Prescribing art therapy for Parkinson's disease

Art therapy improved brain connectivity in patients with Parkinson’s disease, suggesting that creating art may help treat it and other neurodegenerative diseases.

Sep 02, 2021
Stephanie DeMarco, PhD
Prescribing art therapy for Parkinson's disease

They braved the slushy streets after snowstorms and the cacophony of Manhattan rush hour traffic. Some pushed walkers or rolled wheelchairs. Others walked through the doors, looking no different than anyone off the street.

As they took their seats around a long table in one of New York University (NYU) Steinhardt’s art buildings, the outside world faded into one of pastels, watercolors, and clay. With blank paper taped to the table, and paint brushes fanned out in a can like a bouquet, they picked their tools and faced the diagnosis that brought them together: Parkinson’s disease.

In one of the first clinical trials of its kind, NYU neurology researchers and art therapists investigated how art therapy affected the visuospatial regions of the brain and the psychological wellbeing of people with Parkinson’s disease (1).

“It just takes you out of the disease,” said Andrea Casson, a participant in the clinical trial. “Parkinson’s disease is feeling like you're losing control every day, and this reminds you that you're not.”

Andrea Casson painted “PD Dance in Art Therapy a la Keith Haring.”
Credit: Andrea Casson

Art therapy successfully reduces anxiety and depression, but scientists are also finding that it increases brain connectivity and relieves symptoms associated with neurodegenerative diseases like dementia, Alzheimer’s disease, and Parkinson’s disease.

Over the past 20 years, clinicians noticed that Parkinson’s disease patients administered dopamine treatment often experienced an increased desire to produce art. Additionally, many Parkinson’s disease symptoms impact visual processes such as depth perception, spatial relationships, and contrast sensitivity. While the results are preliminary, this recent trial showed that art therapy improved numerous visual symptoms and increased functional brain connectivity in the visual systems of patients with Parkinson’s disease. The results suggest that art therapy may offer a complementary approach for treating the symptoms of Parkinson’s disease and potentially other neurodegenerative disorders.

Dopamine lights the artistic spark

In Parkinson’s disease, neurons in a region of the brain called the substantia nigra begin to die, leading to a reduction in the amount of dopamine produced in the brain. What causes Parkinson’s disease isn’t entirely clear, and there is no cure for the neurodegenerative disorder.

Loss of dopaminergic neurons in the brain eventually leads to the typical motor symptoms associated with Parkinson’s disease: tremors, slow movements, stiffness, and balance problems. But people can also experience non-motor symptoms of Parkinson’s disease up to 20 years before motor symptoms arise.

“There are changes with sleep, changes with mood, [and] changes with swallowing that can have a huge impact on your life,” said Alby Richard, a clinical neurologist at the University of Montreal who works with patients with movement disorders including Parkinson’s and Huntington’s diseases. Patients can also experience a loss of smell, constipation, vision problems, and eventually cognitive decline as the disease progresses.

“It's a disease that involves almost every area of the brain, directly or indirectly,” Richard said.

To treat their motor symptoms, patients with Parkinson’s disease usually begin dopamine replacement therapy. While dopamine is important for controlling movement and tremor, it also acts in brain circuits important for reward behaviors, parts of the sensory system, and decision making.

“By basically turning a firehose on and having [patients] ingest larger and larger amounts of dopamine to control their symptoms, it's not surprising that you're probably going to see changes in those other functions,” said Richard.

In the late 1980s and 1990s, doctors started to notice that their patients with Parkinson’s disease on dopamine replacement treatments suddenly became very creative.

Creating art like this sculpture has helped Rita, a patient in the art therapy clinical trial, face her Parkinson's disease diagnosis.
credit: rita

“They started drawing everywhere, and they'd never done it before in their life. Or suddenly, their style completely changed. They became an abstract expressionist overnight, whereas before they were a hyper-realistic painter,” said Matthew Pelowski, a professor of Psychology of Cognitive Neuroaesthetics at the University of Vienna.

“Quite often, the patients themselves say it was totally the drugs,” he added. Some patients even lied to their doctors about their current medication dose because a higher one made them feel more creative. One case study reported that when doctors increased a patient’s dosage of dopamine treatment, he went from occasionally drawing for fun to creating two new pastel drawings almost every day (2).

But the act of creating art involves more than just dopamine circuits.

When someone makes an artistic choice, Richard explained, “what you're implicating is a concert of activity between your primary sensory areas like your primary visual cortex, your auditory cortex [with] your memory areas, your emotional areas, and also the areas that are responsible for motivation and reward.”

All of these processes pinpoint to specific regions or structures in the brain. But, Richard said, if you were to draw lines connecting them, “what you'd see is a web of circuits that involves more or less the whole brain.”

One of those systems is the visual system, and so far, it has evaded treatment in patients with Parkinson’s disease.

An artist’s eyes

To be able to move somewhere, it is helpful to see the surroundings. But people with Parkinson’s disease can have difficulty discriminating between colors and adapting to dark and bright lighting conditions. They often experience irregular eye movements, have impaired motion perception, and have an altered perception of their personal space.

Difficulty perceiving objects in the environment can lead to a common Parkinson’s disease symptom: freezing gait. Patients suddenly feel like their feet are glued to the ground; when they try to move, this can lead to a fall.

“It can be dangerous, and it's very disabling,” said Alberto Cucca, a clinical neurology researcher at NYU Langone and a senior author of the art therapy clinical study.

Because freezing gait often occurs while patients walk through narrow spaces, find themselves in a crowd, or when they need to change direction quickly, scientists think that this symptom depends on the visual perception of a person’s surroundings. Freezing gait and other associated visual impairments can impact a patient’s ability to drive, read, and simply walk, becoming a substantial detriment to their daily lives.

Andrea Casson, a patient in the art therapy clinical trial, continued painting after the end of the trial.
Credit: Andrea Casson

“If we can improve somehow those visual functions that are very important to influence the way we move, the hope is that we can really have an impact on our patients’ quality of life and motor function,” Cucca said.

To do this, Cucca and his colleagues took a cue from art.

For centuries, visual artists have mastered the portrayal of visual features such as perspective, depth, and scale onto a flat surface like a canvas or a wall. In doing so, they developed a deep understanding of the spatial relationships between objects and how they fit into a scene — features that patients with Parkinson’s disease have difficulty perceiving.

“If there is also this potential element of recruitment and training of visual functions that we know can be affected in patients with Parkinson’s, why don't [we] look specifically at the effects of an art therapy intervention aimed to improve those visuospatial skills,” said Cucca.

Art therapy for Parkinson’s disease

There have been studies investigating the effectiveness of art therapy for Parkinson’s disease and other neurological conditions, but they have been small and exploratory for the most part. The results, however, look promising. A 2010 study found that Parkinson’s disease patients experienced improved psychological symptoms after participating in art therapy (3). Another study using clay as the art medium reported that patients with Parkinson’s disease experienced a significant improvement in hand dexterity, self-expression, mood, and quality of life after the therapy (4).

Although not conducted with Parkinson’s disease patients, an art therapy clinical trial showed that people with age-related cognitive decline experienced improved memory and had increased cortical thickness in the right middle frontal gyrus region of their brains, a region devoted to reorienting attention to an external stimulus (5). These changes in brain structure significantly correlated with the improved memory results.

In collaboration with Ikuko Acosta, the director of the art therapy program at NYU Steinhardt, Cucca and his team recruited patients with all stages of Parkinson’s disease to participate in the art therapy study.

When Casson heard about the trial in an email from her neurologist’s office, she thought that it sounded like a fun thing to try.

“I really enjoy doing [art], but I literally have no talent,” she laughed. “It was going to be one semester, so if I hated it, how bad could that be?”

Before beginning art therapy, patients and healthy age-matched control participants underwent a series of tests that probed their visuospatial functions. The scientists tested their ability to discriminate between large and small stimuli. In real-life settings, this capacity helps us recognize small details against a distracting or noisy background. 

The team also tested the participants’ visual reaction times and their ability to recognize a visual stimulus regardless of the orientation in which it was presented. Using functional magnetic resonance imaging (fMRI), the team assessed brain connectivity in both the patients and healthy controls.

And then, it was time for art.

Under the direction of Acosta and her fellow art therapists, the patients focused on their first assignment: draw a house, a tree, and a person. They could arrange these features in any way that they wanted, as long as their drawing included all three.

For these pre-therapy assessments, the art therapists created a numeric scale to assess features such as line pressure and how the participants arranged the objects in space in addition to qualitative descriptions.

From then on, the patients spent two 90-minute sessions per week creating art with a range of materials from acrylic paints to watercolors to dioramas.

“When we started the first few sessions, I was saying to myself, ‘so where's the therapy?’ But it's really in every little detail: the way they structure the sessions, the questions or the challenges they present, [and] the materials that are being used,” said Tamar Gisis, a patient in the trial.

Rita painted a portrait including Parkinson’s disease medications.
Credit: Rita

For many of the patients, it was their first time meeting other people with Parkinson’s disease. One patient, Rita, who asked to go by her first name only, found that meeting the other trial participants helped her confront her Parkinson’s disease diagnosis.

“There were some participants who are at a much more advanced stage than I am, and it's something that's very hard to see and to deal with,” she said. “But I have to say that being in the group helped me accept the fact that I do have this disease. Because until then, without having anyone else in the situation around me, it was easy to be in denial.”

Acosta and her team encouraged the participants to talk about the meaning behind their artwork. The patients found themselves just as often talking about why they chose a particular shade of blue as they did about their diagnosis.

Casson appreciated the supportive environment of the art therapy sessions. “It was definitely a space where I didn't care if I trembled, dropped, or fell off balance,” she said. “I had never experienced that before.”

At the end of the 10-week session, the researchers administered the same neurological tests and the art assessment as at the beginning.

The effects of the art therapy were undeniable. Patients drew with more pressure, indicating greater confidence. They also exhibited better spatial awareness, adding depth and connecting elements in their drawings. And the neurological data were just as positive. 

“We were thrilled and excited to see that according to our preliminary data, patients’ visual function improved,” said Cucca. The fMRI data showed that “there is an increased connectivity in areas of the brain that are involved with the processing of visual stimuli,” he added. While Cucca and his team did not test the healthy controls in the art therapy intervention, they plan to do so in a follow-up trial.

But how can art therapy lead to changes in the brain?

“We are wondering why this improvement happened because art therapy doesn't cure people, particularly people [who have] Parkinson’s,” Acosta said. “We don't expect that we're going to be fixing their neurological system, nothing like that. But it's coming from the concept of brain plasticity. The brain can be retrained.”

The brain is a dynamic organ. While many once thought that when a portion of the brain is damaged, nothing can be done, scientists know that’s not the case. There are numerous examples of diseases where different parts of the brain compensate for the function of the regions that are damaged, Richard explained.

“We just have to leverage that in the sense of Parkinson's and creative interventions because it could be a really potent way to engage a neuroplastic process,” he said.

“Creating art takes a lot of thought. We don't just throw paint on paper or just draw lines,” Rita agreed. “It forces the brain to work in different ways.”

Creating new art

Since the completion of the trial, many of the participants have continued creating art. Gisis discovered an interest in three-dimensional art, which she combines with her love of singing to produce a soundtrack for interacting with her art pieces. In addition to painting, Rita has taken up stone sculpting. 

For Casson, art has become an important way for coping with her Parkinson’s disease symptoms. “If I'm feeling particularly off, if I pull out paints, my body calms down, and my symptoms calm down,” she said. “Art has been definitely a place of respite and calm.”

With high demand from the study participants, Acosta and her team set up community-based art therapy sessions twice a week, where the former clinical trial participants can come together to work on their independent art projects and share their progress. Attendance has remained strong, even when they switched to a virtual format during the COVID-19 pandemic.

Cucca is eager to confirm their findings in a larger clinical trial and to compare their art therapy intervention to a complimentary one.

“Further studies are needed because it's a complex topic. So, we're really at the beginning,” he said.

Richard agreed: “Art is something that speaks to everyone, and it's universal. If we can harness that awareness in the context of neurological patients, I think there's a lot of potential.”

Besides the improvement in their visuospatial processes, Cucca noticed a new sense of confidence in the patients after art therapy that was not there before.

“They begin to look at themselves like someone who is able to say something, to create something, to be proactively engaged in their community,” he said. “There’s no pill that is able to do that.”

References

  1. Cucca, A. et al. Art therapy for Parkinson’s disease. Parkinsonism and Related Disorders 84, 148-154 (2021).
  2. Walker, R. H., Warwick, R., & Cercy, S. P. Augmentation of artistic productivity in Parkinson’s disease. Movement Disorders 21, 285-286 (2006).
  3. Strand, S., & Waller, D. The experience of Parkinson’s: Words and images through art therapy—a pilot research study. International Journal of Art Therapy 15, 84-93 (2010).
  4. Bae Y-S, Kim D-H. The Applied Effectiveness of Clay Art Therapy for Patients With Parkinson’s Disease. Journal of Evidence-Based Integrative Medicine 23 (2018).
  5. Yu, J. et al. The Art of Remediating Age-Related Cognitive Decline: Art Therapy Enhances Cognition and Increases Cortical Thickness in Mild Cognitive Impairment. Journal of the International Neuropsychological Society 27, 79-88 (2021).
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