation	F	p
Right Hand	Group A Group B Group C	29 29 29	2.07 2.47 3.03	1.81 1.87 1.45	2.30	.106
Left Hand	Group A Group B Group C	29 29 29	1.81 2.22 2.60	1.61 1.37 1.35	2.18	.119
Two Hands	Group A Group B Group C	29 29 29	1.50 1.67 2.03	1.13 .93 .84	2.13	.125
Assembly Tasks	Group A Group B Group C	29 29 29	7.19 5.99 4.83	4.03 3.63 3.65	2.83	.065

Performance of VMI、VP、MC

Table 7 presents the pre-test and post-test results for VMI as well as the two supplementary tests, VP and MC. From the mean scores, it is evident that the intervention program had a positive impact on participants, as shown by the improvements in post-test performance. Table 8 further examines the score differences before and after the intervention using paired-sample t-tests. The results indicate that, across Groups A, B, and C, post-test scores in VMI, VP, and MC were all significantly higher than pre-test scores, reaching statistical significance (p < .05).

Table 7 also reveals the number of participants who showed improvement in VMI and the supplementary tests VP and MC. It can be observed that the proportion of participants improving in the VMI test was higher than in VP or MC (average proportions of improvement across groups: VMI, 87.4%; VP, 63.2%; MC, 81.6%). Moreover, improvements in MC were greater than those in VP, and for both VMI and MC, Group A had slightly more participants showing improvement compared to Groups B and C. According to the standardized scores provided in the BeeryVMI manual (Beery & Beery, 2004) [110], these gains generally correspond to an increase of approximately one standard level, with VMI and MC scores moving from “below average” to “average.” These findings suggest that using bamboo weaving as the intervention activity effectively enhanced visual-motor integration and motor coordination, and that the simpler program in Group A was particularly effective in promoting participants’ skill development. As for visual perception, although improvements were observed across all three groups, the varying levels of task difficulty did not produce significant differences. To determine whether the difficulty level of the intervention programs contributed to differences in performance gains, an ANOVA was conducted on the post-test score improvements among Groups A, B, and C (Table 9). The results showed that VMI performance was significantly influenced by the difficulty level of the bamboo weaving activities (p < .05), with Group A (simplest program) showing the greatest improvement, followed by Group B, and lastly Group C (most complex program). This pattern aligns with the numbers of participants showing improvement reported in Table 7. In contrast, for the supplementary tests VP and MC, no significant differences were found among the three groups in post-test score improvements (p > .05).

Table 7

Summary Table of VMI Pre-test and Post-tests
	M (SD)
Group	Pretest VMI-R.S	Pretest VMI-S.S	Posttest VMI-R.S	Posttest VMI-S.S	Pretest VP-R.S	Pretest VP-S.S	Posttest VP-R.S	Posttest VP-S.S	Pretest MC-R.S	Pretest MC-S.S	Posttest MC-R.S	Posttest MC-S.S
Group A	23.2(2.0)	81.9(7.6)	25.8(1.0)	94.8(8.0)	22.3(2.3)	79.6(9.3)	23.8(1.8)	85.7(7.8)	22.3(2.4)	80.0(10.1)	23.3(1.4)	92.6(5.7)
Case Observation (N)	VMI Progress 27; No Change 2; Decline 0				VP Progress 17; No Change 8; Decline 4				MC Progress 26; No Change 2; Decline 1
Group B	22.8(2.7)	80.8(10.9)	25.4(0.9)	91.8(4.7)	22.3(2.5)	80.2(11.2)	23.8(1.5)	85.8(6.7)	22.8(2.7)	81.1(11.0)	25.4(0.8)	92.0(3.3)
Case Observation (N)	VMI Progress 26; No Change 3; Decline 0				VP Progress 19; No Change 4; Decline 6				MC Progress 22; No Change 7; Decline 0
Group C	24.0(1.1)	85.1(4.3)	25.4(1.1)	92.2(7.1)	22.3(2.0)	79.6(7.8)	23.3(2.0)	84.3(8.6)	23.1(1.4)	83.2(5.9)	25.1(1.5)	91.6(5.8)
Case Observation (N)	VMI Progress 23; No Change 4; Decline 2				VP Progress 19; No Change 4; Decline 6				MC Progress 23; No Change 6; Decline 0
Note: Note: R.S. = Raw Score; S.S. = Standard Score. “Progress” = posttest > pretest; “No Change” = posttest = pretest; “Decline” = posttest < pretest.

Table 8. Summary of VMI pre-test and post-test for paired samples of T-test

Note 1. R.S. denotes Raw Score; S.S. denotes Standard Score.
Note 2. The correlation coefficients in the table are Pearson product–moment correlations between pre-test and post-test scores, used to assess the consistency of participants’ scores and individual variability.
Note 3. Differences between pre-test and post-test scores were analyzed using paired-sample t-tests to examine whether the intervention produced significant improvements.
Note 4. p < .05 indicates the level of statistical significance

Table 9

Variance Analysis of VMI Post-test Score Increase
		Descriptive Statistics			Analysis of Variance
Test-Score Category	Group	N	Mean	Standard Deviation	F	p
VMI-R.S.	Group A	29	2.62	2.01	3.73	.028
	Group B	29	2.66	2.73
	Group C	29	1.34	1.23
VMI-S.S.	Group A	29	12.83	9.96	3.07	.048
	Group B	29	11.97	11.80
	Group C	29	7.14	6.80
VP-R.S.	Group A	29	1.48	2.21	.504	.606
	Group B	29	1.55	2.32
	Group C	29	1.03	1.88
VP-S.S.	Group A	29	6.17	9.07	.196	.822
	Group B	29	5.66	10.35
	Group C	29	4.69	7.87
MC-R.S.	Group A	29	3.07	2.40	1.55	.218
	Group B	29	2.62	2.54
	Group C	29	2.07	1.36
MC.S.S.	Group A	29	12.59	9.97	1.63	.202
	Group B	29	10.86	10.23
	Group C	29	8.41	5.13

The application of creative activities as an intervention in occupational therapy has become increasingly widespread, with handicrafts being among the most commonly employed activities in this context. Through continuous learning, older adults are able to maintain or enhance their physiological and cognitive functions, and even generate or train new cognitive abilities to compensate for their lost sensory receptivity. Furthermore, it facilitates the development of new cognitive strategies for sensory deprivation [111, 112], as well as dexterity [47], and response time [15, 113, 114]. The findings of the present study are consistent with those of previous studies [2, 44, 82], which confirmed that, following the bamboo weaving intervention programme, participants showed statistically significant increases in both manual dexterity (PPT) and visual-motor integration (VMI, VP, MC) tests. The varying levels of difficulty of the intervention resulted in different levels of improvement in ability; however, it failed to achieve statistical significance in terms of improvement in manual dexterity (PPT). In the visual-motor integration (VMI, VP, MC) test, the improvement of VMI was found to be significantly influenced by the difficulty level of the intervention programme. Nevertheless, a detailed and valuable reference can be obtained from the observation of the difference in scores between the pre-test and post-test. For instance, dexterity gains are higher in the dominant hand than in the non-dominant hand, while gains in two-handed tasks are even lower. Judge & Stirling [97] attribute this phenomenon to the fact that such a two-handed test lacks ecological validity (i.e., in an applied setting it is unusual to use the hands in this way). Furthermore, regarding the difficulty level of the intervention programs, the present study confirmed that they significantly facilitated improvements in PPT performance for unilateral, bilateral, and assembly tasks. However, no significant differences were observed among programs of varying difficulty levels. In contrast, within the bamboo weaving activities, simpler programs produced significantly greater improvements in VMI and MC. These preliminary findings seem to suggest that, when designing bamboo weaving intervention programs, it is not necessary to pursue higher levels of difficulty or complexity in the weaving process—at least within the scope of a 48-hour bamboo weaving intervention. Simpler programs not only help reduce program costs but also minimize stress for participants, while further enhancing improvements in VMI and MC.

It should be emphasized, however, that the intervention program in this study was designed as a 48-hour experimental course. The relatively short duration of the intervention may partly explain why older adults participating in programs of different difficulty levels did not show significant differences in PPT improvements. Future studies might extend the duration of intervention, which could potentially make the differences among programs of varying difficulty levels more pronounced.

In the early phase of the study design, we referenced Leonard et al. [44] and Kim's [2] protocol, which recommended planning intervention sessions over an 8-week period. However, McGarrigle and Nelson [115], who conducted a 6-week study, suggested that shorter interventions may be less responsive to improvements in visual-motor integration (VMI). Similarly, Kannegieter [116] argued that interventions shorter than three months are limited in detecting changes in VMI. Extending the intervention duration to 5–8 months may yield more significant improvements [117, 118, 119]. It is important to note that in planning the duration of craft activity sessions, the physical conditions of individual older participants should be carefully considered. Even when an activity generates high levels of engagement, attention must still be paid to the risk of fatigue-related injury from excessive practice [34]. In addition, we recommend that future studies remain mindful of the potential ceiling effect of intervention training on skill enhancement. This caution is informed by Mieiro, L. et al. [131], who observed the presence of a ceiling effect in hand dexterity tests among older adults. Although the current study did not appear to exhibit such an effect, it remains essential that future intervention designs and evaluations carefully consider the sensitivity and appropriateness of the assessments used, so as to avoid misinterpretation due to a ceiling effect.

Pöllänen [84] suggests that engaging in crafts as a meaningful occupation can enhance well-being. Craft activities carry special meaning and value. As highlighted by Polatajko et al. [120], who emphasize that such occupational activities must be meaningful, purposeful, and achievable by the individual. These perspectives informed the design of the bamboo weaving intervention program in this study. Participants were guided through a phased production process with sub-targets, enabling them to learn bamboo weaving techniques step by step. This approach allowed participants to complete tasks in an enjoyable and supportive environment, fostering self-confidence and a sense of achievement [27]. All projects completed by Groups A, B, and C were functional, visually pleasing, and meaningful to participants. However, during recruitment, a notable gender disparity in interest was observed. Female participants dominated the groups, with males comprising only 13.8% of the total. This imbalance limited the ability to make effective gender-based comparisons. The impact of gender on manual dexterity remains a debated topic. Haward and Griffin [121] found no gender differences in manual dexterity using the Purdue Pegboard Test (PPT), while Harwin and Adams [93] reported that females outperformed males in both dominant and non-dominant hand dexterity. Peters et al. [122] offered a different perspective, suggesting that gender may not be the primary factor influencing fine manual dexterity. Instead, they highlighted the importance of finger size, noting a negative correlation between finger size and PPT performance. Additionally, studies on VMI have demonstrated that women generally exhibit superior VMI abilities [123, 124]. In conclusion, future craft intervention programs should address gender-specific interests and preferences. While the current programs improved PPT and VMI performance overall, designing interventions that appeal to diverse gender interests would enhance occupational therapy practices and serve as a valuable area for future research.

As noted previously, this study highlights the advantages and value of craft activities as an occupational therapy intervention. Creative activities like crafting are more likely to evoke motivation in elderly individuals compared to mechanical interventions. High levels of motivation foster decision-making before undertaking tasks and regulate behavior and performance, thereby enhancing learning effectiveness and skill acquisition [125]. Craft-based intervention programs are grounded in goal-setting strategies, which emphasize specific and challenging goals. These goals help participants develop meaning and self-commitment, encouraging them to invest effort, perform better, and gain a positive self-identity [126, 127]. Leonard et al. [44] similarly confirmed this motivational effect in an occupational therapy study on older adults' participation in knitting crafts.

Limitations and Future Studies

The present study focused on the physiological enhancement aspect, particularly due to the highly repetitive and quantifiable nature of the bamboo weaving process, which lends itself well to a quantitative research design. However, craft activities have been shown to increase parasympathetic and sensorimotor indices, creating a sensory flow response in participants [32, 84, 128]. Additionally, the creative aspect of crafting significantly impacts happiness, well-being, and self-esteem [31, 129, 130]. Crafting is a recreational behavior that connects to everyday life situations and fosters the development of important skills such as socialization, collaboration, and problem-solving through collective crafting [45]. This can help older adults, who may have become disconnected from their usual activities, regain their sense of connection to everyday life and mitigate the negative impacts of physical deterioration and illness, such as loneliness. Craft activities have been shown to reduce these effects and improve self-esteem [18, 24, 31, 129, 130].

Despite the widespread use of crafts and arts as creative activities in occupational therapy, and the considerable evidence supporting their contribution to functional recovery, the specific benefits and definitions of these activities remain unclear in clinical research [27, 69]. It is also important to recognize the diversity of crafts, and we suggest that future research explore the unique qualities of different crafts. For example, from a physiological perspective, this could include examining the body parts involved, force application, movement repetition, sensory stimulation, and integration of various elements. From a psycho-spiritual perspective, research could focus on the social behaviors associated with collective creation, such as the sense of belonging and security it fosters, the self-identity and self-esteem gained from completing the work, and the positive emotional effects—including anxiety reduction—resulting from the mental flow during the creative process. We suggest that a thorough analysis of the possible benefits of each craft's properties and their integration into the study design of a clinical trial can demonstrate the high value of the use of craft activities in occupational therapy.

This study confirmed that using bamboo weaving as an intervention program can significantly enhance hand dexterity and VMI abilities in older adults. The findings provide supportive evidence for occupational therapy practice and for the design of intervention programs.

This study focused on hand dexterity and visual–motor integration, as these are key abilities directly reflected in daily living. The research serves as a valuable cornerstone, since the diversity of crafts provides numerous possibilities for incorporating creative activities into occupational therapy. At present, although craft-based creative activities are commonly used in occupational therapy [31; 37], many craft activities and their benefits have yet to be clearly and objectively measured and verified. Furthermore, the professional expertise in these creative activities has not been systematically integrated into higher education in occupational therapy, and the implementation of craft-based programs is not generally an area of expertise for occupational therapists—at least in Taiwan. This may partly explain why creative activities have not received the attention they deserve within occupational therapy [128].

For future research, we advocate making fuller use of the unique qualities of different crafts, while also considering mechanisms for interdisciplinary collaboration—for example, partnerships between artisans and occupational therapists. Such collaboration could effectively enhance a range of abilities in older adults, help maintain their quality of life, and ultimately contribute to the overall health and well-being of the aging population.

Ethics approval and consent to participate

Informed consent was obtained from all subjects and/or their legal guardian(s). All methods were carried out in accordance with relevant guidelines and regulations. The study was approved by the Central Regional Research Ethics Committee China Medical University, Taichung, Taiwan “Craft therapy for the elderly research project” (CRREC No.) on Jun. 28, 2023 (CRREC-112-048).

Consent for publication

Not applicable.

Availability of data and materials

If further material is needed, please contact the corresponding author.

Competing Interests

The authors declare no competing interests.

Funding

Not applicable.

Authors' contributions

Conceptualization:Y.-C.L.Methodology:Y.-C.L. Software:C-S.H. validation:T-L.C.Formal analysis: Y.-C.L.&C-S.H. Investigation:Y.-C.L. Resources:C-S.H. Data curation:Y.-C.L. Writing—original draft preparation: Y.-C.L. Writing—review and editing:T-L.C&C-S.H;.Visualization, Y.-C.L. Supervision:T-L.C. Project administration: T-L.C&C-S.H. All authors have read and agreed to the published version of the manuscript.

Acknowledgements

The authors would like to express their gratitude to all those who participated in this study, including the scholars and craftsmen who provided valuable advice during the study's design phase, as well as the participants who took part in the study. Additionally, the study procedures adhered to the principles of the Declaration of Helsinki and were guided by the Regional Review Committee of the Chinese University of Medical Sciences (CUMS), along with contributions from experience sharing.

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No competing interests reported.

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A Study on Creative Activities for Enhancing Manual Dexterity and Visual- Motor Integration in Older Adults: Focus on Bamboo Weaving

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Abstract

Introduction

Materials and methods

Interference Design

Data collection

Purdue Pegboard Test

Berry-Buktenica Developmental Test of Visual-Motor Integration (VMI)

Data analysis method

Results and discussion

PPT Performance

Discussion

Limitations and Future Studies

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1