Feasibility study of the effects of art as a creative engagement intervention during stroke rehabilitation on improvement of psychosocial outcomes: study protocol for a single blind randomized controlled trial: the ACES study

Are neuroaesthetic principles applied in art therapy protocols for neurorehabilitation? A systematic mini-review

Art is an instrument created by humans as an alternative way of expression. For this reason, it has found its use in clinical contexts to improve mood, increase participation in therapy, or improve communication for patients with different pathologies. In this systematic mini-review, the Preferred Reporting Item for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were adopted. Internet-based bibliographic searches were conducted via major electronic databases (Web of Science and PubMed). We analyzed the quantitative studies in which art figures as a neurorehabilitation treatment to identify whether standard art therapy protocols exist and whether these are based on the principles of neuroaesthetics. Our review identified 8 quantitative and 18 qualitative studies. Although art therapy has been used for more than 20 years as a clinical tool, there are no standard protocols to refer to when planning interventions. Although the effectiveness of using arts as therapy has been reported in many qualitative or feasibility studies, there is still a lack of quantitative studies in which the outcomes of art therapy are directly based on the principles of neuroaesthetics.

Creative Art Therapy for Improving Depression, Anxiety, and Stress in Patients with Stroke: A Quasi-Interventional Study

Introduction

Creative art therapy is a psychotherapeutic approach used to enhance the mental health status of patients.

Objectives

This study aimed to evaluate the effect of creative art therapy on the levels of depression, anxiety, and stress in Jordanian patients following stroke.

Methods

One-group pretest-posttest design was used; it included four sessions of creative art therapy which were conducted as two sessions for two weeks. This study recruited 85 participants who were within three months poststroke diagnosis. The Depression, Anxiety, and Stress Scale was used to assess the levels of psychological reactions pre and post creative art therapy intervention.

Results

The data showed that there was a statistically significant improvement in the levels of depression (t = 37.98; p < .001), anxiety (t = 20.59, p < .001), and stress (t = 35.52, p < .001) post-intervention. There was a statistically significant improvement in the study-related psychological aspects following creative art therapy.

Conclusion

The findings of this study suggest that creative art therapy is a valuable method to complement other types of treatments among patients with stroke, resulting in positive patient mental health outcomes. Creative art therapy could be used as a psychotherapeutic approach to manage mental health complexities among patients with stroke. Health policymakers are invited to use the findings of this study to establish tailored counselor services using this new psychotherapeutic approach.

Art Making as a Health Intervention: Concept Analysis and Implications for Nursing Interventions

Art making has been adopted across multiple disciplines as a health intervention. However, our understanding of art making as a health intervention and how it differs from art therapy is still limited. Therefore, we conducted a concept analysis to better understand art making as a health intervention guided by Walker and Avant's approach. We examined 85 studies in which we found 4 defining attributes, 4 antecedents, and physical, cognitive, emotional, and psychological consequences. We suggest several nursing research and practical implications for nurse researchers and clinicians to aid in designing and implementing art making health interventions.

A randomised controlled trial of expressive arts-based intervention for young stroke survivors

BACKGROUND

Stroke causes lasting brain damage that has numerous impacts on the survivor's physical, psychosocial, and spiritual well-being. Young survivors (< 65 years old) tend to suffer more because of their longer overall survival time. Expressive arts-based intervention is considered a holistic approach for stroke rehabilitation because it allows participants to express their thoughts and emotions through the arts. The group environment also promotes mutual support among participants. The creative art-making process helps expand participants' creativity and imagination as well as promote a sense of aesthetic appreciation. Previous studies have shown the effectiveness of the arts-based intervention in managing stroke and its psychosocial-spiritual comorbidities. Nevertheless, a systematic study has not been conducted, including in young survivors. This trial plans to investigate the effectiveness of an expressive arts-based intervention on bio-psychosocial-spiritual outcomes in young Chinese stroke survivors.

METHODS/DESIGN

A single-blind, two-arm cluster randomised control trial with a waitlist control design will be adopted. One hundred and fifty-four stroke survivors, aged 18-64 years with modified Rankin Scale scores of 1-4, will be screened and randomised to either an expressive arts-based intervention group or a treatment-as-usual waitlist control group. The intervention group will receive a 90-min session once a week for a total of 8 weeks. All participants will be assessed three times: at baseline, 8 weeks, and 8 months after the baseline. Study outcomes include measures of depression and anxiety, perceived stress, perceived social support, hope, spiritual well-being, quality of life, salivary cortisol, blood pressure, and heart rate.

DISCUSSION

This study is expected to contribute to the current knowledge on the effectiveness of an arts-based intervention on the holistic wellness of young stroke survivors. The findings will help stroke survivors and healthcare professionals make better choices in selecting practices that will yield maximum benefits, satisfaction, adherence, and sustainability. In addition, the examination of the relationships between bio-psychosocial-spiritual variables will help contribute to the development of holistic care for the survivors.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03729648 . Registered 31 October 2018 - Retrospectively registered, (329 words).

How does art making work? Testing the hypothesized mechanisms of art making on pain experience

BACKGROUND

Pain is a multidimensional experience that requires a holistic pain management approach. Art making, a holistic, mind-body-spirit approach, has been used as a pain management strategy. Although findings of empirical studies point toward several potential mechanisms through which art making activity may affect the pain experience, these mechanisms have not yet been tested. Therefore, the purpose of this study is to evaluate whether perceived control, self-efficacy, spirituality, and mood mediate the effect of art making activity on pain.

MATERIALS AND METHODS

This study is a secondary analysis of cross-sectional survey data collected in 2014 for the Health and Retirement Study (HRS). Data from a national sample of 731 adults, 50 years of age or older were analyzed for the current study. Participants completed a health survey which included measures of art engagement (representing 'effect of art making' in this study), pain severity and interference, and proposed mediating variables (e.g., perceived control, self-efficacy, spirituality and mood). The joint significance test was used to test hypothesized mediation.

RESULT

We found that positive mood mediated the effects of art engagement on pain, but perceived control, self-efficacy, spirituality, and negative mood did not. Engagement in art making activity was associated with more positive mood (β = 0.213, p = .001). In turn, greater positive mood was associated with lower pain severity (β = -.147, p = .010) and pain interference (β = -.519, p = .034).

CONCLUSION

Results of this study provide preliminary evidence that engagement in art making activity impacts pain experience by enhancing positive mood. A large prospective study examining the hypothesized mediating relationship is necessary to confirm our findings.

Playing to live: outcome evaluation of a community-based psychosocial expressive arts program for children during the Liberian Ebola epidemic

BACKGROUND

This paper reviews the efficacy of a community psychosocial arts program focused on building mental health capacity within post-Ebola Liberia. The aim of this paper was to evaluate the outcome effects of two groups using pre- and post-treatment data. We hypothesized that there would be a difference in symptoms pre- and post-treatment, and the longer program would yield more significant results.

METHODS

There was a total of 870 child participants. Of 40 sites, 24 were selected for a 5-month treatment (TG1) while the remaining 16 sites received 3 months of treatment (TG2). Paired t tests and a mixed-model analysis of variance (ANOVA) were used to analyse pre- and post-psychological stress symptoms (PSS) for samples from both groups.

RESULTS

Separately, treatment group 1 (TG1) and treatment group 2's (TG2) paired t test yielded significant results (p < 0.001) for the decrease of PSS. The mixed-model ANOVA found that there were significant differences in total pre- and post-test PSS and a significant difference in PSS means over time.

CONCLUSIONS

Results indicated that there was a statistically significant decrease in reported symptoms in both treatment groups pre- to post-intervention and a significant difference in total symptoms over time. However, the findings do not indicate that the longer programming was statistically different compared to the shorter programming. The study presented had gaps in data, largely due to limits in research during the crisis. However, this paper provides a unique case study for challenges that can be faced for project evaluation in emergency settings.

HeART of Stroke: randomised controlled, parallel-arm, feasibility study of a community-based arts and health intervention plus usual care compared with usual care to increase psychological well-being in people following a stroke

INTRODUCTION

People often experience distress following stroke due to fundamental challenges to their identity.

OBJECTIVES

To evaluate (1) the acceptability of 'HeART of Stroke' (HoS), a community-based arts and health group intervention, to increase psychological well-being; and (2) the feasibility of a definitive randomised controlled trial (RCT).

DESIGN

Two-centre, 24-month, parallel-arm RCT with qualitative and economic components. Randomisation was stratified by centre and stroke severity. Participant blinding was not possible. Outcome assessment blinding was attempted.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults ≤2 years poststroke recruited via hospital clinical teams/databases or community stroke/rehabilitation teams.

INTERVENTIONS

Artist-facilitated arts and health group intervention (HoS) (ten 2-hour sessions over 14 weeks) plus usual care (UC) versus UC.

OUTCOMES

The outcomes were self-reported measures of well-being, mood, capability, health-related quality of life, self-esteem and self-concept (baseline and 5 months postrandomisation). Key feasibility parameters were gathered, data collection methods were piloted, and participant interviews (n=24) explored the acceptability of the intervention and study processes.

RESULTS

Despite a low recruitment rate (14%; 95% CI 11% to 18%), 88% of the recruitment target was met, with 29 participants randomised to HoS and 27 to UC (57% male; mean (SD) age=70 (12.1) years; time since stroke=9 (6.1) months). Follow-up data were available for 47 of 56 (84%; 95% CI 72% to 91%). Completion rates for a study-specific resource use questionnaire were 79% and 68% (National Health Service and societal perspectives). Five people declined HoS postrandomisation; of the remaining 24 who attended, 83% attended ≥6 sessions. Preliminary effect sizes for candidate primary outcomes were in the direction of benefit for the HoS arm. Participants found study processes acceptable. The intervention cost an estimated £456 per person and was well-received (no intervention-related serious adverse events were reported).

CONCLUSIONS

Findings from this first community-based study of an arts and health intervention for people poststroke suggest a definitive RCT is feasible. Recruitment methods will be revised.

TRIAL REGISTRATION NUMBER

ISRCTN99728983.

Creative art therapy to enhance rehabilitation for stroke patients: a randomized controlled trial

Objective:

To examine the efficacy of creative art therapy plus conventional physical therapy, compared with physical therapy only, in increasing cognitive ability, physical functions, psychological status and quality of life of stroke patients.

Design:

Randomized controlled trial with blinded assessor.

Setting:

An in-patient setting

Participants:

One hundred and eighteen stroke patients aged ⩾50 years who could communicate verbally.

Interventions:

All participants received conventional physical therapy five days per week. An intervention group received additional creative art therapy, twice a week for four weeks, in a rehabilitation ward.

Main outcomes:

Cognitive function, anxiety and depression, physical performance and quality of life were measured with the Abbreviated Mental Test, the Hospital Anxiety and Depression Scale, the modified Barthel Index scale and the pictorial Thai Quality of Life questionnaire, respectively.

Results:

Mean differences for the intervention group were significantly greater than the control group for depression (−4.5, 95% CI −6.5, −2.5, p< 0.001), physical functions (1.2, 95% CI 0.1, 2.3, p= 0.043) and quality of life (8.9, 95% CI 3.8, 13.8, p< 0.001).Compared with baseline measures, both groups experienced improved cognition, physical functions and quality of life and reduced anxiety and depression. Eighty-five percent of patients were satisfied with the creative art therapy and most reported improved concentration (68.5%), emotion (79.6%), self-confidence (72.2%) and motivation (74.1%).

Conclusion:

Creative art therapy combined with conventional physical therapy can significantly decrease depression, improve physical functions and increase quality of life compared with physical therapy alone.

'HeART of Stroke (HoS)', a community-based Arts for Health group intervention to support self-confidence and psychological well-being following a stroke: protocol for a randomised controlled feasibility study

INTRODUCTION

Over 152,000 people in the UK have strokes annually and a third experience residual disability. Low mood also affects a third of stroke survivors; yet psychological support is poor. While Arts for Health interventions have been shown to improve well-being in people with mild-to-moderate depression post-stroke, their role in helping people regain sense of self, well-being and confidence has yet to be evaluated. The main aim of this study is to explore the feasibility of conducting a pragmatic multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of an Arts for Health group intervention ('HeART of Stroke' (HoS)) for stroke survivors. HoS is a 10-session artist-facilitated group intervention held in the community over 14 weeks. It offers a non-judgemental, supportive environment for people to explore sense of self, potentially enhancing well-being and confidence.

METHODS AND ANALYSIS

Sixty-four people, up to 2 years post-stroke, recruited via secondary care research staff or community stroke/rehabilitation teams in two UK centres will be randomised to either HoS plus usual care or usual care only. Self-reported outcomes, measured at baseline and approximately 5 months postrandomisation, will include stroke-related, well-being, mood, self-esteem, quality of life and process measures. Analyses will focus on estimating key feasibility parameters (eg, rates of recruitment, retention, intervention attendance). We will develop outcome and resource use data collection methods to inform an effectiveness and cost-effectiveness analysis in the future trial. Interviews, with a sample of participants, will explore the acceptability of the intervention and study processes, as well as experiences of the HoS group.

ETHICS AND DISSEMINATION

National Health Service (NHS), Research and Development and University ethical approvals have been obtained. Two peer-reviewed journal publications are planned plus one service user led publication. Findings will be disseminated at key national conferences, local stakeholder events and via institutional websites.

TRIAL REGISTRATION NUMBER

ISRCTN99728983.