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 Table of Contents  
BRIEF REPORT
Year : 2017  |  Volume : 12  |  Issue : 2  |  Page : 94-96

Use of art as therapeutic intervention for enhancement of hand function in patients with rheumatoid arthritis: A pilot study


1 Department of Community Physiotherapy, Sancheti Institute College of Physiotherapy, Pune, Maharashtra, India
2 Research Department, Sancheti Hospital, Pune, Maharashtra, India

Date of Web Publication27-Jan-2017

Correspondence Address:
Dr. Apurv P Shimpi
Department of Community Physiotherapy, Sancheti Institute College of Physiotherapy, Sancheti Healthcare Academy, Shivaji Nagar, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-3698.199130

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  Abstract 

Background: Conventional physiotherapy treatment for patients with rheumatoid hand emphasizes on single-plane movements and strengthening exercises directed toward improvement of function and prevention of deformities. This may be nondirective and lacks creativity and hence may predispose to a high attrition from therapy. The current study aimed to evaluate the efficacy of art as a creative therapeutic procedure for enhancement of hand functions, self-perception, and quality of life in patients with rheumatoid arthritis (RA).
Methods: A single-blinded, randomized controlled pilot study was conducted on 17 participants suffering from RA. The control group received conventional physiotherapy while the experimental group received art-based intervention with bimanual projects (viz., origami, paper quelling, clay modeling, and oil painting). Both groups received intervention for 45 min daily for 4 weeks. Pre- and post-interventional assessment was done using grip and pinch strength, Grip Ability Test (GAT), Jebsen–Taylor Hand Function Test (JHFT), Australian-Canadian Osteoarthritis Hand Index (AUSCAN), Michigan Hand Outcome Questionnaire (MHQ), and Health Assessment Questionnaire (HAQ).
Results: There was an improvement in hand functions (grip strength [P = 0.042], two-point pinch strength [P = 0.039], three-point pinch strength [P = 0.043], GAT [P = 0.043], JHFT [P = 0.043]), self-perception (AUSCAN [P = 0.043], MHQ [P = 0.043]), and quality of life (HAQ;P = 0.043) in art therapy patients which was similar to conventional therapy patients.
Conclusion: Art is an equally effective therapeutic intervention to conventional therapy for the enhancement of hand functions, self-perception, and quality of life in patients with RA.

Keywords: Bimanual tasks, hand performance, intrinsic muscle strength, physical rehabilitation, quality of life, rheumatoid hand, self-perception


How to cite this article:
Khedekar S, Shimpi AP, Shyam A, Sancheti P. Use of art as therapeutic intervention for enhancement of hand function in patients with rheumatoid arthritis: A pilot study. Indian J Rheumatol 2017;12:94-6

How to cite this URL:
Khedekar S, Shimpi AP, Shyam A, Sancheti P. Use of art as therapeutic intervention for enhancement of hand function in patients with rheumatoid arthritis: A pilot study. Indian J Rheumatol [serial online] 2017 [cited 2019 Jan 20];12:94-6. Available from: http://www.indianjrheumatol.com/text.asp?2017/12/2/94/199130


  Introduction Top


Rheumatoid arthritis (RA) is known to severely affect the hand, making it difficult for the patients to perform many gross and fine dexterous activities such as opening jar lids, turning door knobs, gripping small objects, and holding heavy objects.[1] The aim of treatment in patients with RA is to achieve pain relief, prevent joint damage and functional loss.[2] Applications such as physiotherapy and rehabilitation significantly augment medical therapy in patients with RA by preventing disability, increasing functional capacity, providing pain relief by educating the patients for prevention of comorbidities associated with the disease, and help them lead a better life.[2],[3] Hand exercise programs that include mobility and strengthening activities are important components of nonpharmacological management in people with RA.[2],[4] Conventional physiotherapeutic treatments comprise a set of tasks and functional training activities which aid in the betterment of the patient's basic and instrumental activities of daily living (ADL). These may include single-plane movements and strengthening exercises directed toward the improvement of function and prevention of deformities.[3] However, being a lifelong process, there may be challenges to the conventional form of therapy as far as its continuation on a regular basis is concerned.[5] Due to mundane nature of therapy, patient motivation is important to prevent withdrawal from therapy. An alternative to this can be sought by using bimanual components in fine arts as a therapeutic tool, because when people are provided with an opportunity to work with creative and artistic processes, they are able to create congruence between their illness and conceptual sense.[6] Thus, the current study aimed to evaluate the efficacy of art as a therapeutic procedure for enhancement of hand functions, self-perception, and quality of life in patients with RA.


  Methods Top


This single-blinded, randomized, controlled pilot study was conducted on 17 participants suffering from RA with hand involvement. Participants belonging to Class II and Class III by Steinbrocker criteria for classification of functional capacity in RA [7] and Class II and Class III by the American College of Rheumatology revised criteria for classification of functional status in RA [8] and who were not on a disease modifying antirheumatic medication (DMARD) or were on a stable DMARD regimen for 3 months or more were considered in the study and they were divided into two groups by computerized randomization. The pre- and post-interventional assessments were assessed by an independent blinded trained physiotherapist and were based on three hand function outcome measures, namely, (a) Grip strength, two-point and three-point pinch strength (b) Grip Ability Test (GAT), and (c) Jebsen–Taylor Hand Function Test (JHFT); two tests for self-perception of hand functions, namely (a) Australian-Canadian OA Hand Index (AUSCAN) and (b) Michigan Hand Outcomes Questionnaire (MHQ) and one test for the quality of life in patients, i.e., Health Assessment Questionnaire (HAQ). In the present study, the self-reported HAQ was used to assess and understand the disease activity in the studied population. We considered this more relevant than the disease activity score as there is dissimilarity between patient's perception of their disease severity to the physician's perception and thus considered patient's perception more relevant. The control group (n = 9) received conventional physiotherapy while the experimental group (n = 8) received art-based intervention with bimanual projects (namely, origami, paper quelling, clay modeling, and oil painting) [Figure 1] for 45 min daily for 4 weeks (three supervised sessions interspersed with three unsupervised sessions per week and with 1 day given for rest). Intragroup analysis was performed using Wilcoxon signed-rank test while intergroup analysis was performed by Mann–Whitney U-test with alpha set at ≤0.05 at 95% confidence interval (SPSS 17, IBM Corporation, USA).
Figure 1: Using art therapy in the form of (a) origami, (b) paper quelling, (c) oil painting, and (d) clay molding

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Ethical approval

The study was approved by the ethics committee of the institute. Informed written consent was obtained from all patients prior to their enrollment in this study.


  Results Top


[Table 1] compares the differences between both the groups for hand function, self-perception of pain, and quality of life, which were found to be equally effective in both the groups (P > 0.05).
Table 1: Comparison between both groups for mean difference values in the hand function, self‑perception, and quality of life parameters postintervention

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Of the 17 participants, three participants in the experimental group and four in the control group discontinued intervention. The remaining participants were reassessed after 4 weeks. There was an improvement in hand functions in both the groups as follows: art therapy group (grip strength [P = 0.042], two-point pinch strength [P = 0.039], three-point pinch strength [P = 0.043], GAT [P = 0.043], JHFT [P = 0.043]), self-perception (AUSCAN [P = 0.043], MHQ [P = 0.043]) and conventional therapy group (grip strength [P = 0.043], two-point pinch strength [P = 0.042], three-point pinch strength [P = 0.043], GAT [P = 0.043], JHFT [P = 0.043]), self-perception (AUSCAN [P = 0.043], MHQ [P = 0.043]). Similar results were found for quality of life in art therapy group (HAQ; P = 0.043) and conventional therapy group (HAQ; P = 0.042).


  Discussion Top


Conventional exercises for the hand are indicated to maintain joint range of motion, improve muscle strength, prevent ankylosis of reducible deformities, and reduce functional incapacity.[3],[4] Manual activities have proven to be effective on morning stiffness, pain, and functional capacity.[2] Although we agree that training in routine tasks and ADLs would be of importance for the patients, we believe that by involving them in a creative component may not only help improvise their hand function, but also raise their self-esteem, prevent attrition, and maintain adherence to the therapeutic regimen, to have a longitudinal benefit on their disease status.[6] In the present trial, art therapy consisted of a sequence of manual tasks and activities which used the hand in a similar fashion to the conventional treatment protocol.[4] But, rather than focusing on the routine tasks, it focused on the application of skilled performance.[1] Effectiveness of art as therapy could be attributed to the fact that it involves fine bimanual motor dexterity, gross motor function, strength, trunk stability, visual–motor co-ordination, and creativity. All the four techniques used in art promoted the use of isolated finger movements, helped strengthen thumb-index web space, intrinsic muscles, lateral pinch grip and rotations, develop stable arches within the hand, and encouraged the use of asymmetrical motor patterns of functions of the two sides of the hand along with providing a mental and physical stimulus. It also encouraged the patients to carry out tasks in multiple planes and axis promoting combined movement patterns of the upper extremity.[1] “Art Therapy” in itself complemented the biomedical view by focusing not only on sickness and symptoms themselves, but also on the holistic nature of the person.[6]

The present study found that art is an equally effective therapeutic intervention for the enhancement of hand functions, self-perception, and quality of life in patients with RA. Use of arts in healing complimented the medical view in bringing emotional, somatic, artistic, and spiritual dimensions to learning.[9] It can also prove to be an effective medium for outlet of feelings such as anger, frustration, depression, and sadness, which can be observed in chronic, longstanding disease conditions such as RA.[10] Nonspecific conventional exercises can be monotonous for the patients,[4] whereas art therapy can be equally effective and interesting as it encourages patients by creating varied opportunities that revolve around tasks and activities which help them improve their hand function.[9]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Srikesavan CS, Shay B, Robinson DB, Szturm T. Task-oriented training with computer gaming in people with rheumatoid arthritisor osteoarthritis of the hand: Study protocol of a randomized controlled pilot trial. Trials 2013;14:69.  Back to cited text no. 1
    
2.
Cooney JK, Law RJ, Matschke V, Lemmey AB, Moore JP, Ahmad Y, et al. Benefits of exercise in rheumatoid arthritis. J Aging Res 2011;2011:681640.  Back to cited text no. 2
    
3.
Kavuncu V, Evcik D. Physiotherapy in rheumatoid arthritis. MedGenMed 2004;6:3.  Back to cited text no. 3
    
4.
Buljina AI, Taljanovic MS, Avdic DM, Hunter TB. Physical and exercise therapy for treatment of the rheumatoid hand. Arthritis Rheum 2001;45:392-7.  Back to cited text no. 4
    
5.
Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Man Ther 2010;15:220-8.  Back to cited text no. 5
    
6.
Stuckey HL, Nobel J. The connection between art, healing, and public health: A review of current literature. Am J Public Health 2010;100:254-63.  Back to cited text no. 6
    
7.
Steinbrocker O, Traeger CH, Batterman RC. Therapeutic criteria in rheumatoid arthritis. J Am Med Assoc 1949;140:659-62.  Back to cited text no. 7
    
8.
Hochberg MC, Chang RW, Dwosh I, Lindsey S, Pincus T, Wolfe F. The American College of Rheumatology 1991 revised criteria for the classification of global functional status in rheumatoid arthritis. Arthritis Rheum 1992;35:498-502.  Back to cited text no. 8
    
9.
Hajar R. Art and Healing. Heart Views 2015;16:116-7.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Ettun R, Schultz M, Bar-Sela G. Transforming pain into beauty: On art, healing, and care for the spirit. Evid Based Complement Alternat Med 2014;2014:789852.  Back to cited text no. 10
    


    Figures

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    Tables

  [Table 1]


This article has been cited by
1 Exercise for rheumatoid arthritis of the hand
Mark A Williams,Cynthia Srikesavan,Peter J Heine,Julie Bruce,Lucie Brosseau,Nicolette Hoxey-Thomas,Sarah E Lamb
Cochrane Database of Systematic Reviews. 2018;
[Pubmed] | [DOI]



 

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