Efficacy of a Virtual Reality Rehabilitation Protocol Based on Art Therapy in Patients with Stroke: A Single-Blind Randomized Controlled Trial

Abstract

Background: Art therapy has a long history of applications in cognitive and motor rehabilitation. More recently, a growing body of scientific literature has highlighted the potential of virtual reality in neurorehabilitation, though it has focused more on the technology itself than on the principles adopted in digital scenarios.

Methods: This study is a single-blind randomized controlled trial conducted on 40 patients with stroke, comparing conventional therapy (physical therapy for the upper and lower limbs, for posture and balance, cognitive therapy, occupational therapy, speech therapy, and specific therapy for swallowing, bowel, and bladder dysfunctions) to a protocol in which the upper limb physical therapy was substituted with art therapy administered by means of virtual reality exploiting the so-called Michelangelo effect.

Results: After 12 sessions, patients in the virtual art therapy group showed a significantly greater improvement in independence in activities of daily living, as assessed by the Barthel Index (interaction of time and group: p = 0.001). Significant differences were also found in terms of upper limb muscle strength (Manual Muscle Test, p < 0.01) and reduction in spasticity (Ashworth scale, p = 0.007) in favor of the experimental group. In the virtual art therapy group, the effectiveness of the intervention was significantly correlated with patient participation (Pittsburgh Rehabilitation Participation Scale: R = 0.41), patient satisfaction (R = 0.60), and the perceived utility of the intervention by the therapist (R = 0.43).

Conclusions: These findings support the efficacy of virtual art therapy leveraging the Michelangelo effect. Further studies should also focus on cognitive domains that could benefit from this type of approach.

Keywords: art therapy; cerebrovascular accident; neuroaesthetics; neurological rehabilitation; neurorehabilitation.

Figure 1

The figure illustrates a virtual art therapy example. The left panel depicts a person wearing a VR headset and holding the Oculus controller in her right hand. The right panel presents the first-person perspective within the virtual environment, where the virtual canvas is occluded by white pixels. The green spherical brush (placed in the same position of the joystick grasped by the participant) is used to remove the white pixels, revealing the underlying image.

Figure 2

Mean ± standard deviation of Barthel Index pre- and post-treatment for Experimental Group (EG, in blue) and Control Group (CG, in red).

Figure 3

Box whiskers plot of Manual Muscle Score for shoulder abduction (blue bars), elbow flexion (green bars), and pinch (yellow bars) pre- and post-treatment for Experimental Group (EG, on the left) and Control Group (CG, on the right). The boxes represent the distance between 1st and 3rd quartiles and contain the medians (wide black lines), whereas the black whiskers represent 1.5 times the interquartile ranges, with values out of this range reported as circles.