Leisure, creativity and creative therapies

Creativity appeals to the senses and can help people to express themselves in many ways. Many people say that their symptoms tend to lessen when absorbed in creative processes. 

The brain has the ability to alter in structure in response to experiences, as has been shown by research into war veterans who acquire new skills to compensate for those lost as a result of injury or trauma. Although the mechanism for these positive changes in the brain is unclear, the important thing is to take advantage of these opportunities. So, even if you don’t think you are particularly creative, have a go and you may well be surprised.

The range of creative therapy activities is wide, some of the most popular being:

• art – including painting, sculpting and drawing
• music – listening to music, playing an instrument or singing, either independently or in a group
• dance - usually in a group exploring a variety of different styles, particularly those that most stimulate and engage participants
• writing – both as a therapeutic and creative pursuit, for example keeping a diary, writing poetry or short stories.

Other activities can also be therapeutic, such as photography, jewellery-making or working with fabric or ceramics.

Don’t be put off by thinking that your symptoms might make some pursuits difficult, for example holding a paintbrush. There are many different techniques and specially adapted tools that can help you. And remember, in all creative pursuits no prior knowledge or experience is necessary. Many people try new activities after being diagnosed with Parkinson’s and derive so much pleasure from them that they wonder why they didn’t start before!

Art therapy is the therapeutic use of art as a means of working through illness or challenges to everyday living. Many people who have become involved in art maintain that they feel empowered by the creative process and more in control of their lives. As well as being very satisfying, art can also be a useful communication tool, providing a vehicle for describing your thoughts and feelings. It can be an escape, providing a haven of peace or calm, or it may stimulate the visualisation of happy memories.

Art therapy and Parkinson’s

Art can encourage a previously hidden creative streak in response to the changes Parkinson’s brings to life. The creative process is therapeutic and liberating, and the knowledge that an art project is there to return to can be encouraging and motivating. Self-expression can also help with depression and can rekindle motivation in other aspects of life.

Art therapy seems to help by working on the subconscious, reducing stress and releasing frustration while stimulating the imagination and promoting a sense of inner peace. Both therapists and participants say that when absorbed in the art-making process, symptoms tend to subside. One person with Parkinson's said, “When I am painting I forget about Parkinson’s, and it forgets about me”.

Research

Exactly why art therapy seems to help is still an area for research. Some think that creativity may be heightened by Parkinson’s itself, aided perhaps by the fact that many people stop working and have more time for such hobbies. Others speculate that it may be related to a lack of dopamine or other chemical imbalances in the brain.

For those who cannot paint but enjoy looking at picture books and art, research is now under way into the benefits this can bring, especially for those with dementia who cannot access normal books. Many believe that sharing pictures can encourage communication and closeness between two people, and it appears to have a calming and uplifting affect.

See Pictures to Share for more information.

Activities and techniques

The range of art activities is wide – from doodling with eyes closed or finger painting, to randomly applying paint with a dropper or modelling with clay.

Trying to control involuntary movement can be tiring but there are ways of achieving a satisfying outcome without strain. Playing with materials, rather than controlling them, is usually more enjoyable so make the most of chance effects - accidental marks and textures can create original and unique imagery. Below are some examples of different techniques and mediums you may like to experiment with:

• Drawing to music – the listening process diverts attention from concern about the ability to draw, while rhythm prompts movement, and pleasant sounds are relaxing.
• Meditation and breathing exercises - reduce stress and allow creativity to flourish.
• Waving Tai Chi movements – this starts as an arm exercise and can then develop into undulating line drawings that become paintings of heaving seas. The trick is to divert attention from worrying about making a finished work of art and ‘go with the flow’ instead.
• Wet-on-wet watercolour - this is often a preferred medium as the spreading pigment creates its own dynamic and has a calming, therapeutic effect on the mind.
• Taking part in art therapy groups - can induce positive changes in mood and an increased sense of wellbeing. It can also provide valuable social stimulation. 

Looking at art

For those who are limited either physically or cognitively and cannot produce art themselves, looking at art can be just as therapeutic as creating it and can have a calming and uplifting effect. Enjoying and reacting to other’s artwork can provide an outlet for your own emotions, help evoke memories or stretch your imagination.

How do I get started?

The following may help you to begin exploring the opportunities art can bring.

• Experiment with a variety of different types of art and find those which most stimulate and uplift you and aid movement. Be patient if this takes time.
• Visit local groups, especially those run by trained art therapists.
• Go to art galleries or other public shows to explore new ideas and build on your experiences.
• Build up a picture or photo album of paintings and other art that inspires you and turn to this when you need inspiration or motivation.
• Practice at home any techniques or activities you have learned in groups. Many have a ‘carry over’ effect so the benefits can be felt beyond the period of activity.

In recent years, simple music-based methods have been developed that enable health care workers without specific musical training to aid people with Parkinson's through voice, movement and music listening, e. g. Music-based caregiving (MBC)¹. Specifically, Rhythmic auditory stimulation (RAS) is a well-researched specific use of metronomic rhythm to aid gait for PwP that can be easily learned and applied safely with a minimum of training².

There are two types of music therapy: ‘active’ involves the use of voice (including speech and language therapy), instruments and movement, while ‘passive’ involves structured listening to music.

Music therapists are trained to design specific music programmes for individuals or groups according to their emotional, physical, social and cognitive abilities. Sessions may include the use of music improvisation, both playing and listening to music, song writing and performance.

Many believe that the effectiveness of music therapy lies in its ability to bring into consciousness activities that were previously performed subconsciously, such as walking. Such therapy appears to help with walking or dancing because of the musical rhythm or beat. These motor benefits, as well as the psychological benefits, have made music therapy increasingly popular³.

Music therapy and Parkinson's

Music therapy can help improve the quality of life for people with Parkinson’s by:

• promoting a sense of well-being
• reducing stress,
• improving movement
• improving breathing
• improving verbal and non-verbal communication
• promoting self-expression
• improving memory.

Rhythm

Automatically or subconsciously initiating a movement or a sequence of movements can become increasingly difficult for people with Parkinson’s. Rhythm acts as a stimulus and template for organising a series of movements consciously, like walking. By focusing on a rhythm and feeling its beat, many people notice improvements in bradykinesia, gait, difficulty initiating a movement and freezing – it is as if the rhythm helps you to discover your own lost automatic rhythm.

Rhythm also seems to improve tremor and dyskinesia by providing a template or pattern that allows movement to be synchronised and controlled again. Slow rhythmic music in particular may help by slowing down body rhythms and helping you to relax. It is not surprising that drumming groups have become increasingly popular as they provide obvious rhythms to follow. 

Other benefits

Music can also help overcome non-motor symptoms, such as depression, anxiety or feelings of isolation, while at the same time providing an opportunity for self-expression and social interaction. Many people report a lowering in blood pressure, more relaxed muscles, uplifted spirits and a new sense of energy and optimism. Others find that they tire less easily when moving to music as less effort is required.

There are cognitive benefits too because when responding to music the brain works on processes that are involved in other activities that have become difficult such as cutting food or dressing. As a result, music may be able to help in coping with complex everyday activities that have become too much for you. Reading and learning music can also be a valuable brain training exercise. 

Research

It is increasingly recognised that music can affect the way we function and has real benefits. Some neuroscientists believe that certain types of music stimulate the production of the neurotransmitters dopamine and serotonin which are reduced in people with Parkinson’s. However, this has not been proved so far.

Professor Michael Thaut has researched the effect of music on the brain⁴, including rhythmic music stimulation on gait and other motor performance, for over twenty years. His team’s research has produced some of the most solid evidence that music may help those with Parkinson’s and Thaut has developed specific music therapy techniques aimed at its symptoms⁵:

• Rhythmic Auditory Stimulation (RAS) is a method that enables the therapist to find the exact rhythm that supports optimum gait. RAS may improve initiating movements, rhythm, freezing, coordination and endurance.
• Patterned Sensory Enhancement (PSE) uses music to enhance complex movements requiring coordination. PSE tailors the music movement to the motor movement, making it more efficient and fluid.
• An Italian study⁶ looked at 16 people receiving music therapy in relation to 16 receiving physical therapy. The results showed that those receiving music therapy had significant improvements in bradykinesia and the performance of daily activities, such as cutting food and dressing, as well as a greater sense of happiness and improved quality of life. Those receiving physical therapy saw improvements in rigidity but not in other areas. Music therapy also reduced freezing and start hesitation.

Further research is also under way which aims to determine which musical rhythms are more therapeutic and stimulating for people with Parkinson's. Their goal is to ultimately create a device, perhaps similar to a personal music player, that can be tailored to each individual’s needs.

References

1. Myskja, A. (2012). Integrated music in nursing homes – an approach to dementia care. Bergen: UiB (PhD dissertation)
2. Bella, S. D. et al (2017). Gait improvement via rhythmic stimulation in Parkinson's disease is linked to rhythmic skills.
   Nature, Sci Rep. vol. 7; article number 42005 - view article
   
3. Sabado, J. J., & Fuller, D. R. (2008). A Preliminary study of the effects of interactive metronome training on the language skills of an adolescent female with a language learning disorder. Contemporary Issues in Communication Science and Disorders vol. 35; 65-71 - download PDF
4. How music helps to heal the injured brain - view article
5. Thaut, M. H. & Hoemberg, V. (Eds.) (2014). Handbook of Neurologic Music Therapy. Oxford: Oxford University Press
6. Pacchetti, C., Mancini, F., Aglieri, R., Fundarò, C., Martignoni, E., & Nappi, G. (2000). Active music therapy in Parkinson’s disease: an integrative method for motor and emotional rehabilitation.  Psychosomatic medicine, 62(3), 386-393 - view abstract.

How do I get started?

Music can help in many ways to improve quality of life and the following may help you to explore opportunities to their fullest:

• Listen to a variety of different types music and find those which most stimulate and uplift you and aid movement. Be patient if this takes time.
• Contact local groups, especially those run by trained music therapists.
• Turn to music if you feel stress levels rising or if you want to induce sleep.
• Go to concerts to explore new music and build on your experiences.
• Find music you like to sing along to help keep your voice strong.
• Build up a collection of music that helps you recall happy memories.
• Practice at home techniques or activities you learn in groups. Many have a ‘carry over’ effect so the benefits can be felt beyond the period of activity in the session.

Important!  If using headphones to listen to music when out and about, be careful not to be distracted when near roads or busy places.

Singing has all the benefits mentioned so far and can also be very helpful in improving speech which has become slurred and unclear as a result of Parkinson’s. Breathing exercises and vocal techniques used when singing can help with:

• sustaining the voice
• increasing and controlling volume
• varying pitch and expression
• improving diction and fluidity of diction
• controlling vocal speed
• improving posture.

Not surprisingly there are a growing number of informal singing groups for people with Parkinson’s or other conditions, such as Alzheimer’s. The opportunity to work on vocal and breathing techniques in an informal setting with people who share similar difficulties can be a valuable social activity and can help with self-confidence and overcoming depression. And you don’t generally need to be able to sing to participate because such groups are not usually choirs and most do not give performances.

Typical singing activities which can help with improving posture, breath work and diction include:

• taking your voice ‘for a walk’ up and down in pitch
• lifting the tongue to the roof of the mouth
• practicing trills (rapid alternation between two adjacent notes of a scale) with lip and tongue
• making different types of sighs
• humming
• echoing tunes
• singing in rounds (one voice starts and others join in one after another until all are singing different parts of the same song at the same time)
• experimenting with a variety of pitch, pace and mood in songs.

Singing techniques have also been used to aid fluidity of speech and combat stuttering. Melodic Intonation Therapy (MIT)¹ involves repetition, loud counting and the rhythm of a metronome and this has been found to be helpful in:

• helping to initiate or complete movements
• reducing tremor and dyskinesia
• boosting self-confidence when practiced in a group
• improving slurred speech and poor articulation.

Many believe that function and memory skills also improve in learning and repeating songs, and this can be helpful in dementia, although more research into this is needed. A UK initiative, Singing for the Brain, found that singing not only helped with memory and emotional well-being, but also improved the patient-carer relationship and provided a varied channel of communication.

References

1. Sabado, J. J., & Fuller, D. R. (2008). A Preliminary study of the effects of interactive metronome training on the language skills of an adolescent female with a language learning disorder. Contemporary Issues in Communication Science and Disorders, 35, 65-71 - download PDF.

Dance Movement Therapy (DMT) uses movement and dance to engage creatively in a process which enhances emotional, cognitive, physical and social well-being. It is based on the principle that movement reflects a person's feelings and patterns of thinking, and can be used to explore and express emotional and creative experiences.

Dance Movement Therapy and Parkinson's

Dance can be exhilarating mentally, physically and emotionally and the benefits of exercise and having fun are of course numerous.

There are many dance and/or movement classes for people with neurological illnesses. They are generally informal and provide a relaxed environment in which to express your thoughts and emotions. Becoming a member of a dance group can also be a valuable social activity, helping with communication, self-confidence, self-esteem, independence and overcoming depression or anxiety. They also provide an opportunity to share difficulties with people who face similar challenges to you.

As there are many different types of dance there is a good chance of finding something you will enjoy. Some dance groups include a variety of styles of dancing, but if you just like one particular style, for example Salsa, that's fine. It's not the dance itself that matters, but that you have fun dancing and exercising this way!

How DMT can help with Parkinson's symptoms

For people with Parkinson's the connection between the intention to move and actually starting and/or completing an action is disrupted because levels of dopamine (a neurotransmitter which passes messages from the brain to the muscles) are depleted. Movement may no longer be automatic and a conscious effort may be necessary in order to initiate or execute a given action.

The rhythmic and repetitive movements of dance can help with motor symptoms, such as bradykinesia, gait, start hesitation and freezing, by providing a model for movement, making you think about how to move before you actually do so. It can also help train the mind to initiate and complete sequences and patterns of movement. In time and with practice this becomes easier and easier and so confidence builds, which can be very helpful in everyday activities, such as maintaining a steady pace on a crowded street or keeping moving when paying at a shop checkout.

Some people have found that marching music helps them to overcome 'freezing' episodes. If feet feel 'glued' to the floor, singing or humming a marching tune can help to get the feet moving again. See Coping Strategies - Tips & Tricks.

In some, but by no means all cases, dance can also improve tremor and dyskinesia (involuntary movements) by providing patterns to synchronise and control movements again. This tends to be helpful when symptoms are not too severe.

Posture and balance may also improve, particularly if you follow a warm up routine using either a proper dance barre or even the back of a steady chair for support. Choosing the right dance can help with particular symptoms, for example, some people find that certain tango movements have improved their balance, mobility, flexibility, and also starting, stopping and restarting movement. Tango can improve your ability to move at different speeds forwards and backwards, while the waltz can train you to take big steps and hold a good, tall posture. Dancing can also improve cardiovascular fitness.

See also Coping Strategies - Tips & Tricks for suggestions on how dance can improve movement and symptoms.

Research

There has been a considerable amount of research^1,2,3 which points to the quality of life benefits of dance for people with Parkinson's and their carers, as well as improved mobility. Many studies have investigated the effects of Argentine tango (AT) on Parkinson’s symptoms. Results indicate that AT may be able to improve balance⁴. Although we don’t know which is the most effective frequency, intensity, duration of the dance class and the type of dance for people with PD, dance may benefit people with mild to moderate Parkinson's⁵.

A study⁶ published in 2007 compared the effects on mobility of 20 one-hour Argentine tango lessons in relation to the same number of exercise or strengthening classes in 19 people with Parkinson's. The dance lessons included stretching and balance exercises, tango-style walking, footwork and dance with and without a partner. The exercise classes included seated exercises, followed by standing exercises with chair support, core strengthening and stretching.

Both groups showed significant improvements in functional mobility using standardised tests but those in the tango group showed greater improvement in balance. Further studies are needed to confirm these findings but this does suggest that dance can be beneficial to people with Parkinson's.

References:

1. Dance therapy for individuals with Parkinson's disease: improving quality of life - view abstract
2. Impact of a weekly dance class on the functional mobility and on the quality of life of individuals with Parkinson's disease - view abstract
3. Effects of dance on balance and gait in severe Parkinson disease: a case study - view abstract
4. Argentine tango in Parkinson disease--a systematic review and meta-analysis - view abstract
5. Dance for people with Parkinson disease: what is the evidence telling us? - view abstract
6. Tango improves balance, mobility in patients with Parkinson's disease - view abstract.

How do I get started?

The following may help you to explore opportunities to their fullest:

• Explore a variety of different types dance to find those which most stimulate and uplift you and aid movement. Be patient if this takes time.
• Contact local groups, especially those run by trained dance therapists.
• Don't over-do it, particularly if you've previously been inactive. Start slowly to avoid the risk of injury.
• Always warm up and cool down at the beginning and end of each session.
• Go to dance shows to explore new ideas and build on your experiences.
• Wear light, comfortable clothing and low-heeled shoes, preferably with a leather sole to avoid sticking.
• Practice at home techniques or activities you have learned in groups. Many have a 'carry over' effect so the benefits can be felt beyond just the period of activity.

There are also many YouTube videos on Parkinson's and dance. Remember, though, to see advice from your care team before trying any dance that you are not familiar with so as to avoid the risk of injuring yourself.

Writing is accessible to everyone and often people with Parkinson's find it very therapeutic. It can take many forms - poetry, short stories or novels for example - and you can write on your own or as part of a group. No special skills or experience are needed – just a willingness to explore experiences and thoughts.

Some say that when they write they feel able to express their feelings more openly because paper does not comment or judge. They also explore issues that they would not otherwise delve into. It can be easier to tackle worries or difficult issues in writing, particularly if they are hard to discuss in person. Words can always be rewritten and writing can be helpful preparation for vocalising some of your thoughts. For some, writing can help overcome physical and emotional challenges and can bring with it a sense of optimism and satisfaction.

Creative writing is often pursued as a means of sharing thoughts, memories, hopes or ideas, whether real or fictitious. This can bring satisfaction in achieving a goal as well as a sense of optimism and well-being in being able to express yourself.

Therapeutic writing

Therapeutic writing aims to focus on and explore subjects that are troubling; expressing such worries can help to overcome them or find a way forward. You may need to focus on a subject over and over again in order to achieve the self-expression you hope for but this can be a cathartic process because 'bottling' worries up can make them worse. For this type of writing the 'normal' rules don't need to be observed – you can just write down whatever is in your head, paying no heed to grammar and spelling. The idea is simply to express what you are feeling and often this can bring with it a sense of control and purpose.

Research

Little scientific research has so far been conducted into the benefits of writing in Parkinson's, although improvements in the symptoms of other conditions such as asthma and rheumatoid arthritis have been noted. General studies have shown that when writing, heart rates tend to slow down and blood pressure tends to drop and so stress may be relieved, but further research in this area is needed.

How do I get started?

Just grab a pen! Writing can help in many ways to improve quality of life and the following may help you to explore opportunities to their fullest.

• Explore a variety of different types of writing, and find those which most stimulate and uplift you, and aid movement. Be patient if this takes time.
• Try to find quiet times of the day when you can concentrate on your thoughts.
• Investigate local groups, especially those run by trained writing therapists.
• Turn to writing if you feel stress levels rising or if you want to induce sleep.
• Build up a library of writing that inspires you and turn to this when you need inspiration or motivation.
• Practice at home techniques or activities you have learned in groups.

Music and singing:

We would like to thank Prof Audun Myskja MD, PhD (Senter for Livshjelp, Norway) for his help in reviewing this information.

Articles from Parkinson's Life online magazine

• How one family-run clothing company is “sharing the story of Parkinson’s”
• 5 filmmakers on making movies about Parkinson’s disease 
• 6 works of art shedding light on Parkinson’s
• Podcast: Getting creative with Parkinson’s
• The dopamine effect? Why people with Parkinson’s are more creative

Art therapy:

• “Exercise is important – but so is exercising the mind and soul”
• How Parkinson’s disease could impact the way you see art
• Parkinson’s Portrayed: real stories reflected through art
• “I hope it empowers people with Parkinson’s to be more open and honest”
• “Not every day will be a day to create art”
• “Sometimes, art can communicate what words cannot”
• Could art therapy help people with Parkinson’s?
• John McLean: Parkinson’s has exposed me to new painting techniques
• Paint relief: “The joy of painting outshines my Parkinson’s symptoms

Music:

• The Covid Chronicles: connecting performers with Parkinson’s disease
• “Music can take me to a special place in my head that Parkinson’s can’t get to”
• Musical therapy study to receive $20 million in funding
• A window into the world of Parkinson's
• “Parkinson’s doesn’t know when it’s Christmas”
• Simply having a wonderful Christmas time
• World Parkinson Congress 2019 song competition
• Moving to the beat: can techno help Parkinson’s patients walk better?

Singing:

• Parkinson’s Choir: Singing away symptoms

Dance Movement Therapy:

• Investigating rhythm, dance and Parkinson’s disease
• Could dance help to treat Parkinson’s disease?
• Dance for Parkinson’s: “We believe in the power of dance”
• Brazilian dance could improve mobility in people with Parkinson’s, study finds
• Dancing with Parkinson’s: “I feel completely changed”
• ‘Performing arts help shake off the burden of Parkinson’s’
• Step up for Parkinson’s: getting people moving in Malta
• Scottish Ballet: dance therapy for Parkinson’s
• Dancing across the globe for Parkinson’s
• Tango treatment: dance to improve your Parkinson’s
• The body-popping dance class that helps people “forget” they have Parkinson’s
• Parkinson’s is left outside – they come here to dance
• Dance like Parkinson’s ain’t watching!
• Dreaming with their feet – ballet programme for PwPs

Creative writing:

• The challenges and joys of writing with Parkinson’s 
• World Poetry Day: Parkinson’s, marriage and grief
• Enter our Parkinson’s Life poetry competition
• “I came home, spoke to my wife, and we cried together” - The Parkinson's Blues
• Why I promise to make poetry, not Parkinson’s disease, my daily challenge

Other resources

Art therapy:

• New Art Initiative Aims to Improve Understanding and Discussion of Parkinson’s Off Periods
• Parkinson's brings out creativity  – article about the research work of Prof. Rivka Inzelberg
• Enhanced creative thinking under dopaminergic therapy in Parkinson disease. Annals of Neurology 2014 Jun. Vol. 75(6); 935-942 - view abstract
• The awakening of artistic creativity and Parkinson's disease. Behavioral Neuroscience 2013 Apr. Vol. 127(2); 256-261 - view abstract

Theatre:

• Modugno N., Iaconelli S., Fiorilli M., Lena F., Kusch I., Mirabella G. (2010). Active Theater as a Complementary Therapy for Parkinson's Disease Rehabilitation: A Pilot Study. TheScientificWorldJOURNAL, Vol. 10; 2301-2313 - view abstract
• Mirabella G., De Vita P., Fragola M., Rampelli S., Lena F., Dilettuso F., Iacopini M., d’Avella R., Borgese M. C., Mazzotta S., Lanni D., Grano M., Lubrani S., Modugno N. (2017). Theatre Is a Valid Add-On Therapeutic Intervention for Emotional Rehabilitation of Parkinson’s Disease Patients. Parkinson’s Disease, Vol. 2017; article ID 7436725, 11 pages - read article