about 65% of 
 all people with a visual impairment are 50  years old and older , and this age group currently 
 comprises about 20% of the world s population . with an increasing elderly population 
 worldwide , more people will be at risk of visual impairment due to chronic eye diseases and 
 ageing processes1 .
serious concern has 
 emerged about the primary medical and nursing care treatment of individuals with 
 disabilities due to their increasing severity and complexity along with their increasing 
 cost to society . in japan , while the number of patients blinded by diabetic retinopathy is 
 decreasing , the percentage of those receiving dialysis in connection with diabetes increased 
 by 0.7% from fy2009 to 35.8% in 20152 . 

this converts to 2,320 people per year . in the rural japanese community of kusatsumachi in gunma prefecture , which was
the focus of 
 this study , the rate of dialysis treatment for those who are visually impaired was 3% out of 
 a total population of 7,1203 . 

additionally , the management of lifestyle diseases for those with vision impairment is 
 inadequate .
indeed , compared to sighted people , visually impaired people have limited 
 ability to obtain information necessary to learn about exercise and dietary habits for 
 personal health maintenance . along with advances in wearable devices ,
instructional video 
 technology supporting physical activities has been on a rise4 , and the number of healthy people utilizing it is increasing . 
 however , blind or visually impaired individuals will have inadequate access to such 
 information technology because of the long time it takes to universalize or convert its 
 content to auditory information that would be able to support the physical activities .
these studies 
 investigated physical activities in competitive sports through analyzing athletes 
 movements5 or  clinical fear ,  a 
 neglected causal factor regarding the training of activities of daily living ( adl ) that many 
 people complain of during movement .
one possible reason for this is that there are no 
 provisional methods to diagnostically define  clinical fear ,  and such reports will not lead 
 to the development of evaluative methods to predict performance . with a focus on recent and interesting theories of cognitive behavioral science , we aimed 
 to develop a clinical diagnostic index as a method to diagnostically define  clinical fear .  
 additionally , using the presence or absence of a sense of danger as a standard , we examined 
 whether the fear experienced during movement acquisition in adults with visual impairment 
 was classifiable .
experimenters focused on the presence of an observable  freeze  response , which is believed 
 to be a sign of the participant sensing danger and used as the criterion for determining the 
 presence or absence of a sense of danger . additionally ,
 fear  was divided into two 
 categories , fear 1 and fear 2 , which from the perspective of early developmental criteria 
 become  innate fear  and  learned fear .  from the perspective of full maturity , these could 
 respectively be referred to asnon - dangerous fear ,  and  dangerous fear .  accordingly , based 
 on whether a corresponding relationship exists between danger and fear , the following four 
 classifications were considered and utilized to classify fear preceding the movement : type 1 
 = danger with fear ; type 2 = danger without fear ; type 3 = no danger with fear ; and type 4 = 
 no danger and no fear .
this typological configuration is known as a dual - process model6,7,8 , which has recently been equivalently , 
 expressed , as a 2-systems model9 , 10 . the present pilot study aimed to classify the fear that occurs
when movement acquisition is 
 impaired based on the interviews and the results of autonomic functional analyses conducted 
 during the process of squat - like movement acquisition undergone for individual health 
 maintenance by adults with visual impairment who had never received aerobic exercise 
 instruction .
it further sought to clarify which instructional content was perceived as safe 
 and effective at alleviating fear for participants .
subjects were fifteen participants , 45  years old and older , selected randomly from a pool 
 of 72 adults with visual impairment who were independently performing activities of daily 
 living ( adl ) in kusatsumachi , gunma , japan .
the study was conducted at the kusatsumachi welfare center from march through august 2015 . 

participant recruitment was done by our staff who explained the study intent to the society 
 for the visually impaired ( which has approximately 72 members in total ) and the social 
 welfare council , both of which were already involved in providing activity support to 
 visually impaired individuals in kusatsumachi , gunma prefecture .
subsequently , we recruited 
 potential research subjects based on verbal communication with relevant parties . 

discontinuance criteria specified situations that arise in which there is a legitimate 
 reason for a participant to withdraw from the study ( e.g. , changes in the home environment , 
 aggravation of disease , declines in physical function ) .
ethics review and approval was obtained from the gunma paz college ethics committee ( no . 

a 
 desk and chair were prepared for observation and listening and a 30  cm force 
 plate ( pasco ps2142 force plate , usa ) was placed on the floor to measure ground reaction 
 force ( grf ) .
the participants were asked to stand on the plate , and their condition was 
 uncontiuuonsly observed during the daytime from 10 a.m. until 5 p.m. while they performed 
 squat - like movements following verbal instruction .
grf measurement and the protocol assessed  the level of comprehension of the pointers used 
 in movement execution .  in the protocol for movement instruction , the assessor provided 
 verbal instruction to the participant , saying ,  to squat , lower your hips towards your feet , 
 bend your knees as far as you can without straining them , and then raise your hips up 
 again . 
participants were then prompted with ,  now , to your own ability , let s try a quick 
 and easy set of five repetitions .
 participants were then told ,  if at any time you feel 
 afraid that you will fall , please call out .
i can support you so that you wo nt fall , but 
 please do your best to complete the exercise by yourself .  in provision of verbal support , 
 the assessor also provided feedback when the movement was performed consistently by saying , 
  you re doing a good job of maintaining your form throughout the repetitions .  to assess the 
 comprehension of the pointers used in movement execution , the assessor interviewed the 
 participants and asked about impressions regarding their understanding of movement 
 orientation , the effects of pointers on movement speed , the use of movement repetition 
 timing cues , and pointers regarding spatial location information .
ground reaction force ( grf ) was measured on the 
 floor where the participants stood .
the presence or absence of subjective fear assessed the 
 presence of anecdotal expressions of fear immediately prior to the squat - like movement on 
 the force plate . presence or absence of objective fear as thru an anxiety index measures the 
 ratio of low and high frequency components ( lf / hf ratio ) of heart rate variability spectra 
 ( cm / hz ) based on resting rate ( rr ) intervals ( actigraph wgt3x - bt , usa ) . 

autonomic hyperactivity was defined as over 2.0 ( lf / hf ratio ) , indicating that objective 
 fear was occurring .
statistical analysis first included a typological analysis for which a dual - process theory 
 was adapted to classify clinical fear based on the relationships between danger and 
 subjective and objective fear .
the fear types included perception of danger with freeze 
 response that one was in a position to fall from a top a platform , type 1 is danger with 
 anxiety , type 2 is danger without anxiety , and type 3 is no danger with anxiety , type 4 is 
 no fearless . danger and no anxiety .
we then sought the frequency of occurrence of each of 
 these clinical fear types .
a fisher s exact test was conducted to examine the relationships 
 among evaluated fear types and expected types ( p<0.05 ) using ibm - spss ver . 20 .
participants were asked to stand on a ground reaction force ( grf ) plate placed on the 
 floor .
subsequently , they were evaluated on aerobics state , or their movements were 
 evaluated the presence of an observable  freeze  response ( table 1table 1.ground reaction force plate on the floor utilized by participants ( persons with 
 visual impairment)idgenderbody height ( cm)body weight ( kg)vertical impulse*horizontal impulse*mean of vertical impulsemean of horizontal impulse1male15349.19,727 163 1,945 33 2male15763.424,096 340 4,819 68 3male16557.518,522 326 3,704 65 4female1153418,522 326 3,704 65 5male16854.57,485 220 1,497 44 6male149.549.729,753 109 5,951 22 7male16565.416,275 281 3,255 56 8female1415933,353 80 6,671 16 9male161.554.922,125 151 4,425 30 10female14040.57,502 29 1,500 6 11male16961.66,816 77 1,363 15 12male17066.18,887 152 1,777 30 13female13841.310,670 207 2,134 41 14male167557,252 132 1,450 26 15female14252.919,443 141 3,889 28 * impulse : five repetitions of integrated force ( ns ) of ground reaction force ( grf ) , 
 sampling frequency 200  hz.pasco 2-axis force platform ps2142 ) . *
impulse : five repetitions of integrated force ( ns ) of ground reaction force ( grf ) , 
 sampling frequency 200  hz .
pasco 2-axis force platform ps2142 the relationships between a sense of danger and subjective / objective ( autonomic arousal ) 
 fear during movement were evaluated , and the results are shown in tables 1 and 2 .
all 15 
 participants were able to execute the squat - like movements until the end of the session .
the 
 relationships of sensing and not sensing danger with the presence or absence of  freeze  

the fear types were able to divide into four 
 types reflecting combinations of danger and objective fear factors .
the clinically 
 categorized subjective fear was noted for two ( type 1 = danger with fear ) , seven ( type 3 = 
 no danger with fear ) , six ( type 2 = danger without fear ) , and zero ( type 4 = no danger and 
 no fear ) persons for each type ( tables 
 2table 2.cross tabulation of sense of danger with  freeze  and subjective fear in people 
 with visual impairment ( n=15 ) congenital ( 7 ) or acquired blindness ( 8)acquired or congenitalno fearfeartotalacquired blindness feeling danger with freeze ( n)303no feeling of danger with freeze ( n)415total718congenital blindnessfeeling danger with freeze ( n)303no feeling of danger with freeze ( n)224total527a fischer s exact test in acquired blindness vs. congenital blindness by no fear vs 
 fear : n.s . and 3table 3.cross tabulation of sense of danger with  freeze  and  objective anxiety  as 
 objectiveover or under the set point of lf / hf(2.0)no fearfeartotalunderfeeling danger with freeze ( n)011no feeling of danger with freeze ( n)101total112overfeeling danger with freeze ( n)606no feeling of danger with freeze ( n)527total11213fear ( lf / hf ) in people with visual impairment ( n=15 ) .
fischer s exact test with  different of set point of lf / hf  by no fear vs. fear : 
 n.s . ) .
a fischer s exact test in acquired blindness vs. congenital blindness by no fear vs 
 fear : n.s .
fischer s exact test with  different of set point of lf / hf  by no fear vs. fear : 
 n.s .
the frequencies of occurrence of clinically categorized subjective fear were two , seven , 
 six , and zero persons for types 1 , 3 , 2 , and 4 , respectively .
when looking at cases in which 
 there was a sense of danger , the relationship of congenital and acquired blindness with the 
 frequency of occurrence of the four fear types was non - significant ( table 4table 4.cross tabulation of fear and subjective classification in persons with visual 
 impairment ( n=15)acquired or congenitalclassificationno fearfeartotalacquired blindness subjective ( feeling based ) fearfeeling danger ( n)classification 1415no feeling danger ( n)classification 2000subjective ( feeling based ) no fearfeeling danger ( n)classification 3303no feeling of danger ( n)classification 4000total718congenital blindnesssubjective ( feeling based ) fearfeeling danger ( n)classification 1112subjective ( feeling based ) no fearfeeling danger ( n)classification 2112subjective ( feeling based ) fearno feeling of danger ( n)classification 3303subjective ( feeling based ) no fearno feeling of danger ( n)classification 4000total527fischer s exact test of acquired blindness vs. congenital blindness by 
 classifications : n.s . ) .
the clinically categorized frequency of objective fear for those with innate 
 blindness was three , six , zero , and six people in types one , 3 , 2 , and 4 , respectively 
 ( table 5table 5.cross tabulation of relationship in  acquired or congenital blind , observation 
 fear / no fear , feeling danger , classifications of persons with visual impairment 
 ( n=15)acquired or congenitalclassification*no fearfeartotalacquired blindness * observation ( feeling based ) fearfeeling danger ( n)classification 1011no feeling of danger ( n)classification 2044observation ( feeling based ) no fearfeeling danger ( n)classification 3000no feeling of danger ( n)classification 4303total358congenital blindness*observation ( feeling based ) fearfeeling danger ( n)classification 1022observation ( feeling based ) no fearfeeling danger ( n)classification 2022observation ( feeling based ) fearno feeling of danger ( n)classification 3000observation ( feeling based ) no fearno feeling of danger ( n)classification 4303total347a fischer s exact test in the matrix cells , acquired or congenital blind vs. 
 classifications : linear - by - linear association , p=0.011 ; 1 , linear - by - linear 
 association , p=0.019 ) .
when looking at cases in which there was a sense of danger , a significant 
 relationship was found between the occurrence frequency of the four fear types and innate 
 people with blindness ( tables 4 and 5 ) .
fischer s exact test of acquired blindness vs. congenital blindness by 
 classifications : n.s .
a fischer s exact test in the matrix cells , acquired or congenital blind vs. 
 classifications : linear - by - linear association , p=0.011 ; 1 , linear - by - linear 
 association , p=0.019
the findings suggest a possible feasibility of fear classification based on examining the 
 process of a squat - like movement of persons with visual impairment .
our results indicated 
 that a sense of fear and the presence or absence of a sense of danger affected movement 
 learning .
all 15 participants in this study were able to execute the squat - like movements until the 
 end of the experiment .
of these , the lf / hf ratio of hrv was measurable in eight participants 
 until the end of the experiment . when we controlled for objective fear , the relationships 
 among congenital blindness , sense of danger , and fear were significant but when adapting for 
 subjective fear these relationships were non - significant .
that our classification method 
 adopted for objective fear ( autonomic hyperactivity ) found significant relationships 
 independently between congenital blindness , sense of danger , and fear , and did not find 
 significant relationships when adapted to subjective fear , which can be taken as an 
 indication of its effectiveness of optimize subjective fear as follow as types by 
2-systems 
 model9 , 10  . in corroboration with a report by shibasaki et al . in which 
 autonomic functional determinants were used in prognosis estimations of elderly persons and 
 exercise function ,
the circumstances of stable physical function are thought to be 
 predictable and have constant applicability .
although almost objective fear corresponds to subjective fear , congenitally - blind people do 
 not feel fear when they do not sense danger which may explain why significant independent 
 relationships emerged for clinical fear classifications when autonomic function was included 
 to discriminate objective fear .
innate fear is similar to physiological fear , and it should 
 be manifested in a manner opposite to that of psychological fear .
thus , the existence of danger , which can not be learned , may suggest the existence of fear 
 that can not be verified . if so - called type 1 was a cognitive process possessed by everyone . 

the present study confirmed cases 
 that were classifiable as type 2 fear in those with congenital blindness who sensed neither 
 subjective fear nor danger , a previously unobtainable result in dual - process theory - based 
 classification of fear in sighted people .
it is thought that the present study is the first in the world to successfully verifiably 
 demonstrate the lack of fear manifestation in correspondence with a 2-systems model .
type 2 
 is re - defined as the predictable  anxiety  that can be described no - orally before exercising 
 in response to an unprecedented event that requires the subject to perform repetitive 
 tasks .
on the other hand , type 3 is able to defined that can not be described orally before 
 exercising in response to an unprecedented event that requires the subject to perform 
 repetitive tasks .
furthermore , through our experiment , we confirmed that type 2 shows the changes in 
 autonomic nerve functions .
therefore , in reference to the principles of behavioral science , 
 it is possible to express as danger without fear . additionally , while type1 and type 2 reflect subjective anxiety , we defined dangerous 
 conditions as those that are evident in subjects before exercising as presence of danger and 
 clearly seen by third parties .
when there is clear danger that can be seen objectively , such 
 as the subject s foot being off the base , this is defined as danger . in other cases , it is 
 possible to refer to as no danger .
these operative definitions are possible to adopt to test interactions between fear and 
 danger .
the motive behind 
 this study is to find a clue to the problem of not being able to acquire certain levels of 
 aerobics activities in a given period compared to able - bodied subjects using these results 
 of oral expression data .
this study conducted this research to quantitatively measure the 
 anxiety that goes along with exercise / movements to make circumstantial judgments .
the novel 
 finding in the present study identifies shortcomings in our prior understanding of fear 
 response and dual - process models that could not have been explained based on 2-systems 
 models11 .
our new theory hypothesizes 
 that explanations of fear and danger by conventional dual - process models , which do not 
 consider the effects of physical movement , are limited to static conditions and that fear , 
 when accompanied by conditions that demand the acquisition of movement and the mastery of 
 exercise training , is expressed by physiological phenomena12 .
thus , even if complaints of subjective fear are not exhibited when 
 providing support for aerobic exercise movement acquisition in adults with visual 
 impairment , an exercise physiologist and physical therapist could give them a better safety 
 in particular conduct by this classification of clinical fear like a human factors .
the 
 limitations of this study include the difficulty of statistical estimates due to the small 
 sample size .
the present study was limited in terms of insufficient measurement due to the 
 inability to continuously monitor subjective fear over a sufficient length of time . 
 moreover , our results lack generalizability , as we can not rule out the possibility of bias 
 based on the unique characteristics of the community examined .
the procedure is used to classify fear might be increased safety feasible during the 
 process of squat - like movement by persons with visual impairment .
unconscious fear does not 
 show to be exist , but the classification of clinical fear based on physiological alterations 
 in autonomic activity could be of significance for the development of instructional methods 
 to support the health of the elderly with visual impairments .
 [ purpose ] this study aimed to classify the fear that occurs during the process of a 
 squat - like movement by persons with visual impairment . 
 [ subjects and methods ] fifteen 
 persons with a visual impairment , 45  years and older , who were independent in daily living 
 were recruited for the study . 
 the study utilized a field experiment design . 
 the setting 
 was the kusatsumachi welfare center , and the study period was from march through august 
 2015 . 
 outcome measures included the presence or absence of fear during attempt of a 
 squat - like movement on a force plate . 
 metrics included the ratio of low and high frequency 
 components of heart rate variability spectra ( cm2/hz ) based on resting rate 
 intervals ( actigraph wgt3x - bt , usa ) . 
 autonomic hyperactivity was defined as the occurrence 
 of objective fear with lf / hf ratio of over 2.0 . 
 statistics included fischer s exact test . 
 
 [ results ] four fear types included the combination of danger and objective fear factors . 
 
 the frequencies of occurrence of clinically categorized subjective fear across the four 
 fear types were two ( danger , fear ) , seven ( no danger , fear ) , six ( danger , no fear ) , and 
 zero ( no danger , no fear ) persons . 
 [ conclusion ] this procedure of classifying fear might 
 be feasible during evaluation of a squat - like movement by persons with a visual 
 impairment . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION