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

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

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.
The above forms of support that include group therapy could
provide a helping hand to appropriately select PWEs, targeted at
improving their QOL. Group therapies are suggested as a treatment
option for PWEs, as they offer peer support, access to information,
sense of belongingness as part of a group with common problems,
and assist in increasing a positive self-image and overcoming
stigma [12,13].
An occupational therapy consulting approach in combination
with a complementary treatment expressive approach, such as
expressive drama activities, could provide an additional way of
obtaining helpful information, advice, and support from peers.
Having a good QOL is not an aspect that can only be achieved
through cognitive guidance. Emotions, feelings, communication,
expression, and body participation are under-recognized in the
well-being process. Nonverbal expressions, such as the use of
image, play, sound, movement, cloth, and other materials, could
provide opportunities to work with populations that are limited
in their verbal expression and deepen the understanding of the
group clientele [14]. Patients with epilepsy are not always verbally
low in their expression, but in many cases, they are made invisible
behind their seizures and suffer from a sense of community stigma.
Drama activities (DAs) use verbal and nonverbal means of expres-
sion and methodically combine the practices of theater and
psychotherapy.
Drama activity is a creative complementary treatment to more
traditional forms of supportive therapy, with its roots in the drama
and theater processes. Participants were encouraged to explore or
re-examine personal or group issues. Drama activity involves a
wide variety of styles, such as transformation, storytelling, use of
masks, movement, work with both the voice and the body,
improvisation, and theater games, including role-play [15]. Drama
activity is being used to help people build communication between
the body and mind, facilitating experiences in the here and now,
without focusing on performance but freeing them from the
pressure they experience. Drama activity has been used in
hospitals, schools, and outpatient centers, especially in addressing
mental health issues and in patients suffering from psychiatric
disorders, guiding them to achieve therapeutic goals [16–19]. In
Greece, dramatherapeutic methodology has been practiced in
PWEs as a psychological treatment with ‘‘Metamyth”Ó philosophy
and practice, being one of the successfully tried approaches.
Valeta T. was the pioneer in bringing together epilepsy and
dramatherapy [20].
Conversely, an occupational therapy consulting approach can
investigate the changes that have occurred in the activities of daily
life due to epilepsy and inform the patient concerning the risks and
offer personalized ergonomic advice and solutions [21].
The purpose of this research was to investigate the possible
changes in the QOL in PWEs after the implementation of an occu-
pational intervention with drama activities. Data collection and
comparison were based on pre- and post-program data from self-
assessment of the QOLIE-31 scale.
2. Methods
2.1. The research protocol
Data were obtained from patients attending our Epilepsy Out-
patient Clinic of Alexandroupolis University Hospital between
September 2018 and December 2019. All procedures performed
in the study were in accordance with the ethical standards of the
Democritus University Ethics Committee, which approved the
study in alignment with the standards of the Declaration of
Helsinki. Informed consent was obtained from all the study
participants.
2
Epilepsy & Behavior 130 (2022) 108694
The research protocol focused on the probable changes after the
intervention program in all aspects of QOL on PWEs. A combination
of methodological approaches was used in this study. Primarily, to
evaluate patient needs, a qualitative approach was chosen to
decide whether the patients had a genuine request and needed
to participate. Second, a quantitative approach was used to
research, measure, and evaluate the impact of a DA approach on
the QOL through an evaluation scale (Greek version of QOLIE-31).
2.2. Participants
Participants in the study were drug-resistant PWEs, who were
monitored and followed up at the epilepsy outpatient clinic of
the Department of Neurology of the Democritus University of
Thrace for 6 months. All patients for whom a medical visit was
organized in the outpatient clinic between September 2018 and
December 2019 were informed about the occupational therapy
program with drama activities (OTDA) regardless of whether or
not they consented to participate. The inclusion criteria were
age  18 years, duration of epilepsy for 1 year, and a stable
antiepileptic drug regimen for the entire duration of the interven-
tion. The exclusion criteria were active treatment of psychiatric
diseases and modifications in antiepileptic drugs. If there was a
need for pharmacological revision and the patient is eligible for
the OTDA process, the patient was still excluded from the analysis.
Individuals undergoing psychiatric or psychological treatment
were not included. The OTDA sessions had a 3-month duration.
The participants had a once weekly group meeting that lasted for
2 h. A total of 12 sessions were completed.
2.3. Data collection
The attending neurologist identified the patients fulfilling the
inclusion criteria, and patients were assessed by an occupational
therapist prior to inclusion. The participants should be very willing
and motivated to participate in the OTDA sessions, because the
success or failure of the venture would be affected by the intention
of self-disclosure and the application of methods and practices to
improve their QOL. Data collection was divided into three stages:
the first stage was the identification of occupational personal
needs; the section stage was the evaluation of the QOL of group
members; and the third stage was the application of the interven-
tion program. The patients who fulfilled the criteria to participate
in the OTDA protocol created five groups consisting of three per-
sons. Once the intervention started, no new members could join
the group. The decision to set a cutting point of three PWEs for
each group was based on the following states: (a) Dividing the time
between fewer individuals offers a more complete and fair distri-
bution of time for personal expression; (b) the introduction of
big groups could involve a higher risk of its members developing
feelings of anxiety and insecurity; (c) if a group was created by
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-
tics of each PWE. A weekly implementation of a common program
in each of the groups was followed, aiming at identical reproduc-
tion of each session for each OTDA group. The sessions were orga-
nized in the afternoon, from Monday to Friday, and the therapist
followed the same program for each of the five groups.
There was no financial obligation for the participants.
2.4. Procedure
2.4.1. The first stage: Identification of personal needs
Initially, each patient was interviewed to reveal his personal
needs. The domains of the first interview were his/her knowledge
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
The first step of the intervention program was an occupational
therapy counseling program that lasted for five weeks. The occupa-
tional therapy–counseling program was organized by a neurolo-
gist, performed by an occupational therapist, and was built on
five axes: 1. knowledge of epilepsy, 2. activities in daily life, 3.
safety at home, 4. safety outdoors, and 5. communication with
family/friends/environment (Table 1).
The project of DA was organized into two axons, the involve-
ment in purposeful daily tasks and the drama activities [22] and
lasted for 7 weeks. The use of drama activities techniques focuses
on exploring the fear and anxiety that a person with epilepsy
may feel and a loss of control or a sense of abandonment from
the stigma of society. The OTDA intervention followed the specific
needs of participants. The primary focus was on the dramatic activ-
ities. Moreover, these works focused on the reflections [22,26]. The
main body of the therapeutic interventions was constructed on
four axons, with a number of drama activities, as shown in Table 2.
2.5. Data analysis
Data analysis was performed using the open-source program
Statistical Processing PSPP v.1.4.0. A Barlett’s test (p <.05) and a
sample adequacy test were concurrently performed with data col-
lection, and a reliability analysis was performed using Cronbach’s
Transforming an object/follow my dance/walk my walk/
9th-10th Character types/roles/emotional expression/
week Self-expression 30
Emotional greetings/calling out Emotions/Creative writing
about life and epilepsy
11th-12th The work is focused on their real lives roles_ their fears created
week by Epilepsy
Recognizing feelings/story telling 28
alpha method (alpha > 0.05). The original scales were correlated
with the factor-reduced solution scales, and the mean score of each
original or reduced scale pre- and post-program was compared
(mean difference). In this study, the framework of explanatory fac-
tor analysis was used. Regarding the demographics of participants,
percentage points were recorded, as well as frequency.
3. Results
The intention to participate in the study lasted for five months.
A total of 26 patients were interested in participating, out of 109
patients who were followed up by the neurological department.
Six PWEs lived in remote areas and refused to participate. Two
PWEs started with the OTDA program, but were excluded as they
discontinued after the second session, while the other three did
not commit to attending their weekly session and they were also
not calculated. No patient was excluded due to medication

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

3
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.

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

6
V. Pinelopi, T. Aikaterini, T. Anna et al.
used, and change instead of improvement or worsening is consid-
ered. An estimated threshold of 5.31 for the total score is associ-
ated with a minimal change in the QOLIE-31 scale. In our
research, the change in the total score is 9.27 points is character-
ized as minimal and much change combined according to the
Borghs scale. These results reveal the impact of the OTDA program
on PWEs, as they determine the changes that have occurred in
their total QOL. The participants who underwent an occupation-
DA program expressed an overall improvement in the quality of
their lives.
In the subscale of emotional well-being, we considered a max-
imum change of 14.5 points with a threshold of 12.69, for much
change. The implementation of a consulting and expressive pro-
gram in PWEs can possibly give back to them more confidence
and strength to feel emotionally healthy according to our findings,
as all PWEs seemed to have benefited (100% percentage of a posi-
tive change).
After the OTDA program, the subscale of energy fatigue showed
a minimal change (participants’ average score was 10 points with
the cut point set at 7.54). A minimal change was considered in sei-
zure worry, as 16.25 points was defined as the mean score of par-
ticipants, with the minimally important change threshold set at
13.43 points.
In contrast, according to our findings, no change was detected
for cognitive and medication subscales. The same result was pre-
sented for the social function subscale, with a very low percentage
(only 6.67%) showing a reliable change. No change in social func-
tion was present in 14 of the 15 PWEs, which should be re-
examined in future studies.
To the best of our knowledge, no articles related to the main
question of our research work concerning the implementation of
a combined occupational therapy-consultant and DA program in
PWEs, presenting quantitative measurements and results regard-
ing QOL, have been reported to date.
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
studies and have been used in few neurological conditions only in
qualitative research protocols. Haste and McKenna support the
clinical effectiveness of DA in neurotrauma recovery as it nurtured
the self-esteem of the group studied, without associating their
results with the QOL of the patient [30]. A pilot study that aimed
to evaluate the effect of DA on the QOL of people suffering from
dementia (mild to moderate) was performed by Jaaniste et al., fol-
lowing our study, which was both a quantitative and a qualitative
approach. The researchers did not focus on the lack of statistical
significance on the QOL score, but underlined an improvement in
the QOL of participants through self-report [31]. These findings
were similar to ours, although they addressed another target
group.
The occupational therapy approach in PWEs has only been stud-
ied by identifying deficits in activities of daily life [32]. The imple-
mentation of a consultant occupational therapy program in PWEs
concerning the QOL, with pre- and post-intervention evidence,
has not been studied. Aliasgharpour et al. reported the positive
effects of an educational program on self-management in PWEs
[33]. Pfaffin revealed better tolerability in antiepileptic drug
administration [34], which is in contrast with our results, as we
did not record any change in the subcategory of the QoLIE-31 for
medication reflecting the beliefs of patients about drug consump-
tion for epilepsy. Guilano et al. conducted a study in Bolivia in
PWEs to assess the changes in the level of knowledge, attitudes,
beliefs, and QOL. Patients with epilepsy underwent assessment
pre- and post-intervention. A significant improvement in knowl-
edge, attitudes, and practices toward epilepsy was revealed, as well
as a reduction in stigma levels [35]. Although in QOL, no significant
7
Epilepsy & Behavior 130 (2022) 108694
changes were recorded after the training, researchers underlined
the patient’s perception of experiencing less depression, fewer
memory difficulties, work or social issues, and less seizure worry
[35]. The medium improvement in the QOL could be interpreted
in accordance with our results for the total QOL [35].
Despite several important findings, the following limitations of
our study should be mentioned. The study was limited by the
heterogeneity of the epilepsy subtypes. The number of PWEs
selected to participate in every group and the internal relationships
in the core of every OTDA group could be subjects under dispute, as
there is a hypothesis that a different group composition could
reflect different individual outcomes. The content of each OTDA
session or the therapist’s attitude may have guided PWEs in engag-
ing in the research. In addition, a limited number of variables was
investigated in this study. More variables could be included for fur-
ther evaluation in the future with similar interventions.
A longitudinal study or randomized controlled trial is suggested
to reduce possible biases and offer causal relationship answers
concerning the difference in the pre- and post-values of QOLIE-
31. Moreover, follow-up examinations may offer significant long-
term results.
5. Conclusion
An occupational therapy-consultation intervention with DAs
positively affects the QOL of PWEs. The combination of these two
interventions could be considered as a complementary approach
for patients suffering from complex diseases, such as epilepsy.
Conflict of interest
The authors declare no conflicts of interest regarding this
research or the preparation of this manuscript.
Acknowledgements
There are no acknowledgments.
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