Research Article
Research Article
Research Article
Research Article
Expressive Arts Therapy Combined with Progressive Muscle
Relaxation following Music for Perioperative Patients with
Gynecological Malignancies: A Pilot Study
Correspondence should be addressed to Se-Ge Ma; [email protected] and Yan Huang; [email protected]
Received 26 November 2021; Revised 16 March 2022; Accepted 18 March 2022; Published 29 March 2022
Copyright © 2022 Xing Liu et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. We aimed to assess the impact of an expressive arts therapy combined with progressive muscle relaxation following
music on mental health (anxiety and hope) in patients with gynecological malignancies undergoing surgery. Methods. This was a
nonrandomized controlled trial. Eligible patients had a primary or recurrent gynecological malignancy scheduled to be treated
with surgery. The intervention consisted of three sessions (preoperation, postoperation, and predischarge) during the peri-
operative period. Firstly, before starting the first session of intervention, all patients completed three questionnaires including a
Hospital Anxiety and Depression Scale (HADS), a Herth Hope Index (HHI), and a State Anxiety Inventory (SAI), and the
intervention group patients also had to complete the SAI questionnaire again after completing the intervention. Secondly, after the
second session of intervention, all patients completed the SAI questionnaire, with the intervention group completed the SAI
questionnaire before the intervention. Thirdly, after the third session of intervention, all patients completed HHI and SAI
questionnaires, with the intervention group completed the SAI questionnaire before the intervention. Also, to subjectively rate the
benefit of expressive arts therapy, the intervention group additionally completed a separate, supplemental questionnaire. Results.
A total of 116 patients were enrolled and 110 included in the final analysis. No group differences were found for HHI scores
between the intervention and control participants (Cohen’s d � 0.19, P � 0.31), although there was a substantial improvement in
intervention participants’ HHI scores compared to the standard care control participants. There was a statistically significant
improvement in intervention participants’ SAI from preintervention to postintervention of preoperation (Cohen’s d � −0.23,
P � 0.002) and postoperation (Cohen’s d � −0.34, P ≤ 0.001). However, no differences were observed for the predischarge period
(Cohen’s d � −0.09, P � 0.118). Besides, a supplemental questionnaire indicated that 52 (98%) patients felt that expressive arts
therapy was beneficial. Conclusions. Expressive art therapy combined with progressive muscle relaxation under music may be of
some effect on alleviating perioperative anxiety in patients with gynecologic malignancies. Therefore, further relevant studies with
large samples and multicenters are urgently needed to provide a reliable evidence-based basis for perioperative psychological care
of patients with gynecologic malignancies and to promote rapid recovery of patients. It is recommended that further art therapy
studies to examine the impact of patient-tailored arts therapy interventions on spiritual well-being in patients with gynecological
malignancies, especially in the perioperative period.
2 Evidence-Based Complementary and Alternative Medicine
impairment; (3) patients combined with severe postopera- relaxation practice to empty and release themselves
tive complications; (4) participants withdrew from the study wholeheartedly.
at any point before the end of the study; and (5) the vacant Before the intervention, the intervention group were
content of filled questionnaire ≥20%. invited to complete the SAI questionnaire. Also, after the
intervention, all patients completed the SAI questionnaire.
The final session: i am discharged today. The interven-
2.3. Intervention. Based on the participants’ decisions, the tion was carried out one day before the discharge one-to-one
116 included patients were divided into the intervention at the bedside. The patients were provided with colored pens
group (59) and the control group (57). At the end of the and paper to draw and free write to record the current
study, four patients fell off in the intervention group and two feelings, such as expectations for the future, hospitalization
in the control group. The flow diagram of participant re- experience, saying to family members and medical staff, and
cruitment is shown in Figure 1. The control group used the vision of life after discharge.
conventional perioperative care. In addition to conventional Before the intervention, the intervention group were
perioperative care, the intervention group systematically invited to complete the SAI questionnaire. Also, after the
applied expressive arts therapy with three consecutive in- intervention, all patients completed HHI and SAI ques-
terventions: preoperation, postoperation, and predischarge. tionnaires and the intervention group additionally com-
The expressive arts therapy was performed by nurses who pleted a separate, supplemental questionnaire to rate the
had successfully completed coursework approved for benefit of expressive arts therapy (a scale of 1 to 10 : 1 being
60 hours of training credits in the expressive arts therapy and not beneficial and 10 being extremely beneficial) [22].
obtained expressive arts therapy certificate. All patients were
not allowed to receive psychological interventions or psy-
chotropic medication except the intervention during the
2.4. Assessments
study to avoid contamination. The expressive arts therapy
sessions were further described in detail below. 2.4.1. Hospital Anxiety and Depression Scale (HADS).
The HADS was developed by Zigmond and Snaith [24] in
2.3.1. Conventional Perioperative Care. The conventional 1983 to provide clinicians and scientists with a reliable,
perioperative used for the control group was as follows: valid, and practical tool for identifying and quantifying
perioperative routine nursing, psychological nursing, anxiety and depression in medical patients [25]. The scale
symptom management, and health education, including consisted of 14 items of seven rated anxiety and another
encouraging and comforting patients, establishing good seven depression (with possible ranges of 0–21 for each
nurse-patient relationships, and explaining the knowledge of subscale), making it easy to administer and well-accepted
the disease. [26, 27].
2.3.2. Expressive Arts Therapy Intervention. The expressive 2.4.2. Herth Hope Index (HHI). The HHI [28] was devel-
arts therapy intervention consisted of three consecutive oped by Herth in 1992, to measure a global, nontime
sessions: preoperation(T1), postoperation(T2), and predis- oriented sense of hope based on the multidimensional
charge(T3), duration was left to the patients’ decision. concept of hope as theorized by Dufault and Martocchio.
The first session: power and blessing. The intervention It consisted of three dimensions: (1) inner sense of
was carried out one day before the operation. It was group temporality and future, (2) inner positive readiness and
therapy that patients were encouraged to dance and expectancy, and (3) interconnectedness with self and
handcraft under music. The handicraft creations included others. The items were scored on a 4-point Likert-type
various forms of beads stringing, rope weaving, clay making, scale (1 � strongly disagree to and 4 � strongly agree) and
etc. Patients could freely choose one or more materials to calculated by summing each item’s score, with items 3 and
create their works to express their surgical blessings. Upon 6 reverse-scored. Scores range from 4 to 48, and a higher
completion, participants shared the content and meaning of value signifies a higher hope. The HHI had been widely
their work to express their feelings before surgery. used in research and clinical practice in different cultural
Before starting the intervention, all patients completed settings for various health areas [29, 30].
three questionnaires comprising of a Hospital Anxiety and
Depression Scale (HADS), a Herth Hope Index (HHI), and a
State Anxiety Inventory (SAI). Also, the intervention group 2.4.3. State Anxiety Inventory (SAI). The State-Trait Anxiety
were also invited to complete the SAI questionnaire again Inventory (STAI) was developed by Charles Spielberger and
immediately after the completing intervention. his co-authors. It was a brief, reliable, valid, self-report, 40-
The second session: enjoying the tranquil moment. The item psychological test for adults in research and clinical
intervention was carried out one day after the patient settings to assess feelings of immediate anxiety that an in-
returned to the ward after the operation one-on-one at the dividual feels at the current moment (state anxiety, SAI) and
bedside. The patient listened to music under the guidance of dispositional anxiety (trait anxiety, TAI) [31]. It consisted of
the nurse’s instruction, with relaxation. Patients were guided a 20-item state anxiety scale and a 20-item trait anxiety scale.
to follow the music and perform progressive muscle Higher scores reflected higher levels of anxiety.
4 Evidence-Based Complementary and Alternative Medicine
Excluded (n=450)
▶ Did not meet inclusion criteria
Randomly assigned
(n=116)
Allocation
Allocated to Art Therapy Allocated to Control Group
(n=59) (n=47)
Follow-up
Discontinued intervention (n=4) Discontinued intervention (n=2)
▶ Server postoperative complications (n=3) ▶ Server postoperative complications (n=1)
▶ Refused further participation after allocation (n=1) ▶ Refused further participation after allocation (n=1)
2.5. Statistical Analyses. The descriptive statistics were used to P � 0.31), although there was a substantial improvement in
create a demographic profile of the intervention and control the intervention group participants’ HHI scores compared
groups. Baseline equivalence between the two groups was to the control group participants. However, the patients’
examined by use of chi-square and independent samples t-test. HHI scores in both groups improved from preintervention
Since data met the criteria for parametric statistics, the dif- to postintervention of the three consecutive sessions with
ferences in the scores of HHI between the intervention and statistically significant differences (Table 2).
control groups were evaluated by use of an independent There was a statistically significantly greater improve-
samples t-test, and a paired samples t-test was applied to ex- ment in the intervention group participants’ SAI from
amine the within-group differences for the intervention group preintervention to postintervention of the first session
for SAI over the three consecutive sessions (preoperation, (preoperation, T1) and the second session (postoperation,
postoperation, and predischarge). All statistical computations T2), with p value 0.002 and ≤ 0.001, respectively. However,
were performed using IBM SPSS Statistics version 23.0 and there were no statistically significant differences from pre-
Microsoft Excel 2016. The P value of less than 0.05 was con- intervention to postintervention of the final session (pre-
sidered a statistically significant difference. The effect size was discharge, T3), with a p value of 0.118 (Table 3 and Figure 2).
calculated (expressed as Cohen’s d), with ‘small,’ ‘medium,’ and Besides, 55 patients completed the supplemental ques-
‘large’ effects (d � 0.2, 0.5, and 0.8, respectively) [32]. tionnaire that asked how beneficial the session to her on a
scale of 1 to 10. The supplemental questionnaire indicated
3. Results that 94.5% (52/55) of the patients felt that expressive arts
therapy was beneficial (score >5), and the remained (3/55)
3.1. Participant Characteristics. A total of 116 patients who rated the expressive arts therapy as 5.
consented to participate in the study were enrolled and
divided into either the intervention group (n � 59) or the 4. Discussion
control group (n � 57) and completed baseline measure-
ments. At the end of the study, four patients fell off in the Gynecological cancer patients bore a tremendous psycho-
intervention group and two in the control group. A total of logical and physiological burden, and the surgery itself as a
110 were included in the final analysis. There were no source of stressor may place an even heavier psychological
significant differences between the intervention group and burden on the patient. Therefore, medical staff must explore
the control group, which was an indication that patients in and evaluate other avenues to improve psychological well-
the two groups were comparable at baseline for socio- being for patients with gynecologic malignancies in the
demographic and clinical characteristics (Table 1). perioperative period. Overall, our study showed that ex-
pressive arts therapy combined with progressive muscle
relaxation following music administered by nurses were
3.2. Quantitative Results. There were no statistically sig- effective in reducing patients’ immediate anxiety. That
nificant differences between the intervention group and further consolidated the findings that art therapies can help
control group participants for HHI scores (Cohen’s d � 0.19, patients with malignancies alleviate anxiety levels and alter
Evidence-Based Complementary and Alternative Medicine 5
Table 2: Comparison of HHI scores between the two groups (mean ± sd; effect size).
Groups Preintervention (T1) Postintervention (T3) t Value P value Effect size (Cohen’s d) T3-T1
Expressive arts therapy group
22.87 ± 3.45 29.60 ± 2.29 12.64 ≤0.001 2.28 6.73 ± 3.95
(n � 55)
Standard care control group (n � 55) 24.00 ± 3.72 29.98 ± 1.86 12.14 ≤0.001 2.02 5.99 ± 3.65
t Value −1.648 −0.960 1.028
P value 0.10 0.34 0.31
Effect size (Cohen’s d) −0.31 −0.18 0.19
HHI, Herth Hope Index; sd, standard deviation; T1, treatment 1 (preoperation); T3, treatment 3 (predischarge).
the mood [33–36]. Therefore, these expressive arts therapies 4.1. Expressive Arts Therapy Combined with Progressive
can be considered effectively adjunct to traditional treat- Muscle Relaxation following Music for HHI. Hope is a belief
ments for gynecological cancer patients with anxiety during in the perseverance of life, regardless of the future outcome.
the perioperative period. Hope can alleviate pain and physical function obstruction
6 Evidence-Based Complementary and Alternative Medicine
Table 3: Comparison of SAI for the three consecutive sessions within the intervention group (mean ± sd; effect size).
The three sessions Preintervention Postintervention t Value P value Effect size (Cohen’s d)
Preoperation (T1) 59.91 ± 7.16 58.25 ± 6.88 3.33 P � 0.002 −0.23
Postoperation (T2) 61.02 ± 6.97 58.82 ± 5.86 4.92 P < 0.001 −0.34
Predischarge (T3) 57.93 ± 8.98 57.20 ± 7.32 1.59 P � 0.118 −0.09
S-AI, State Anxiety Inventory; T1, treatment 1 (preoperation); T2, treatment 2 (postoperation); T3, treatment 3 (predischarge).
P<0.05 P<0.05 P>0.05 most were still confident and hopeful about the future [43].
80.00 Secondly, the intervention effect was underpowered due to
the short duration of perioperative hospital stay. Hope is
70.00
complicated. Many factors affected a patient’s level of hope,
60.00
including interpersonal interactions, value evaluation,
achievable goals, positive personality traits, and spiritual
50.00 beliefs [44]. Therefore, understanding hope from a disease
perspective may allow healthcare staff to develop strategies
40.00 to better foster hope so that patients can cope with disease
positively [45]. Thirdly, the study was underpowered due to
30.00 the study sample, a larger study sample, significant between-
group differences may be obtained.
20.00
anxiety of patients with gynecologic malignancy undergoing anxiety and hope in various surgical populations with gy-
surgery, nurses need to comprehensively understand the necological malignancies.
patients’ readiness for discharge to make targeted inter-
ventions to effectively alleviate the patients’ predischarge 5. Conclusions
anxiety and thus improve the patients’ quality of life after
hospital discharge. Therefore, expressive arts therapy based This study did not find statistically significant differences in
on patient needs for perioperative patients’ anxiety states is hope between participants in the expressive arts therapy
crucial. However, evidence of art therapy in gynecological combined with progressive muscle relaxation following music
perioperative cancer patients was quite insufficient [21]. group and the standard care control group, although hope in
both groups improved from preintervention to post-
intervention with statistically significant differences. In the
4.3. Expressive Arts Therapy Combined with Progressive expressive arts therapy combined with progressive muscle
Muscle Relaxation following Music for Patient Experience. relaxation following music group, participants’ immediate
In our study, all but three patients receiving expressive arts anxiety was statistically significantly improved from pre-
therapy combined with progressive muscle relaxation fol- intervention to postintervention in preoperation and post-
lowing music evaluated the overall experience as very operation periods. Nevertheless, there were no statistically
positive, which further confirmed the current conclusions significant differences in the pre-discharge period. Besides,
for the benefit of art therapy [22, 35]. Expressive arts therapy most participants felt that expressive arts therapy was bene-
can be therapeutic in an expressing and ventilative manner, ficial. It is recommended that further expressive arts therapy
and it should be encouraged into the treatment practices for studies examine the impact of patient-tailored arts therapy
our patients. As reflected in our study, expressive arts interventions on spiritual well-being in patients with gyne-
therapy combined with progressive muscle relaxation fol- cological malignancies, especially in the perioperative period.
lowing music resulted in a significant impact that should not
be underestimated on perioperative anxiety in patients with Data Availability
gynecological malignancies.
The authors maintain full control of all the primary data and
agree to allow the journal to review the data upon request.
4.4. Limitations. The findings reported in the present study
must be considered in light of the study design and inter-
ventional approach. Some limitations of this study included
Ethical Approval
a small sample size. Since we had a limited number of eligible This study was approved by the Ethics Committee of West
patients at only an institution, a randomized sample was not China Second University Hospital, Sichuan University, with
feasible. That limited the applicability of the study across all the reference Medical Research 2020 Lun approval no. (160)
gynecological perioperative cancer patients. Another limi- on August 1, 2020.
tation was that nurses and participants could not be blinded
due to the treatment’s nature, which may have introduced Consent
bias into the results. Besides, for the questionnaire evaluating
the benefit of expressive arts therapy intervention, though Oral informed consent was obtained from the patients.
told that this survey was anonymous and to respond
truthfully, patients may have felt that they needed to respond Conflicts of Interest
positively to the treatment due to social desirability bias.
The authors declare that they have no conflicts of interest.
4.5. Implications for Future Studies. In oncology, art therapy Authors’ Contributions
as a supportive care intervention was a relatively new and
studies used a variety of study designs, making it hard to Xing Liu, Yan Huang, and Se-Ge Ma made substantial con-
draw conclusions [58, 59]. What was worse, studies in this tributions to the conception and design of the study. Jian-Hua
field contained some limitations, including our study. Ren gave suggestions and supports on study implementation.
Therefore, more randomized controlled trials with larger Sha-Sha Jiang and Yan Tan made contributions to the inter-
sample sizes are needed to establish the evidence of ex- ventions and data collection. All authors made contributions to
pressive arts therapy’s effectiveness for patients with gyne- data analysis and interpretation. Se-Ge Ma wrote the manu-
cological malignancies, particularly in the perioperative script. Yan Huang and Xing Liu revised the manuscript. All
period. The expressive arts therapy could possibly help authors approved the final version of the manuscript.
decrease symptoms of anxiety and depression in adult
cancer patients, and further research using stringent Acknowledgments
methods was urgently needed because of the heterogeneity
of the interventions and limited methodological quality of The authors thank Meng-Qin Zhang, Lu-Ling Li, Xin-Nan
the previous studies [60]. The findings of our study may Hou, and Yuan-Yuan Li for their assistance in patient en-
provide a basis for future research with regard to evaluating rollment and collection of data. The authors also thank the
the use of expressive arts therapy in the management of patients who participated in this study.
8 Evidence-Based Complementary and Alternative Medicine
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