Epilepsy & Behavior 130 (2022) 108694

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Epilepsy & Behavior

journal homepage: www.elsevier.com/locate/yebeh

Changes in the quality of life of persons with epilepsy, after the

implementation of an occupational therapy intervention with drama
activities
Vlotinou Pinelopi a, Terzoudi Aikaterini a, Tsiakiri Anna a, Nikova Alexandrina b,⇑, Vorvolakos Theofanis c,
Vadikolias Konstantinos a, Heliopoulos Ioannis a
a
Department of Neurology, Democritus University of Thrace, Alexandroupolis, Greece
b
Department of Neurosurgery, Evangelismos General Hospital, Athens, Greece
c
Department of Psychiatry, Democritus University of Thrace, Alexandroupolis, Greece

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Epilepsy is a chronic disorder that affects all domains of daily living. Especially, in the case of
Received 4 July 2021 drug resistance, it is usually associated with impairment of quality of life (QOL). The opportunity to
Revised 25 March 2022 self-express is crucial for maintaining mental health. Therefore, many non-pharmaceutical interventions
Accepted 31 March 2022
have been utilized to relieve psychiatric symptoms, such as fear, anxiety, and depression in persons with
Available online 14 April 2022
epilepsy. In this study, we aimed to investigate the effect of the occupational therapy program with
drama activities (ODTA) on the QOL of patients with epilepsy.
Keywords:
Methods: In total, 15 patients with epilepsy from the region of Thrace, Greece, were enrolled in a 3-
Complementary therapy
Epilepsy
month OTDA program focusing on the relief of anxiety symptoms and self-regulation. Each patient’s
Occupational therapy QOL was measured using the Quality of Life in Epilepsy Inventory (QOLIE-31) mean scores. The reliability
Dramatherapy change index was calculated and the Wilcoxon paired test was used to determine QOL changes post-
Quality of life intervention compared to pre-intervention.
QOLIE-31 Results: Statistically significant improvements were observed in fear of having a seizure (p =.004), overall
quality (p =.001), emotional well-being (p =.004), energy fatigue (p =.014), and total QOLIE (p =.001) score
after the intervention. The changes in the QOLIE score were more prominent among female individuals
(male vs female: p =.028 vs p =.008).
Conclusion: This study highlights the importance of providing an ODTA program in patients with epilepsy
and proposes its broader combined application as a complementary intervention in such patients.
Ó 2022 Elsevier Inc. All rights reserved.

1. Introduction etiology, seizure frequency, antiepileptic drug treatment, and

comorbidities, such as sleep and mood disorders, as well as by
Epilepsy is a common neurological condition that affects not self-efficacy in managing individual negative attributes [3,4]. Then,
only physical health but also psychosocial well-being and is usu- the QOL is characterized as poor, and the patient expresses nega-
ally associated with quality of life (QOL) impairment. Patients with tive feelings, lack of control, anxiety, and other emotional or psy-
epilepsy (PWEs) may experience psychosocial difficulties, emo- chological disturbances [5]. Furthermore, PWEs were found to
tional and behavioral problems, low self-esteem, learning difficul- have a higher prevalence of psychiatric comorbidities, such as anx-
ties, cognitive dysfunction, and fewer employment opportunities. iety and depression [6]. The early identification and management
These difficulties, enhanced by the stigma associated with epi- of signs of anxiety in combination with focused information could
lepsy, may cause restrictions on independence, reduced function- be translated into an improvement in the patient’s resilience to the
ing, and difficulties in solving daily problems [1]. negative effects of the disease and its reflection on his/her daily
The score of PWEs is lower in QOL scales compared to that of QOL [7].
the general population [2]. The QOL of PWEs is affected by epilepsy Psychological interventions and different types of psychother-
apy are used to reflect positivity in the QOL of PWE. The
⇑ Corresponding author at: Department of Neurosurgery, Evangelismos General importance of maintaining and enhancing the QOL of patients with
Hospital, Ipsilantou 45-47, 10676 Athens, Greece. epilepsy is evidenced by several previous works [8–11].
E-mail address: [email protected] (N. Alexandrina).

https://doi.org/10.1016/j.yebeh.2022.108694
1525-5050/Ó 2022 Elsevier Inc. All rights reserved.
V. Pinelopi, T. Aikaterini, T. Anna et al. Epilepsy & Behavior 130 (2022) 108694

The above forms of support that include group therapy could The research protocol focused on the probable changes after the
provide a helping hand to appropriately select PWEs, targeted at intervention program in all aspects of QOL on PWEs. A combination
improving their QOL. Group therapies are suggested as a treatment of methodological approaches was used in this study. Primarily, to
option for PWEs, as they offer peer support, access to information, evaluate patient needs, a qualitative approach was chosen to
sense of belongingness as part of a group with common problems, decide whether the patients had a genuine request and needed
and assist in increasing a positive self-image and overcoming to participate. Second, a quantitative approach was used to
stigma [12,13]. research, measure, and evaluate the impact of a DA approach on
An occupational therapy consulting approach in combination the QOL through an evaluation scale (Greek version of QOLIE-31).
with a complementary treatment expressive approach, such as
expressive drama activities, could provide an additional way of 2.2. Participants
obtaining helpful information, advice, and support from peers.
Having a good QOL is not an aspect that can only be achieved Participants in the study were drug-resistant PWEs, who were
through cognitive guidance. Emotions, feelings, communication, monitored and followed up at the epilepsy outpatient clinic of
expression, and body participation are under-recognized in the the Department of Neurology of the Democritus University of
well-being process. Nonverbal expressions, such as the use of Thrace for 6 months. All patients for whom a medical visit was
image, play, sound, movement, cloth, and other materials, could organized in the outpatient clinic between September 2018 and
provide opportunities to work with populations that are limited December 2019 were informed about the occupational therapy
in their verbal expression and deepen the understanding of the program with drama activities (OTDA) regardless of whether or
group clientele [14]. Patients with epilepsy are not always verbally not they consented to participate. The inclusion criteria were
low in their expression, but in many cases, they are made invisible age  18 years, duration of epilepsy for 1 year, and a stable
behind their seizures and suffer from a sense of community stigma. antiepileptic drug regimen for the entire duration of the interven-
Drama activities (DAs) use verbal and nonverbal means of expres- tion. The exclusion criteria were active treatment of psychiatric
sion and methodically combine the practices of theater and diseases and modifications in antiepileptic drugs. If there was a
psychotherapy. need for pharmacological revision and the patient is eligible for
Drama activity is a creative complementary treatment to more the OTDA process, the patient was still excluded from the analysis.
traditional forms of supportive therapy, with its roots in the drama Individuals undergoing psychiatric or psychological treatment
and theater processes. Participants were encouraged to explore or were not included. The OTDA sessions had a 3-month duration.
re-examine personal or group issues. Drama activity involves a The participants had a once weekly group meeting that lasted for
wide variety of styles, such as transformation, storytelling, use of 2 h. A total of 12 sessions were completed.
masks, movement, work with both the voice and the body,
improvisation, and theater games, including role-play [15]. Drama 2.3. Data collection
activity is being used to help people build communication between
the body and mind, facilitating experiences in the here and now, The attending neurologist identified the patients fulfilling the
without focusing on performance but freeing them from the inclusion criteria, and patients were assessed by an occupational
pressure they experience. Drama activity has been used in therapist prior to inclusion. The participants should be very willing
hospitals, schools, and outpatient centers, especially in addressing and motivated to participate in the OTDA sessions, because the
mental health issues and in patients suffering from psychiatric success or failure of the venture would be affected by the intention
disorders, guiding them to achieve therapeutic goals [16–19]. In of self-disclosure and the application of methods and practices to
Greece, dramatherapeutic methodology has been practiced in improve their QOL. Data collection was divided into three stages:
PWEs as a psychological treatment with ‘‘Metamyth”Ó philosophy the first stage was the identification of occupational personal
and practice, being one of the successfully tried approaches. needs; the section stage was the evaluation of the QOL of group
Valeta T. was the pioneer in bringing together epilepsy and members; and the third stage was the application of the interven-
dramatherapy [20]. tion program. The patients who fulfilled the criteria to participate
Conversely, an occupational therapy consulting approach can in the OTDA protocol created five groups consisting of three per-
investigate the changes that have occurred in the activities of daily sons. Once the intervention started, no new members could join
life due to epilepsy and inform the patient concerning the risks and the group. The decision to set a cutting point of three PWEs for
offer personalized ergonomic advice and solutions [21]. each group was based on the following states: (a) Dividing the time
The purpose of this research was to investigate the possible between fewer individuals offers a more complete and fair distri-
changes in the QOL in PWEs after the implementation of an occu- bution of time for personal expression; (b) the introduction of
pational intervention with drama activities. Data collection and big groups could involve a higher risk of its members developing
comparison were based on pre- and post-program data from self- feelings of anxiety and insecurity; (c) if a group was created by
assessment of the QOLIE-31 scale. two PWEs, then, it could be at risk of failure if one of the partici-
pants decide to interrupt the procedure; and (d) the formation of
the groups was based on the homogeneity of personal characteris-
2. Methods tics of each PWE. A weekly implementation of a common program
in each of the groups was followed, aiming at identical reproduc-
2.1. The research protocol tion of each session for each OTDA group. The sessions were orga-
nized in the afternoon, from Monday to Friday, and the therapist
Data were obtained from patients attending our Epilepsy Out- followed the same program for each of the five groups.
patient Clinic of Alexandroupolis University Hospital between There was no financial obligation for the participants.
September 2018 and December 2019. All procedures performed
in the study were in accordance with the ethical standards of the 2.4. Procedure
Democritus University Ethics Committee, which approved the
study in alignment with the standards of the Declaration of 2.4.1. The first stage: Identification of personal needs
Helsinki. Informed consent was obtained from all the study Initially, each patient was interviewed to reveal his personal
participants. needs. The domains of the first interview were his/her knowledge
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V. Pinelopi, T. Aikaterini, T. Anna et al. Epilepsy & Behavior 130 (2022) 108694

about epilepsy, his/her need for external expression of feelings Table 1

regarding epilepsy, the need to fight against the fear of stigma of The occupational therapy program with drama activities (OTDA).

epilepsy, the ways of managing the environment (family attitude, Week Axel description Guidance questions
friends, others), and a self-referenced QOL. Patients with epilepsy 1st ‘‘Your knowledge What type of epilepsy do you have? Describe
that showed no need for external help to improve their QOL were about epilepsy” your seizures, What do you think epilepsy is,
not informed about the OTDA protocol. Those who mentioned dif- what epilepsy really is. Do you know how
ficulties in their QOL in daily life due to anxiety of seizure occur- medication works? Can you guide someone to
help you after a seizure? Do you wear a
rence, felt different because of having epilepsy, and presented a medical ID card or jewel?
dysfunction in social interaction that affected their QOL were 2nd ‘‘Your activity in What do you do in your every- day living? How
informed about the protocol. Regardless of whether the patients daily living” can seizures affect you? Do these activities
would participate or not, they were all informed concerning epi- have risks for anyone else? Describe the
activities that makes you feel fear
lepsy and how to deal with it. Then, an evaluation to reveal the
3rd ‘‘Your safety at In-home equipment, fire, stairs, cupboards,
level of PWE involvement in drama activities, was then performed. home” bathroom, kitchen, living room, Transferring
The evaluation followed specific criteria that are illustrated in objects, Ergonomic interventions at home, use
Fig. 1. This framework could guide the therapist in selecting the of assistive technology
appropriate exercises for every stage and maintain a structured 4th ‘‘Your outdoor Sporting activities, water sports, height, use of
safety” outdoor equipment, your work
approach [22].
5th ”Communication Communication with family/friend/
and Planning” environment, Family planning, stigma. Your
2.4.2. The 2nd stage: Evaluation of the QOL of group members experience. How often does a seizure occur?
All PWEs were evaluated using the Greek version of Quality-of- Describe the first time. How many people are
informed that you have epilepsy? Do you plan
Life Inventory in Epilepsy 31 (QOLIE-31) [23–25]. The first evalua-
to have a family?
tion was conducted just before entering a group and the last eval-
uation after they completed a 3-month intervention after the 12th
OTDA program. The QOLIE-31 comprises 31 questions, which are
Table 2
summed up in seven sub-categories. The domains examined were The four-axon program.
as follows: 1. anxiety to seizure occurrence, 2. emotional well-
6th week Group introduction: Self -presentation/safe environment/
being status, 3. feeling of fatigue, 4. feeling of epilepsy having influ-
contract between members-to feel free to express themselves
ence on cognitive status, 5. effects of medication, 6. social function, about epilepsy
and 7. overall QOL. A higher score corresponds to a better QOL Experiencing own body – own senses when a seizure comes
expressed through the sum of the subsets on the scale, calculated 7th 8th Activities: Healthy relationship with the body/voice, body and
according to the scoring manual. week others: play a scene that scares you in epilepsy
Activities: Movement/emotion/thought/imagination/ language

2.4.3. The 3rd stage: Application of the intervention program Transforming an object/follow my dance/walk my walk/
9th-10th Character types/roles/emotional expression/
The first step of the intervention program was an occupational week Self-expression 30
therapy counseling program that lasted for five weeks. The occupa-
Emotional greetings/calling out Emotions/Creative writing
tional therapy–counseling program was organized by a neurolo- about life and epilepsy
gist, performed by an occupational therapist, and was built on 11th-12th The work is focused on their real lives roles_ their fears created
five axes: 1. knowledge of epilepsy, 2. activities in daily life, 3. week by Epilepsy
safety at home, 4. safety outdoors, and 5. communication with Recognizing feelings/story telling 28
family/friends/environment (Table 1).
The project of DA was organized into two axons, the involve- alpha method (alpha > 0.05). The original scales were correlated
ment in purposeful daily tasks and the drama activities [22] and with the factor-reduced solution scales, and the mean score of each
lasted for 7 weeks. The use of drama activities techniques focuses original or reduced scale pre- and post-program was compared
on exploring the fear and anxiety that a person with epilepsy (mean difference). In this study, the framework of explanatory fac-
may feel and a loss of control or a sense of abandonment from tor analysis was used. Regarding the demographics of participants,
the stigma of society. The OTDA intervention followed the specific percentage points were recorded, as well as frequency.
needs of participants. The primary focus was on the dramatic activ-
ities. Moreover, these works focused on the reflections [22,26]. The 3. Results
main body of the therapeutic interventions was constructed on
four axons, with a number of drama activities, as shown in Table 2. The intention to participate in the study lasted for five months.
A total of 26 patients were interested in participating, out of 109
2.5. Data analysis patients who were followed up by the neurological department.
Six PWEs lived in remote areas and refused to participate. Two
Data analysis was performed using the open-source program PWEs started with the OTDA program, but were excluded as they
Statistical Processing PSPP v.1.4.0. A Barlett’s test (p <.05) and a discontinued after the second session, while the other three did
sample adequacy test were concurrently performed with data col- not commit to attending their weekly session and they were also
lection, and a reliability analysis was performed using Cronbach’s not calculated. No patient was excluded due to medication

Fig. 1. Domains of Occupational therapy evaluation for the involvement in OTDA process.

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V. Pinelopi, T. Aikaterini, T. Anna et al. Epilepsy & Behavior 130 (2022) 108694

changes. In the end, 15 PWEs (N = 15, mean age = 32.27 years, Table 3
SD = 13.55) completed the evaluation and participated in the OTDA Patients’ demographic characteristics.

sessions (Fig. 2). The majority of PWEs underwent polytherapy Frequency Percentage
(53.3%), had received a diagnosis of focal epilepsy (53.3%), and suf- Age 30 year 7 46.7%
fered from one seizure (at least) during the last month (40%) 31–47 years 8 53.3%
(Table 3). Sex Male 6 40.0%
The patients’ QOLIE-31 scores were compared before and after Female 9 60.0%
Seizure type Focal Symptomatic 4 26.7%
the intervention program. A Wilcoxon paired test was performed Focal 8 53.3%
to compare the pre-post values of all factors. The results for the Generalized 2 13.3%
value of anxiety of seizure occurrence were p =.004, overall quality Unclassified 1 6.7%
p =.001, emotional well-being, p =.004, fatigue p =.014, and QOLIE Seizure Frequency 0 to <1 year 4 26.7%
<1/month 6 40.0%
total score, p =.001, (**p  0.05, *p  0.10. PRE scales correlations
>1 per week 5 33.3%
with POST scales), differentiated between PRE and POST condi- Treatment Monotherapy 7 46.7%
tions, and were statistically significant in favor of POST scales. No Polytherapy 8 53.3%
statistically significant differences in the values of cognitive
(p =.107), medication effects, (p =.068), and social function
Table 4
(p =.176) was observed (Table 4). A Wilcoxon test was also per-
PRE vs POST related comparisons using Wilcoxon paired test (**p  0.05, *p  0.10.
formed between the mean values of men and women and QOLIE- PRE scales correlations with POST scales).
31 values (Table 5). The reliability change index was calculated
PRE vs POST related comparisons using Wilcoxon paired Z p-
to determine if the deterioration was reliable. In Table 6, the reli-
test value
able improvement in favor of post-test is indicated, as well as
Seizure worry 2.85 0.004**
the reliable deterioration in favor of pre-test. In most values in
Overall quality 3.46 0.001**
the subcategories of QOLIE-31, a reliable deterioration was Emotional well-being 2.91 0.004**
observed. However, a lack of change was observed in the subcate- Energy fatigue 2.46 0.014**
gories of anxiety of seizure occurrence and medication effects Cognitive 1.61 0.107*
(Table 6). Medication effects 1.83 0.068*
Social function 1.35 0.176
The difference in the mean scores on the eight subscales ranged QoLIE total 3.41 0.001**
from 3.33 points (cognitive scale) to 20 points (overall quality) in

Fig. 2. Flow chart of PWE participation in OTDA program.

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V. Pinelopi, T. Aikaterini, T. Anna et al. Epilepsy & Behavior 130 (2022) 108694

Table 5
Pre vs Post related Comparisons on Gender Levels **p  0.05, *p  0.10.

PRE vs POST Related Comparisons Sex

Male Female
Z p Z p
Seizure worry 1.83 0.068* 2.20 0.028**
Overall quality 2.24 0.025** 2.65 0.008**
Emotional well-being 1.36 0.173 2.68 0.007**
Energy fatigue 1.51 0.131 1.89 0.059*
Cognitive -0.37 0.713 1.60 0.109*
Medication effects 1.00 0.317 1.60 0.109*
Social function 1.60 0.109* -0.28 0.783
QoLIE total 2.20 0.028** 2.67 0.008**

Table 6
Reliability Change Index: improvement/no change/deterioration and % of reliable improvement.

Number of PWEs with: Improvement No change Deterioration in scores p-value % of PWEs with reliable improvement
Seizure worry 11 2 2 0.015 73.3%
Overall quality 12 0 3 0.000 80%
Emotional well-being 15 0 0 0.006 100%
Energy fatigue 13 0 2 0.000 86,6%
Cognitive 2 13 0 0.839 13,3%
medication effects 2 11 2 0.722 13,3%
Social function 1 14 0 0.012 6,67%
QoLIE total 9 6 0 0.028 60%

Fig. 3. Pre-post Means scores of the subscales of QOLIE-31by means score.

the total range from 0 to 100 (Fig. 3). The pre- and post-related The characterization of changes in QOL subscales, according to
comparisons of mean scores are presented in Table 7. The pre- Borghs et al.’s cutoff points [27] of minimal change, is presented
post mean scores of the subscales of QOLIE-31 and the difference in Table 9, where much change, minimal change combined, mini-
between the averages, expressed in points, are presented in Table 8. mal change, and no change were detected (Table 9).

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V. Pinelopi, T. Aikaterini, T. Anna et al. Epilepsy & Behavior 130 (2022) 108694

Table 7
Pre vs post related comparisons of mean scores.

PRE vs POST Related comparisons using Wilcoxon paired test p-value Pre-Mean SD Post-Mean SD Mean Difference
Seizure worry 0.004 47.81 33.96 64.06 24.15 16.25
Overall quality 0.001 61.67 18.58 81.67 14.84 20
Emotional wellbeing 0.004 65.50 15.04 80.00 13.09 14.5
Energy fatigue 0.014 61.33 21.34 71.33 15.52 10
Cognitive 0.107 77.12 25.48 80.45 26.40 3.33
Medication effects 0.068 59.17 37.34 67.50 38.03 8.33
Social function 0.176 47.50 31.05 53.33 30.79 5.83
QoLIE total 0.001 62.79 16.71 72.06 15.70 9.27

Table 8
Pre-post mean scores of QOLIE-31.

Subscales of QOLIE-31 Pre Post Mean Points Difference

Mean Points SD Mean Points SD
Seizure Worry 47.81 33.96 64.06 24.15 16.25
Overall Quality 61.67 18.58 81.67 14.84 20
Emotional Well-Being 65.50 15.04 80.00 13.09 14.5
Energy Fatigue 61.33 21.34 71.33 15.52 10
Cognitive 77.12 25.48 80.45 26.40 3.33
Medication Effects 59.17 37.34 67.50 38.03 8.33
Social Function 47.50 31.05 53.33 30.79 5.83
QoLIE Total 62.79 16.71 72.06 15.70 9.27

Table 9
Characterization of Changes in Quality-of-life subscales according to Borghs et al.’s cutoff points.

Characterization of score changes

NC MC MCC MuC
Seizure Worry cutoff points (according to Borghs et al. 2012) 0 8.95 13,43 17.9
Points difference (means score) of our research Data 16,25
Ranking of Result for seizure worry Minimal change combined
Overall Quality cutoff points (according to Borghs et al. 2012) 0 7.89 11,84 15,78
Points difference (means score) of our research Data 20
Ranking of Result for Overall Quallity Much Changed
Emotional Well-Being cutoff points (according to Borghs et al. 2012) 0 6.35 9.53 12.69
Points difference (means score) of our research Data 14.5
Ranking of Results for emotional well-being Much Changed
Energy Fatigue cutoff points (according to Borghs et al. 2012) 0 7.54 11.31 15.08
Points difference (means score) of our research Data 10
Ranking of Results for energy fatigue Minimal change
Cognitive cutoff points (according to Borghs et al. 2012) 0 6,95 10,43 13,9
Points difference (means score) of our research Data 3,33
Ranking of Results for cognitive No change
Medication Effects cutoff points (according to Borghs et al. 2012) 0 10.1 15.02 20.03
Points difference (means score) of our research Data 8,33
Ranking of Results for medication No change
Social Function cutoff points (according to Borghs et al. 2012) 0 8.95 13.43 17.9
Points difference (means score) of our research Data 5,83
Ranking of Results for social function No change
QOLIE-31 Total cutoff points (according to Borghs et al. 2012) 0 5.31 7.97 10.62
Points difference (means score) of our research Data 9.27
Ranking of Results for QOLIE-31 Minimal change combined

NC, no change; MC, minimally changed; MCC, minimally changed combined; MuC, much changed.

4. Discussion tion, and total QOLIE score than men. Most of these factors could
be associated with the internal mechanism of the traumatic situa-
Our findings highlight the clinically important changes after tion management of each sex. Women seem to use self-blame
providing the OTDA program in PWEs concerning the following more than men and often feel their emotions are out of control
issues: anxiety to seizure occurrence; the sense of emotional [28,29], and although they tend to express themselves more easily
well-being, which is crucial for everyday living; and the change than men, their experience of being diagnosed with epilepsy is
of feeling in energy, which can strengthen the patient psycho- more difficult than men.
emotionally, aiming to raise the QOL to a higher level. After the To explain and identify the possible clinical importance of our
implementation of the OTDA program, the majority of subscales results, we adopted the anchor-based method of Borghs et al.,
on the QOL of PWEs have changed. which proposes the patient’s perceived level of change to establish
Our results revealed that women showed a greater improve- clinical relevance as it determines the minimally important change
ment in seizure worry, energy fatigue, cognitive and social func- threshold [27]. In this method, the absolute values of QOLIE-31 are

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V. Pinelopi, T. Aikaterini, T. Anna et al. Epilepsy & Behavior 130 (2022) 108694

used, and change instead of improvement or worsening is consid- changes were recorded after the training, researchers underlined
ered. An estimated threshold of 5.31 for the total score is associ- the patient’s perception of experiencing less depression, fewer
ated with a minimal change in the QOLIE-31 scale. In our memory difficulties, work or social issues, and less seizure worry
research, the change in the total score is 9.27 points is character- [35]. The medium improvement in the QOL could be interpreted
ized as minimal and much change combined according to the in accordance with our results for the total QOL [35].
Borghs scale. These results reveal the impact of the OTDA program Despite several important findings, the following limitations of
on PWEs, as they determine the changes that have occurred in our study should be mentioned. The study was limited by the
their total QOL. The participants who underwent an occupation- heterogeneity of the epilepsy subtypes. The number of PWEs
DA program expressed an overall improvement in the quality of selected to participate in every group and the internal relationships
their lives. in the core of every OTDA group could be subjects under dispute, as
In the subscale of emotional well-being, we considered a max- there is a hypothesis that a different group composition could
imum change of 14.5 points with a threshold of 12.69, for much reflect different individual outcomes. The content of each OTDA
change. The implementation of a consulting and expressive pro- session or the therapist’s attitude may have guided PWEs in engag-
gram in PWEs can possibly give back to them more confidence ing in the research. In addition, a limited number of variables was
and strength to feel emotionally healthy according to our findings, investigated in this study. More variables could be included for fur-
as all PWEs seemed to have benefited (100% percentage of a posi- ther evaluation in the future with similar interventions.
tive change). A longitudinal study or randomized controlled trial is suggested
After the OTDA program, the subscale of energy fatigue showed to reduce possible biases and offer causal relationship answers
a minimal change (participants’ average score was 10 points with concerning the difference in the pre- and post-values of QOLIE-
the cut point set at 7.54). A minimal change was considered in sei- 31. Moreover, follow-up examinations may offer significant long-
zure worry, as 16.25 points was defined as the mean score of par- term results.
ticipants, with the minimally important change threshold set at
13.43 points.
In contrast, according to our findings, no change was detected 5. Conclusion
for cognitive and medication subscales. The same result was pre-
sented for the social function subscale, with a very low percentage An occupational therapy-consultation intervention with DAs
(only 6.67%) showing a reliable change. No change in social func- positively affects the QOL of PWEs. The combination of these two
tion was present in 14 of the 15 PWEs, which should be re- interventions could be considered as a complementary approach
examined in future studies. for patients suffering from complex diseases, such as epilepsy.
To the best of our knowledge, no articles related to the main
question of our research work concerning the implementation of Conflict of interest
a combined occupational therapy-consultant and DA program in
PWEs, presenting quantitative measurements and results regard- The authors declare no conflicts of interest regarding this
ing QOL, have been reported to date. research or the preparation of this manuscript.
To date, the implementation of DA has been describing pro-
cesses through experiences, clinical vignettes, and case reports
[28]. Drama activities have produced a limited number of empirical Acknowledgements
studies and have been used in few neurological conditions only in
qualitative research protocols. Haste and McKenna support the There are no acknowledgments.
clinical effectiveness of DA in neurotrauma recovery as it nurtured
the self-esteem of the group studied, without associating their
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