Creative Arts-Based Therapies for Stroke Survivors: A Qualitative Systematic Review

Oh god, trying to make survivors feel better about their disabilities rather than solving those disabilities.
Creative Arts-Based Therapies for Stroke Survivors: A Qualitative Systematic Review 

Temmy Lee Ting Lo¹, Janet Lok Chun Lee¹ and Rainbow Tin Hung Ho^1,2,3*

• ¹Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, Hong Kong
• ²Centre on Behavioral Health, The University of Hong Kong, Hong Kong, Hong Kong
• ³Sau Po Centre on Ageing, The University of Hong Kong, Hong Kong, Hong Kong

Background: Stroke is a life-threating cerebrovascular disease. Without proper and immediate treatment, it can cause long-term disabilities and even death. While current rehabilitation focuses on functional needs, it does not fully address the psychosocial issues. Creative arts-based therapies, however, may have the potential to be of assistance.

Methods: A systematic review was conducted to synthesize the qualitative findings of the stroke survivors' positive and negative experiences in participating in creative arts-based therapies. A systematic literature search was conducted across diverse databases. A thematic synthesis was adopted to analyze the results from different qualitative studies and mix-method studies.

Results: Among the 367 studies extracted from various databases, 11 studies met the inclusion criteria and were of acceptable quality. The following five analytical themes were identified: functional restoration, psychological support, social engagement, spiritual experience, and short-comings and barriers.

Conclusion: Creative arts-based therapies have demonstrated their strengths in addressing psychosocial needs for stroke survivors. Different art modalities are perceived to be useful in achieving different therapeutic goals. Therapies based on a single art modality or combined modalities have different specialties and characteristics. Further research is needed to demonstrate the differential benefits or special advantages of using single or multiple art modalities as well as having qualified therapists in creative arts-based therapies.

Introduction

Stroke is a severe cerebrovascular disease. The World Health Organization (WHO) defined stroke as a disease that has “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin” (WHO MONICA Project Investigators, 1988). Without immediate and proper treatment, it can cause permanent physical disabilities such as paralyzed limbs, or even death. There are three main types of stroke, namely, ischemic stroke, hemorrhagic stroke, and transient ischemic attack (TIA). According to the American Heart Association (2018), ischemic stroke occurs when there is a blockage in the blood vessel which supplies blood to the brain. Hemorrhagic stroke refers to the fracture in a weakened blood vessel in the brain. Transient ischemic attack (TIA), also named “mini-stroke,” occurs when there is a temporary obstruction in the blood vessel(s) of the brain.

Current Situation of Stroke

According to the latest global statistics, the prevalence rate of stroke was approximately 25.7 million and was the second leading cause of death in 2013 (Benjamin et al., 2017). Although older people have a higher risk of stroke, the onset of stroke among people aged 20–64 years has increased by 25% from 1990 to 2010 worldwide (Feigin et al., 2014). In the United States, around 795,000 people experience a new or recurrent stroke every year. Stroke is also the fifth leading cause of death and the leading cause of severe long-term disabilities in the United States (Benjamin et al., 2017). In Hong Kong, there are ~2 million patients with chronic illnesses and 2.2% of them are stroke patients (Census Statistics Department, 2015). Every year, ~3000 people die of stroke (Hospital Authority, 2018). Cerebrovascular diseases, including stroke, are the fourth leading causes of death in Hong Kong (Centre for Health Protection, 2018). These statistics indicate that the world is now facing a grave challenge with an increasing number of stroke survivors, thus more resources are needed for rehabilitation and post-stroke support.

Current Rehabilitation for Stroke Survivors

Current rehabilitation for stroke survivors depends heavily on physiotherapies, occupational therapies, and speech therapies. These rehabilitation programs are essential for stroke survivors as they aid in functional recovery. Physiotherapy, also recognized as physical therapy, focuses on the movement and physical function of patients and aims at the maintenance, development, and restoration of mobility (World Confederation for Physical Therapy, 2017). The main goal of occupational therapy is to facilitate patients to participate in their daily life activities and enhance their self-autonomy (World Federation of Occupational Therapy, 2012). Speech therapy aims at treating the patients' speech, language, and swallowing problems and at enhancing the patients' verbal communication and swallowing abilities (American Speech-Language-Hearing Association, 2018). Functional recovery is of utmost importance in stroke rehabilitation, especially during the first 6 months after the onset of stroke. The sudden loss of physical ability as well as the changes in various aspects of life caused by stroke also trigger psychological distress, social withdrawal and confusion in the meaning in life (Knapp et al., 2000; Yeung et al., 2011), which together need to be further addressed. These psychosocial and spiritual needs are also suggested to be crucial for the quality of life for stroke survivors (Katona et al., 2015). Enhancing the post-stroke quality of life has therefore been increasingly emphasized in recent years, in particular, in the United States (American Heart Association, 2013) and Australia (Australian Stroke Foundation, 2008). Due to their non-intrusive processes, therefore, non-pharmacological approaches, in particular, have been drawing considerable attention. Among them, creative arts-based therapies, which are mostly playful and without side-effects, have been recommended for stroke survivors. Different art modalities are also being suggested to be useful in stimulating different parts of the brain, and the stimulations from diverse art forms may further enhance the neuroplasticity in the brain and this may be helpful for facilitating the recovery process after stroke (Demarin, 2017). In addition, neurological evidence has shown that regularly listening to music after stroke may lead to structural changes in the brain among stroke survivors, and these structural changes may, in turn, relate to improvements in cognition (Särkämö et al., 2014). Moreover, engaging in a regular visual arts intervention has also been proven to facilitate the spatial improvement in functional connectivity in certain parts of the brain which may be associated with the psychological resilience in adults (Bolwerk et al., 2014). Apart from the above evidence, dance movement has also been suggested as an innovative approach for the rehabilitation for stroke survivors, due to its nature of engaging both physical and cognitive functions, dance may thus have the potential to tackle both the physical and cognitive impairments simultaneously (Dhami et al., 2015).