Visual abstract

Introduction

Parkinson’s disease (PD) is the 2^nd most common neurodegenerative disorder after dementia and the most prevalent neurodegenerative movement disorder [1]. Over 6 million people were diagnosed with PD worldwide in 2016, reflecting a 2.5-fold increase in prevalence over 30 years [2]. The increasing socioeconomic costs of PD (as the disease progresses) is driven by higher utilization of healthcare and the caregiver burden [3]. Key motor symptoms in people with PD include tremor, rigidity, bradykinesia/akinesia, and postural instability [4]. Nonmotor symptoms include depression, anxiety, constipation, rapid eye movement sleep behavior disorder, and olfactory dysfunction [4]. The standard care for people with PD includes pharmacological treatment using levodopa preparations and nonpharmacological therapies such as exercise, and physical and occupational therapy [5]. Levodopa remains the most effective symptomatic treatment of PD [6]. However, 40% of people experience side effects within 5 years of levodopa treatment, and its efficacy diminishes as the disease progresses [7]. Consequently, some people adjust their medication dosage without consulting a physician. Due to dopamine agonist phobia [8] or levodopa phobia [9] patients may need an alternative treatment.

In East Asia, various nonpharmacological interventions are utilized to manage symptoms of PD [10]. Approximately 76.4% of Korean people with PD have been reported to use complementary and integrative medicine (CIM) treatments to address issues such as levodopa phobia and polypharmacy [11]. The likelihood of using CIM increases as the disease duration increases or when the daily dose of levodopa is high [12]. Nonmotor features of PD include anxiety/panic attacks, mood swings, slowed thought processes, pain [13], obsessive-compulsive disorder, phobias, severe anxiety regarding functional disability [14], and depression manifesting from the prodromal stage to the later stages of PD [15]. Approximately 50% of people with PD experience nonmotor symptoms related to emotional dysregulation such as reactive depression, apathy, anxiety disorders, and mental/physical fatigue [16]. Art therapy, a nonpharmacological treatment, has been reported to positively impact psychological, neurological, and mental health of PD sufferers [17]. The art experience improves attention, creativity, and visual perception [18], and provides relaxation, reduced arousal, reactivation of positive emotions, and facilitates progressive exposure to traumatic memories [19]. Art therapy employs the use of various materials and modalities [17]. Through painting, people with PD can easily express their anxiety and fear by projecting their underlying negative feelings into their artwork to improve their mood and help relieve symptoms of depression and anxiety [17,20]. Clay therapy, (another modality of art therapy) offers the benefit of immediate sensory awareness through direct physical contact between the hands and the clay. It has been reported that people with PD who used clay therapy had a greater reduction in emotional distress, somatic dysfunction, and fewer negative ruminating thoughts than participants without PD [21,22].

The purpose of this study was to investigate the effectiveness of art therapy on people with idiopathic PD, to address the problems caused by pharmacological treatment of the disease such as dopamine agonist phobia, and to provide basic data for follow-up controlled observational studies. The primary objective was to examine the response of people with PD to art therapy in a real-world setting.

Materials and Methods

This study was approved by the Institutional Review Board of Daejeon University (no.: 1040647-2102-HR-002-03). The protocol was registered with the Clinical Research Information Service established by the Korea Disease Control and Prevention Agency (formerly Korea Centers for Disease Control and Prevention; CRIS; KCT0007483).

1. Study design

This study aimed to compare the nonmotor and motor symptoms, and overall quality of life of study participants before and after the art therapy intervention program to examine their response to treatment. The study was carried out in 9 participants who were diagnosed with idiopathic PD between May and August 2021 at a University Hospital of Korean Medicine in Daejeon. Written informed consent was obtained from all participants before the study began. Owing to the nature of the study, consent was obtained to publish the images created during the art therapy activities. Participants were screened according to the inclusion/exclusion criteria (see below).

A demographic survey of the participants (N = 9) was conducted and the selected study participants (N = 9) completed weekly art therapy sessions for 8 weeks (60 minutes per session; Table 1). This study did not adhere to the standardized qualitative research frameworks such as phenomenology or grounded theory. However, the responses of participants, observations on their participation, and their descriptions during art therapy were documented to report (a different approach to) qualitative analysis. Furthermore, during the study, verbal responses and nonverbal expressions of participants were recorded to provide a comprehensive view of the changes induced by art therapy.

2. Inclusion and exclusion criteria

The inclusion criteria for this study were as follows: (1) males and females who had been diagnosed with PD using the Mini-Mental State Examination questionnaire and scored ≥ 24; (2) those in PD Stages 1–3 of the Hoehn and Yahr Scale; and (3) those with no cognitive function problems who fully comprehended the detailed explanation of the study and made a voluntary decision to participate in the study and provided written informed consent for study participation.

The exclusion criteria for this study were as follows: (1) those with neurological conditions other than PD such as dementia, Huntington’s disease, or hydrocephalus; (2) those with gait disturbance due to suffering a stroke, brain tumor, or other brain diseases; and (3) any other individuals considered inappropriate to participate in the study.

3. Art therapy program

The art therapy program in this study was developed based on the Gestalt art experience and person-centered expressive arts therapy. The program was modified to account for the motor and nonmotor features of study participants, which was consistent with the goal of the program whereby participants would accept their current state and improve their socialization. An art therapist with expert understanding of art materials and tools planned the program and the intervention. The detailed procedures for each art therapy session are described in Supplementary 1.

4. Quantitative clinical outcome measures

To evaluate the nonmotor symptoms of PD, the non-motor symptoms scale (NMSS) for PD was employed [23]. The quality of life of patients with PD was assessed using the 39-item Parkinson’s disease questionnaire (PDQ-39) [24] and the EuroQol 5-dimension questionnaire (EQ-5D) [25]. To measure the improvement in motor function in PD patients, the unified Parkinson’s disease rating scale (UPDRS) was applied [26]. Additionally, the severity of PD was assessed using the Hoehn and Yahr staging scale and the Schwab and England activities of daily living (ADL) scale [27]. The detailed descriptions of the clinical assessment measures used in this study including the purpose, domains evaluated, and scoring criteria for each tool, are outlined in Supplementary 2. All outcome measures were assessed at the initial visit and at the 10^th visit, which was 8 weeks after beginning the art therapy. These assessments were conducted to better understand the effects of art therapy on people with PD.

5. Statistical analysis

In this study, nominal variables were expressed as frequency and percentages, and continuous variables were expressed as mean ± SD. The variables representing outcomes were analyzed using the Wilcoxon signed-rank test, which is a nonparametric test used to compare paired data before and after an intervention when the data are not normally distributed. A two-tailed test was performed and the significance level was set at 0.05. All statistical analyses were conducted using R software, Version 4.3.2 (R Core Team, 2023).

Results

1. General characteristics of participants

The demographic characteristics of the participants in this study were as follows: 6 women (66.7%) and 3 men (33.3%), with a mean age of 58.6 ± 4.57 years. The mean Hoehn and Yahr scale score for the participants was 1.4 ± 0.4. The mean duration of PD was 5.1 ± 2.4 years. Regarding previous experience of art therapy amongst the participants, 8 (88.9%) participants responded that they had participated in at least 1 art therapy program in a professional institution or as personal therapy after being diagnosed with PD. The mean duration of regular participation (at least once per week) in an art therapy program was 0.2 ± 0.4 years. All participants completed the study (Table 2).

2. Improvement in motor and nonmotor symptoms outcome measures

The total NMSS score for nonmotor symptoms of study participants was 79.3 ± 30.9 points at baseline (before participating in the art therapy program) and 59.8 ± 26.1 points after 8 weeks of art therapy intervention indicating a statistically significant improvement (p = 0.01). Statistically significant improvements were also observed in nonmotor aspects of daily living (UPDRS Part I) from 2.6 ± 2.1 points at baseline to 1.0 ± 1.6 points after 8 weeks of art therapy (p = 0.03). However, motor examination scores (UPDRS Part III) worsened over the study period indicating a decline in motor function. The score for the Schwab and England ADL showed a significant improvement in ADL from 84.4 ± 10.7 points at baseline to 88.9 ± 7.4 points after 8 weeks (p = 0.01). The PDQ-39 scores, a PD-specific quality of life questionnaire, and the EQ-5D and EQ-VAS scales, which assess general quality of life, showed improvement following art therapy, although these changes were not statistically significant (Table 3).

3. Qualitative analyses

The individual results from participation over the 8-sessions of art therapy program were collected (n = 9). Personal information that could identify the participants was edited or removed before presenting their artwork.

3.1. Self-portrait of a hand

At the end of this session, the participants made the following comments: “I became grateful and appreciated my hands,” “I was in pain and distress, so I expressed my anger in my drawing,” “I wanted to draw my hand beautifully, but I had tough times in my life, and so the hand in the drawing looks rough,” “Although my hand was shaking, I am determined to take care of myself as long as I can.” After they had completed their hand drawings, they commented that the drawings were “stereoscopic, brilliant, and they excited them.” They also said that they were not bothered by the crooked shape of their hands or the rough lines in the drawings (Figure 1).

3.2. Sharing emotions

The participants shared the following messages: “I feel a weight has been lifted off my chest,” “It would be fun to do this with my children as well,” “It was nice to be able to look back after writing down my negative/uncomfortable feelings,” “Sadness, tribulations, and pain are all part of life,” “I regret that I didn’t take care of myself; now I find it difficult to write words down because my arm hurts,” “I was able to release my stress today; it has been a long time since I had such an opportunity” and “It is important to surround yourself and spend time with good people” (Figure 2).

3.3. Self-portrait from the reflection in crumpled foil

The participants shared the following observations about their self-portrait: “It is nice to see myself smiling,” “Drawing was hard work but my portrait looks good from a distance,” “I look like my mother,” “I drew the portrait as a smiley face because I wanted to give a good impression,” “It looked somewhat distorted but it looked okay from some viewpoints. I thought it was what I would look like when I get healthy.” Most participants drew their portraits on the canvas in a vertical direction. In some cases, although they were wearing masks, they imagined themselves inside the mask. Some participants emphasized their wrinkles because their reflection clearly showed those wrinkles, whilst others modified their reflections seen on the foil to match their desired appearance. Despite finding it challenging to concentrate for an extended period on the distorted reflections, they tried to concentrate on the face reflected in the foil and depicted it across the entire canvas, and completed the drawing in a relatively short time (Figure 3).

3.4. Restoring self-esteem through repetitive self-affirmation and the name-letter effect

They wrote their names with thoughts of forgiveness and love for others, hope for healing, happiness now and in the future, and living the remaining part of their life for themselves. Some of them expressed their commitment to take care of themselves and some expressed their gratitude and love for their spouses. The participants conveyed that it was difficult to repeat the same movements for > 50 minutes. However, they said that they felt a sense of satisfaction that they were drawing with a pencil (Figure 4).

3.5. Drawing through collaborative communication and problem-solving

Participants indicated that this session was the most enjoyable of all the sessions because it involved being engaged throughout the entire process of drawing on a blank canvas: thinking what to draw, verbally expressing their thoughts, listening to others, accepting their suggestions, and drawing according to the instructions. Contrary to expectations of difficulty in articulating their thoughts, there were many complex exchanges such that the participant with the idea did not physically draw anything because the session timed out. Conversely, when drawing freely without suggestion from others, the participants showed a tendency to simplify the artwork by only coloring the outlines or writing some letters. When questioned, the participants responded that the reason for this difference was because they thought that they could ruin the drawing. Reflecting on the completed drawings, the participants commented: “this drawing is actually better than what I could have wished for.” “I do not like it because it looks like someone has made a scribble,” and “although it did not turn out as I wanted, I think this reflects what life is like” (Figure 5).

3.6. Finding a hidden object

During the process of crumpling and unfolding the foil, participants expressed opinions such as, “I do not know where to begin,” “it is difficult,” “it is extremely difficult,” and “it is hard to undo a tight knot.” Only 1 participant, who received positive feedback, commented, “this is fun.” The process of unfolding the foil took approximately 3 minutes. Excluding 2, the participants found this session challenging; however, they were able to complete the unfolding of the foil without tearing it. The abstract pictures drawn on the canvases (created from foil) included a rainbow, rays of sunshine, flowers, a giant gourd, a healthy person, a device that has a rocket attached to the base that allows a person to travel, and a clover. Participants showed significant interest in each other’s disease condition and improvement in symptoms, and identified relevant signs. They also described the each other’s artwork, “The drawing looks like stress in the brain” and, “It looks like cell replication and growth of living organisms” (Figure 6).

3.7. Timed croquis

In the process of identifying (whilst wearing a mask) features which characterized each other, they observed characteristic articles such as glasses and watches, and the color of the clothes worn, and even the number of buttons on items of clothing. Most of the participants showed a strong desire to improve the quality of their drawings, and applied effects to the lines for uniformity, selecting colors matching actual clothing, and highlighted specific body parts by painting or coloring the entire canvas. They expressed that they found it comfortable posing in front of people who understand symptoms of PD, although they felt a bit shy about being the center of attention. Overall, they felt the experience was enjoyable and not negative (Figure 7).

3.8. Collaborative drawing of a tulip by individuals with physical limitations

Regarding the comments related to drawing in an uncomfortable position or posture, participants expressed the following opinions: “It is a shame that I can’t even draw a simple object with my left hand,” “It was a difficult experience because I could not open my hand fully even though I had to,” and “It was hard, but I managed it when I concentrated.” Additionally, they chose bright colors and used a variety of colors and patterns to avoid monotony. The focus turned into depicting the sky, they also included an ivy (which symbolizes genuine affection), and despite the overall outline of the session being on tulips, the drawings reflected their love for art (Figure 8).

Discussion

In this study, 9 people with PD completed an art therapy program comprising 8 sessions. This program integrated drawing-based therapy with the benefits of direct contact between the skin and the materials, a feature commonly associated with clay therapy. Following the art therapy intervention, the overall NMSS and UPDRS I/IV scores improved. However, no significant improvements were observed in study participants’ quality of life as measured by PDQ-39 or EQ-5D scales. Qualitative analysis showed that art therapy positively impacted self-esteem and self-acceptance amongst the participants.

There is currently no cure for the PD. Levodopa remains the gold standard treatment for symptoms of PD [28]. However, around 40% of people with PD experience side effects from levodopa within 5 years of treatment [7]. One common complication is the wear-off phenomenon, which includes unpredictable motor fluctuations, prolonged off-phases, with symptoms such as rigidity, immobility, and tremors, and nonmotor symptoms such as depression, anxiety, and panic attacks [7,29]. Patients may develop dopamine agonist phobia [8] or levodopa phobia [9], leading them to adjust their medication doses (without physician guidance) to avoid side effects. Medications are available to be prescribed to treat levodopa-induced complications. Interestingly, a study has shown that exposure to polypharmacy (with 5 or more prescription drugs) increases the risk of developing PD in people who do not have PD [30].

In a review of 413 studies, it was determined that art therapy was clinically effective for psychological, neurological, and mental health conditions, and has been implemented as a non-nonpharmacological, complementary, and integrative therapy [17]. In 2021, a resting-state functional magnetic resonance imaging study investigated the effect of art therapy in participants with PD and reported improvements in visual-cognitive function, eye movements, and UPDRS scores as well as increased functional connectivity in the primary and secondary visual brain networks [30]. This study determined that art therapy positively impacted not only the motor and nonmotor symptoms of PD but also the psychological and cognitive states of participants (n = 18) [31].

Drawing and painting have been recognized as the most important elements of art therapy and have been shown to be effective at improving the mood of cancer patients because these modalities allow the projection of anxiety or phobia/fear onto the canvas [20,32,33]. Other studies have reported that clay art therapy helps reduce emotional and physical distress in people with PD [21,22]. However, there have been limited studies focusing on the effects of drawing and painting art therapy on people with PD. This current study adopted an art therapy program that combined painting and drawing therapy with the benefits of direct contact between the skin and the materials (a characteristic advantage of clay therapy).

The art therapy implemented had a positive effect on improving self-esteem and self-acceptance amongst participants. During Session 1, which involved the participant drawing their hand, they revealed that the activity allowed them to reflect on their lives and recognize the importance of self-love and care. During Session 3, where they drew self-portraits based on reflections in crumpled foil, the participants were able to recognize and accept their current state, although not as perfectly as they desired. Participants reported that although it was difficult to recognize their reflection on the crumpled foil, they still managed to fill the canvas and they used their individual and unique strategies. Some participants drew their portraits by either envisioning their ideal appearance or by focusing on the most prominent silhouette. Additionally, during the 7^th session, participants experienced being observed whilst managing their tremors and tried to change their perceptions based on positive feedback from others. Initially, participants were reluctant to disclose their illness to family and friends or to share their experiences about being sensitive to others looking at them or judging them. However, during the croquis session, they felt at ease with being observed because they were amongst individuals who understood their condition. Furthermore, they expressed that they enjoyed the feeling of being the center of attention. These feelings were reflected in Domain 8 of NMSS and suggested that art therapy statistically significantly enhanced self-esteem and self-acceptance in participants. During the initial interviews with the participants they revealed that they felt frustration and discomfort owing to deteriorating sexual function. However, after participating in the art therapy program, they were able to accept the discomfort related to their decreased sexual function. The findings indicated that the art therapy positively improved self-esteem and self-acceptance, and helped the participants overcome their frustration, rather than having a direct impact on sexual function or desire.

All sessions of the art therapy program in this study were held in groups and the participants attended the program once per week during the day. During the 60 minutes of the art-making process, the participants engaged in group discussions, which continued during additional social interactions after each session (< 80 minutes). In group therapy, it has been reported that the greater the similarity between group members, the stronger the social identity is amongst them [34]. Participants in this current study reported a high level of satisfaction from interacting with other participants, because they could easily empathize with each other and share experiences. Many people with PD have limited opportunities for regular social activities, and independently, there is a high incidence of mild dementia [35]. When discussing memorable or pleasant events, before starting art therapy, some participants in this current study mentioned that without these sessions, they would have had few chances to laugh or converse. These results suggested that regular interactions, through art therapy, with others who share similar experiences and interests may help alleviate nonmotor symptoms of PD by providing valuable social engagement and emotional relief.

In Session 2, participants applied a varying strength of force on a highly uneven canvas to color it; in Session 4, participants filled the canvas with drawings and wrote a word of their choice using erasers and repeated the process for 50 minutes; in Session 6, participants crumpled the foil, and unfolded it (without tearing) with concentration, and in the last session, participants drew in uncomfortable postures. All these experiences were considered to influence their ability to “maintain normality.” The participants commented: “whilst it was difficult to do the activity due to hand tremor, I managed it,” or “the process was somewhat tedious, but I completed it.” Even when they commented that they were, “not satisfied with having to draw during physical discomfort,” they expressed their satisfaction with the positive feedback they received from several other participants. Maintaining normality helps people with PD become more independent in their lives and better manage their symptoms [36]. Engaging in leisure and social activities, continuing work/job or physical activities serves as a significant motivator for people with PD to regain control of their lives and is crucial for coping with the loss of ADL [37]. Through the art therapy program, building on experiences that facilitate a sense of achievement in activities that required concentration or fine motor skills may have positively influenced the level of motivation/initiative in people with PD.

Art therapy can also help improve the nonmotor symptoms of people with PD. The total NMSS score decreased from 79.3 ± 30.9 points to 59.8 ± 26.1 points after 8 weeks, representing a significant change of 19.5 ± 4.8 (p = 0.01). It is considered that the social activities of people with PD also contributed to a positive change in nonmotor symptom outcomes. However, due to limited research to establish the minimal clinically important difference for NMSS in PD patients, the clinical significance of these results remains unclear and warrants further investigation. These findings demonstrate the magnitude of change in nonmotor symptoms following art therapy intervention, however, further research is necessary.

This study was carried out over a relatively short period of time, and long-term art therapy intervention is necessary for people with PD to determine improvement in motor symptoms potentially induced by art therapy. The UPDRS-III motor scale score worsened from 16 ± 7.5 to 20.3 ± 8.9 (p = 0.02) after 8 weeks, and there were no change in the progression stage of PD as measured by the Hoehn and Yahr stage. Further research with longer-term art therapy intervention is required to determine the longevity of improvements in motor symptoms. Furthermore, owing to a relatively short study period, it was difficult to determine the effect of art therapy on reducing dose escalation, the UPDRS-IV complication scores, or the on-off phenomenon. Therefore, art therapy programs or studies in the future should incorporate longer intervention periods to address these aspects. Additionally, whilst the art therapy program in this study originally focused on improving self-esteem, overcoming depression, and improving lethargy, the small sample size of the study made it difficult to analyze whether the improvement in psychological symptoms was directly correlated with symptom improvement, or was due to regular social activities rather than the effect of art therapy. Therefore, follow-up studies should include a larger sample size and a longer duration to enable quantitative analysis of whether psychological improvement are correlated with improvement in motor and nonmotor symptoms.

There are some limitations to this study. Firstly, to reflect the real-life of people with PD, participants were allowed to use their usual self-care and/or combination therapies, however, there were no control groups in this study. Therefore, it was not possible to ascertain whether the results of this study were solely attributable to the art therapy itself. The purpose and design of this preliminary study was to prescribe a treatment course in real-world practice by closely mimicking clinical settings (not to evaluate efficacy through a controlled setup). The results of this study can be used as basic reference data to design a follow-up, controlled study. Secondly, the challenge was in interpreting clinical significance of the treatment effects due to the lack of well-established minimal clinically important difference values for PDQ-39 and NMSS. Thirdly, owing to the lack of consistency in the art experience of all participants, it is unclear whether the symptom improvements observed in certain participants were influenced by their previous art experience. Future studies should include criteria related to participants’ art experience to ensure a more accurate assessment of the therapy’s effects. Lastly, the study originally planned to recruit up to 14 participants, which although small was determined as the maximum number of participants manageable by a single therapist in 1 session. However, only 9 participants were ultimately recruited. This small sample size may limit the generalizability of the findings. Future studies, with a larger sample size, are necessary.

Conclusion

A single-arm prospective observational study was conducted in people with PD who participated in an art therapy program consisting of 8 sessions. This study showed a statistically significant improvement in the NMSS scores for nonmotor symptoms. However, there was no statistically significant improvement in outcome measures for quality of life or complications. Qualitative analysis showed that art therapy had a positive effect on the mentation, behavior, and mood domain, including motivation/initiative of study participants. Therefore, art therapy might be considered a viable nonpharmacological option for the management of PD in clinical settings. However, given the short duration of this study, small sample size, and the lack of control groups, long-term, controlled, observational studies are recommended.

Supplementary Materials

Article information

Acknowledgments

This study is submitted as a revision and supplementation of the doctoral dissertation of the first author, Wangjung Hur.

Author Contributions

Conceptualization: HY. Methodology: WH, JL, and HY. Formal investigation: WH, JL, and HJ. Data analysis: MP and SP. Writing original draft: WH and JL. Writing - review and editing: WH, JL, HJ, MP, SP, and HY.

Conflicts of Interest

The authors declare that they have no conflict of interest. The funders had no role in the design of the study, data collection, analysis and interpretation, manuscript writing, or decision to publish the results.

Funding

This work was supported by 2 National Research Foundation of Korea grants funded by the Korean government (no.: RS-2019-NR042116 and RS-2022-NR070207).

Ethical Statement

This study was approved by the Institutional Review Board of Daejeon University (no.: 1040647-2102-HR-002-03). The protocol was registered with the Clinical Research Information Service at the Korea Disease Control and Prevention Agency (CRIS; KCT0007483).

Data Availability

Figure 1

The 1^st session. Self-portrait of a hand.

Figure 2

The 2^nd session. Emotional sharing.

Figure 3

The 3^rd session. Self-portrait from the reflection in crumpled foil.

Figure 4

The 4^th session. One word that I would not like to forget.

Figure 5

The 5^th session. Drawings resulting from help sought from others.

Figure 6

The 6^th session. Finding a hidden object.

Figure 7

The 7^th session. Timed croquis.

Figure 8

The 8^th session. Collaborative drawing of a tulip by individuals with physical limitations.

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