Exploring The Integration Of Drama Therapy With Neurorehabilitation For Psychosocial And Functional Outcomes A Pilot Study

Exploring The Integration Of Drama Therapy With Neurorehabilitation For Psychosocial And Functional Outcomes A Pilot Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring The Integration Of Drama Therapy With Neurorehabilitation For Psychosocial And Functional Outcomes A Pilot Study Dr. Sanjivani Kamble, Bhargavi Baria, Aditi Mali, Mehak Khanna, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8624445/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 25 You are reading this latest preprint version Abstract Background Neurological disorders frequently impair emotional expression, social interaction and psychological wellbeing dimensions inadequately addressed by conventional rehabilitation protocols alone. Drama therapy an action oriented expressive modality employing theatrical techniques offers a complementary approach to address these psychosocial dimensions during neurological recovery. Objective To evaluate the efficacy of structured drama therapy as an adjunctive intervention alongside conventional neuro rehabilitation in improving psychosocial and functional outcomes in individuals with acquired neurological conditions. Methods A Pilot pretest and posttest design was conducted with 7 participants (mean age 45.3 years) with hemiplegia and paraplegia. Participants received 6 weeks of drama therapy (three 60 minute sessions weekly) alongside conventional physiotherapy. Primary outcomes included perceived stress (Perceived Stress Scale), anxiety and depression (Hospital Anxiety and Depression Scale), self-esteem (Rosenberg Self Esteem Scale), insomnia severity (Insomnia Severity Index), group cohesion (Group Climate Questionnaire) and quality of life (Short Form 36 Health Survey). Analysis employed paired t tests and descriptive statistics. Results Significant improvements were observed in perceived stress (t = 3.38, p = 0.013), depression (t = 2.52, p = 0.045), self-esteem (t = 8.72, p < .001), Physical Component Summary (t = 6.50, p = 0.0007) and Mental Component Summary of quality of life (t = 17.43, p < .0001). Group engagement significantly increased (t = − 7.25, p < .01) and conflict decreased (t = 3.10, p 0.05) showed no significant change. Conclusion Drama therapy demonstrated efficacy in reducing core psychological distress and improving self-esteem and quality of life when integrated with standard neuro rehabilitation. These findings support the integration of expressive creative modalities to address the holistic recovery needs of individuals with neurological conditions. Further randomized controlled trials are warranted to establish definitively the specific mechanisms and long term sustainability of drama therapy benefits. dramatherapy psychosocial outcomes emotional expression neurological disorders Figures Figure 1 Figure 2 Figure 3 1. Introduction 1.1 Clinical Burden of Neurological Disorders Acquired neurological conditions such as stroke, traumatic brain injury and spinal cord injury result in profound alterations to motor, cognitive and psychosocial functioning. While conventional neuro rehabilitation including physiotherapy, occupational therapy and speech language pathology focuses primarily on restoring physical and cognitive capacities. the psychosocial sequelae of neurological injury remain incompletely addressed. Patients frequently experience significant emotional dysregulation, social withdrawal, diminished self-worth and impaired role adjustment factors that substantially impede motivation for rehabilitation participation and long term functional recovery. The impact of these psychosocial challenges on quality of life is substantial. Longitudinal studies document that individuals recovering from stroke and spinal cord injury exhibit elevated rates of depression, anxiety and post traumatic stress with psychological distress acting as an independent predictor of poor functional outcomes and reduced community reintegration. Traditional biomedical rehabilitation models by emphasizing primarily physical restoration, inadvertently neglect the identity reconstruction and emotional processing necessary for holistic recovery. This therapeutic gap underscores the pressing need for integrative patient centered interventions that address both the physical and psychological dimensions of neurological disability. 1.2 Expressive Arts Therapies in Rehabilitation In recent years, expressive art therapies including visual art, music, dance and drama have gained increasing empirical support as adjunctive modalities within rehabilitation settings. These creative approaches operate on the principle that nonverbal embodied expression provides accessible pathways for emotional processing and psychological integration particularly for individuals whose verbal communication or executive cognitive abilities may be compromised post neurological injury. A randomized controlled trial by Kongkasuwan and colleagues demonstrated that integration of creative art therapy with conventional physical therapy for stroke survivors produced superior reductions in depression, improvements in physical function and enhanced quality of life compared to physical therapy alone. Systematic reviews of performing arts interventions in Parkinson disease identified evidence for beneficial effects on quality of life, emotional wellbeing and social participation across dance, singing and theatrical modalities. Furthermore expressive arts based interventions show promise in addressing psychosocial spiritual dimensions of recovery, facilitating emotional catharsis and rebuilding social connectedness in young stroke survivors. 1.3 Drama Therapy: Rationale and Mechanisms Drama therapy, also termed dramatherapy is defined as the deliberate application of dramatic and theatrical processes including role play, improvisation, character work and symbolic enactment to achieve psychological growth, emotional regulation and enhanced social functioning. Unlike theatrical performance drama therapy prioritizes the therapeutic process over aesthetic product creating a psychologically safe container for participants to explore identity, rehearse adaptive coping strategies and experience mastery through successful role enactment. Mechanistically drama therapy facilitates therapeutic change through multiple processes. First role taking enables cognitive reframing and perspective taking. allowing participants to experimentally engage with alternative responses to illness and disability. Second embodied dramatic action provides a physical medium for expressing emotions that may be inaccessible through verbal means alone particularly relevant to individuals with communication impairments. Third the inherent collaborative and improvisational elements of group drama foster interpersonal connection, mutual support and a sense of belonging factors recognized as fundamental therapeutic agents in group settings. Finally witnessing one's own dramatic competence and receiving affirming feedback from peers and facilitators directly counters the diminished self efficacy and identity disruption commonly experienced in the post neurological injury period. 1.4 Literature Gap and Study Rationale Although emerging evidence supports creative and expressive therapies in neurological rehabilitation a distinct paucity of controlled research specifically examines the efficacy of drama therapy as a structured adjunctive intervention in adult populations with acquired neurological conditions such as hemiplegia and paraplegia. Existing literature predominantly focuses on psychiatric, pediatric, or neurodegenerative (e.g. Parkinson's disease) cohorts leaving a critical evidence gap in acute and post acute neuro rehabilitation of motor impaired populations. Additionally most studies employ non randomized designs limiting causal inference regarding drama therapy's specific contribution to recovery. The present Pilot study was designed to address this gap by evaluating whether structured drama therapy when integrated alongside conventional neuro rehabilitation significantly improves validated measures of psychosocial wellbeing (stress, anxiety, depression, self esteem)and functional capacity and quality of life in individuals with acquired neurological conditions. The findings may inform the development of evidence based integrative rehabilitation protocols and advance a holistic biopsychosocial model of neuro rehabilitation practice. 2. Methods 2.1 Study Design and Setting This was a Pilot Study of pre-post design conducted at the Department of Physiotherapy, Dr. D.Y. Patil College of Ayurveda and Research, between. Participants were consecutively recruited from the inpatient rehabilitation ward. Written informed consent was obtained from all participants and where applicable, their legal guardians prior to enrollment. 2.2 Participants and Inclusion/Exclusion Criteria Participants were adults (≥ 18 years) with clinically diagnosed hemiplegia or paraplegia secondary to acquired neurological conditions, admitted for in patient rehabilitation. Inclusion criteria were: ( 1 ) clinically stable medical status; ( 2 ) ability to understand and follow verbal instructions in Hindi; ( 3 ) adequate cognitive capacity to provide informed consent or assent; and ( 4 ) willingness to participate in group drama therapy sessions. Exclusion criteria were: ( 1 ) severe cognitive or communication deficits precluding meaningful participation in drama therapy; ( 2 ) acute or unstable psychiatric or medical conditions contraindicated for group participation; ( 3 ) current acute suicidality or self harm risk; and ( 4 ) significant hearing or vision impairments uncompensated by assistive devices. A total of 10 individuals were initially screened. Three were excluded: one was transferred to an alternative facility, one declined study participation and one was discharged prior to intervention initiation. The final sample comprised 7 participants (6 male, 1 female; mean age 45.3 ± 12.8 years). 2.3 Intervention Protocol 2.3.1 Conventional Physiotherapy All participants received conventional neuro rehabilitation delivered by qualified physiotherapists five days per week. Standard interventions included independent transfer training, core stabilization exercises, upper and lower limb strengthening, balance training and gait training tailored to individual deficits and goals. 2.3.2 Drama Therapy Intervention The drama therapy intervention was structured in three phases over 6 weeks, delivered three times per week in 60 minute sessions by a therapist. Phase 1 (Week 1): Introductory and Individual Sessions An initial group orientation session introduced participants to dramatherapy principles, objectives and group norms establishing psychological safety and informed participation. Thereafter individual drama therapy sessions (approximately 15 minutes each) were conducted with each participant to establish rapport, assess individual preferences and comfort levels and introduce foundational dramatic techniques (e.g. breathing, movement exploration, simple character work). Phase 2 (Weeks 2–5): Group Drama Therapy Sessions Structured group drama therapy sessions (60 minutes, three times weekly) were conducted with all participants. Sessions employed a consistent format ( 1 ) warm up and check in (10 minutes), ( 2 ) focused dramatic work using improvisation, role play and story creation techniques tailored to themes of identity, coping and social connection (35 minutes) and ( 3 ) group reflection and closure (15 minutes). All group sessions were video recorded with participant consent to enable review and performance improvement across sessions. The dramatic content was delivered in Hindi, the language spoken by all participants to ensure comprehension and accessibility. Specific dramatic techniques included: Role play and role reversal : Participants enacted scenarios related to pre and post disability identity, family relationships and coping with functional limitations with opportunity to explore multiple perspectives. Improvisation and ensemble work : Collaborative unscripted creative activities fostered spontaneity, interpersonal responsiveness and mutual support within the group. Symbolic and metaphorical work : Participants used props, movement and symbolic representation to externalize and process emotions associated with neurological injury and recovery. Reflective dialogue : Structured post activity discussion enabled participants to integrate dramatic experience, articulate insights and apply learning to real world situations. Phase 3 (Week 6): Performance and Closure In the final week participants prepared and presented a culminating group drama performance before an audience comprising physiotherapy department staff. This public enactment provided opportunity for participants to demonstrate competence, receive external validation and celebrate collective achievement factors hypothesized to reinforce self esteem and group cohesion. 2.4 Outcome Measures 2.4.1 Primary Psychosocial Outcomes Perceived Stress Scale (PSS). The 10 item PSS assesses the degree to which individuals perceive situations in their lives as unpredictable, uncontrollable and overwhelming over the preceding 2 weeks. Items are rated on a 5 point Likert scale (0 = never to 4 = very often). Total scores range from 0 to 40, with higher scores indicating greater perceived stress. The PSS has demonstrated good reliability (α = 0.78) and validity across diverse populations, including those with chronic illness. Hospital Anxiety and Depression Scale (HADS). The HADS is a 14 item self report instrument comprising two 7 item subscales assessing anxiety (HADS A) and depression (HADS D) symptoms over the preceding 2 weeks specifically designed to minimize overlap with somatic symptoms of medical illness. Items are rated on a 3 or 4 point scale subscale scores range from 0 to 21. The HADS has been extensively validated in medical populations including those with neurological conditions demonstrating adequate internal consistency (α > 0.70 for both subscales) and sensitivity to treatment induced change. Rosenberg Self Esteem Scale (RSES). The RSES is a 10 item unidimensional scale measuring global self worth through self reflective statements rated on a 4 point Likert scale (1 = strongly disagree to 4 = strongly agree). Total scores range from 10 to 40 higher scores indicate more positive self esteem. The RSES is the most widely employed self esteem measure in clinical and research settings with robust psychometric properties (α > 0.80). 2.4.2 Functional and Sleep Outcomes Insomnia Severity Index (ISI). The ISI is a validated 7 item self report measure assessing the nature, severity and impact of insomnia symptoms. Items address sleep onset, sleep maintenance, early morning awakening, sleep dissatisfaction, functional impairment and distress related to insomnia each rated on a 0–4 scale. Total scores range from 0 to 28 with categories 0–7 (no clinically significant insomnia), 8–14 (subthreshold insomnia), 15–21 (clinical insomnia moderate) and 22–28 (clinical insomnia severe). The ISI demonstrates excellent test retest reliability (r = 0.92) and sensitivity to therapeutic change. Modified Barthel Index (mBI). The mBI is a 10 item instrument assessing functional independence in activities of daily living including feeding, personal hygiene, bathing, dressing, transfers, toileting, bladder/bowel continence, ambulation and stair climbing. Each item is scored on a 5 point ordinal scale reflecting the level of assistance required (0 = dependent to 4 = independent). Total scores range from 0 to 100 with higher scores indicating greater functional independence. The mBI is a standard and validated outcome measure in neuro rehabilitation demonstrating strong inter rater reliability and responsiveness to intervention. Short Form 36 Health Survey (SF 36). The SF 36 is a widely used 36 item instrument measuring health related quality of life across 8 domains that are physical functioning, role limitations (physical), bodily pain, general health, vitality, social functioning, role limitations (emotional) and mental health. Responses are transformed to 0 to 100 subscale scores and combined to generate two composite summary scores Physical Component Summary (PCS) and Mental Component Summary (MCS). Higher scores represent better perceived health and wellbeing. The SF 36 has been validated across diverse populations, including those with neurological conditions. 2.4.3 Group Process Outcome Group Climate Questionnaire (GCQ). The GCQ is a 12 item instrument assessing three dimensions of group therapeutic environment: Engagement (mutual trust, active participation, emotional involvement), Conflict (tension, disagreement, confrontation) and Avoidance (withdrawal, reluctance to share). Each item is rated on a 6 point Likert scale (1 = not at all to 6 = extremely). The GCQ has demonstrated adequate internal consistency (subscale α ranging from .73 to .78) and is commonly used to evaluate group therapy dynamics and outcomes. 2.5 Assessment Timeline All outcome measures were completed at baseline (pre intervention) and after 6 weeks of drama therapy intervention (post intervention) with the exception of the mBI which was not formally reported in final analyses due to incomplete data collection across all participants. Baseline assessments were conducted within 48 hours of study enrollment. Post intervention assessments were administered within 48 hours following completion of the 6 week intervention period. 2.6 Data Analysis Descriptive statistics (mean, standard deviation and range) were calculated for all measures. Paired samples t tests were conducted to assess within group pre post differences for continuous outcome variables, with statistical significance defined as p < 0.05 (two tailed). Effect sizes were estimated using Cohen's d. Data analysis was performed using SPSS version 26.0 (IBM Corporation, Armonk, NY, USA). 2.7 Ethical Considerations Written informed consent was obtained from all participants. Participants were informed that participation was voluntary and that they could withdraw at any time without impact on clinical care. Confidentiality and anonymity were ensured in all reporting. There were no anticipated adverse events associated with drama therapy however any participant distress during sessions was managed through established de-escalation techniques and if necessary referral to mental health services. All methods were performed in accordance with the ethical standards of the institutional research committee and in compliance with the Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects. 3. Results 3.1 Participant Characteristics Seven individuals (6 male, 1 female) completed the study. Mean age was 45.3 ± 12.8 years. All participants had diagnoses of acquired neurological conditions five with hemiplegia (secondary to stroke or traumatic brain injury) and two with paraplegia (secondary to spinal cord injury). Mean time from neurological event to study enrollment was 8.6 ± 4.2 weeks. All participants attended a minimum of 15 of 18 scheduled drama therapy sessions (83% attendance rate or). 3.2 Perceived Stress Scale Pre intervention PSS scores (n = 7) ranged from 21 to 33 with a mean of 24.14 ± 4.72 indicating mild to moderate perceived stress. Two participants scored in the high stress range (≥ 27). Post intervention mean PSS score was 18.57 ± 2.23. A paired samples t test revealed a statistically significant reduction in perceived stress from pre to post intervention (t = 3.38, p = 0.013, Cohen's d = 2.14). The mean reduction was 5.57 points (95% confidence interval 1.44–9.70). All participants exhibited reductions in perceived stress scores. the magnitude of change ranged from 2 to 14 points. The decrease in both the mean and standard deviation suggests notable reduction and stabilization of stress levels following the intervention. Table 1 Perceived Stress Scale: Pre and Post Intervention Comparison Measure Mean Score Standard Deviation (SD) Pre Intervention Score 24.14 4.72 Post Intervention Score 18.57 2.23 Statistical Analysis : t = 3.38, p = 0.013*; Cohen's d = 2.14 3.3 Hospital Anxiety and Depression Scale 3.3.1 Depression Subscale Pre intervention HADS D scores (n = 7) ranged from 1 to 11 with a mean of 7.14 ± 3.53. Post intervention mean HADS D score was 6.29 ± 3.45. A paired samples t test indicated a statistically significant decrease in depressive symptoms (t = 2.52, p = 0.045, Cohen's d = 0.96). The mean reduction was 0.86 points (95% confidence interval: 0.03–1.69). Individual changes in depression scores ranged from 0 to 4 point reductions. Participants P03, P04 and P05 demonstrated the most substantial improvements. 3.3.2 Anxiety Subscale Pre intervention HADS A scores ranged from 3 to 14 with a mean of 6.86 ± 3.85. Post intervention mean HADS A score was 6.71 ± 3.90, reflecting minimal overall change. A paired samples t test revealed no statistically significant difference between pre and post intervention anxiety scores (t = 1.00, p = 0.356, Cohen's d = 0.04). The mean change was − 0.14 points (95% confidence interval: −0.48 to 0.21). While some participants (e.g., Mubarak, Sikander) demonstrated modest anxiety reductions, others (e.g., Rohit, Peter) showed no change or slight increases. This variability indicates inconsistent treatment response for anxiety symptoms across the sample. Table 2 Hospital Anxiety and Depression Scale: Pre and Post Intervention Scores Measure Mean Score Standard Deviation (SD) t Value p Value HADS Depression Pre Test 7.14 3.53 2.52 0.045* HADS Depression Post Test 6.29 3.45 HADS Anxiety Pre Test 6.86 3.85 1.00 0.356 HADS Anxiety Post Test 6.71 3.90 3.4 Rosenberg Self Esteem Scale All 7 participants demonstrated improvements in self esteem across the 6 week intervention period. Pre intervention RSES scores ranged from 15 to 23 (out of 30), with a group mean of 19.43 ± 2.57. Post intervention scores ranged from 21 to 27 with a mean of 24.57 ± 2.23. A paired samples t test revealed a statistically significant increase in self esteem (t = 8.72, p < .001, Cohen's d = 2.00). The mean increase was 5.14 points (95% confidence interval: 3.75–6.53). Individual improvements ranged from 2 to 7 points. Participants with initially lower baseline self esteem scores (P07: 15 → 21; P04: 19 → 26; P05: 19 → 26) exhibited the largest absolute gains suggesting particular benefit for those with greater baseline self worth deficits. Table 3 Individual Pre and Post Intervention Rosenberg Self Esteem Scale (RSES) Scores (N = 7) Participant Pre Intervention Score (/30) Post Intervention Score (/30) P01 23 25 P02 18 22 P03 21 25 P04 19 26 P05 19 26 P06 21 27 P07 15 21 Table 4 Group Descriptive Statistics for Rosenberg Self Esteem Scale (RSES) Scores Before and After the Intervention Measure Mean Score Standard Deviation (SD) Pre Intervention Score 19.43 2.57 Post Intervention Score 24.57 2.23 Statistical Analysis t = 8.72, p < .001***; Cohen's d = 2.00 3.5 Insomnia Severity Index Pre intervention ISI scores (n = 7) ranged from 4 to 17 with a mean of 11.57 ± 5.03 indicating mild insomnia on average. Post intervention scores ranged from 6 to 16 with a mean of 11.71 ± 3.99. A paired samples t test revealed no statistically significant difference in insomnia severity (t = − 0.06, p = 0.952). The mean change was + 0.14 points (95% confidence interval: −3.53 to 3.81), indicating minimal overall effect. However, the reduction in standard deviation (from 5.03 to 3.99) suggests that inter individual variability in insomnia symptoms decreased following the intervention, potentially reflecting stabilization of sleep patterns despite lack of significant group level improvement. Individual responses were heterogeneous with three participants improving two remaining stable and two showing slight increases in insomnia severity. Table 5 Insomnia Severity Index: Pre and Post Intervention Comparison Test Mean Standard Deviation Interpretation Pre Test 11.57 5.03 Mild Insomnia Post Test 11.71 3.99 Mild Insomnia Statistical Analysis t = − 0.06, p = 0.952 (not significant) 3.6 Group Climate Questionnaire 3.6.1 Overall Group Climate Pre intervention group climate assessed across the three GCQ dimensions yielded an overall mean score of 2.92 ± 0.53 (range: 2.24–3.54), indicating a moderately balanced yet suboptimal therapeutic environment. Post intervention overall mean was 2.87 ± 0.98 (range: 1.40–4.27). The lack of overall group level change masks dimension specific improvements detailed below. 3.6.2 Engagement Dimension The Engagement dimension increased substantially from pre intervention mean 2.6 to post intervention mean 4.0 reflecting heightened group participation mutual support and emotional involvement. A paired samples t test indicated a statistically significant increase (t = − 7.25, p < .01, Cohen's d = 2.90). This marked improvement suggests that drama therapy successfully fostered active engagement and emotional connection among group members. 3.6.3 Conflict Dimension The Conflict dimension decreased from pre intervention mean 3.66 to post intervention mean 3.0 reflecting a moderate reduction in interpersonal tension and disagreement. A paired samples t test indicated a statistically significant decrease (t = 3.10, p < .05, Cohen's d = 1.24). This pattern is interpreted as beneficial indicating that while some degree of healthy disagreement and openness persisted (reflecting mature group functioning), overall tension and confrontation diminished. 3.6.4 Avoidance Dimension The Avoidance dimension decreased markedly from pre intervention mean 2.5 to post intervention mean 1.6 reflecting substantially reduced withdrawal and emotional reluctance among members. A paired samples t test indicated a statistically significant decrease (t = 5.45, p < .01, Cohen's d = 2.18). Participants demonstrated increased willingness to express emotions, engage in group discussions and participate openly in dramatic activities. Table 6 Group Descriptive Statistics for Group Climate Questionnaire Scores Before and After the Intervention Measure Mean Score Standard Deviation (SD) Pre Intervention Score (Overall) 2.92 0.53 Post Intervention Score (Overall) 2.87 0.98 Table 7 Group Climate Questionnaire Dimension Wise Analysis Dimension Pre Intervention Mean Post Intervention Mean t Value p Value Cohen's d Engagement 2.6 4.0 −7.25 < .01** 2.90 Conflict 3.66 3.0 3.10 < .05* 1.24 Avoidance 2.5 1.6 5.45 < .01** 2.18 3.7 Short Form 36 Quality of Life 3.7.1 Physical Component Summary Pre intervention SF 36 Physical Component Summary (PCS) scores ranged from 20 to 28.7 with a mean of 23.49 ± 3.42. Post intervention PCS scores ranged from 27.5 to 32.5 with a mean of 29.87 ± 2.29. A paired samples t test revealed a statistically significant improvement in perceived physical health and functioning (t = 6.50, p = 0.0007, Cohen's d = 2.60). The mean improvement was 6.38 points (95% confidence interval: 4.20–8.56). All participants demonstrated improvements in perceived physical health, with increases ranging from 2.5 to 10.5 points. 3.7.2 Mental Component Summary Pre intervention SF 36 Mental Component Summary (MCS) scores ranged from 19.9 to 27.2 with a mean of 23.67 ± 2.52. Post intervention MCS scores ranged from 35.2 to 40.6 with a mean of 37.46 ± 1.88. A paired samples t test revealed a highly statistically significant improvement in perceived mental health and emotional wellbeing (t = 17.43, p < .0001, Cohen's d = 6.98). The mean improvement was 13.79 points (95% confidence interval: 12.18–15.40). This represents one of the most pronounced treatment effects observed in the study. All participants exhibited substantial improvements in mental health perception, with increases ranging from 8.2 to 16.7 points. Table 8 Individual Pre and Post Physical Component Summary of SF 36 Quality of Life (N = 7) Participant Pre PCS Post PCS PT1 20 27.5 PT2 21.2 28.7 PT3 25 32.5 PT4 22.5 28.7 PT5 20 28.7 PT6 25 32.5 PT7 24 30.5 Table 9 Individual Pre and Post Mental Component Summary of SF 36 Quality of Life (N = 7) Participant Pre MCS Post MCS PT1 19.9 35.2 PT2 21.5 37.8 PT3 22.8 39.1 PT4 23.2 37.5 PT5 24.1 39.8 PT6 25.3 40.6 PT7 27.2 38.9 Table 10 SF 36 Quality of Life: Pre and Post Intervention Comparison Measure Mean Score Standard Deviation (SD) t Value p Value Cohen's d SF 36 Physical Component Summary Pre 23.49 3.42 6.50 0.0007*** 2.60 SF 36 Physical Component Summary Post 29.87 2.29 SF 36 Mental Component Summary Pre 23.67 2.52 17.43 < .0001*** 6.98 SF 36 Mental Component Summary Post 37.46 1.88 3.8 Summary of Primary Findings The intervention produced statistically significant and clinically meaningful improvements across the majority of psychosocial and quality of life measures. Significant benefits were observed for perceived stress, depressive symptoms, self esteem and both physical and mental components of quality of life. Group climate improved substantially in the dimensions of engagement and avoidance though conflict remained moderate. Anxiety symptoms and insomnia severity did not show significant group level improvement, though individual variability was evident. Table 11 Comprehensive Summary of All Outcome Measures Outcome Measure Pre Intervention M ± SD Post Intervention M ± SD t Value p Value Cohen's d Perceived Stress Scale 24.14 ± 4.72 18.57 ± 2.23 3.38 .013* 2.14 HADS Depression 7.14 ± 3.53 6.29 ± 3.45 2.52 .045* 0.96 HADS Anxiety 6.86 ± 3.85 6.71 ± 3.90 1.00 .356 0.04 Rosenberg Self Esteem 19.43 ± 2.57 24.57 ± 2.23 8.72 < .001*** 2.00 Insomnia Severity Index 11.57 ± 5.03 11.71 ± 3.99 −0.06 .952 −0.03 GCQ Engagement 2.6 4.0 −7.25 < .01** 2.90 GCQ Conflict 3.66 3.0 3.10 < .05* 1.24 GCQ Avoidance 2.5 1.6 5.45 < .01** 2.18 SF 36 Physical Component 23.49 ± 3.42 29.87 ± 2.29 6.50 .0007*** 2.60 SF 36 Mental Component 23.67 ± 2.52 37.46 ± 1.88 17.43 < .0001*** 6.98 Note M = mean; SD = standard deviation; HADS = Hospital Anxiety and Depression Scale; GCQ = Group Climate Questionnaire; SF 36 = Short Form 36 Health Survey. *p < .05; **p < .01; ***p < .001. 4. Discussion 4.1 Primary Findings and Clinical Significance This quasi experimental study provides evidence that structured drama therapy when integrated alongside conventional neuro rehabilitation produces statistically and clinically meaningful improvements in key psychosocial and quality of life domains for individuals with acquired neurological conditions. The most pronounced benefits were observed in mental health perception (Cohen's d = 6.98), self esteem (Cohen's d = 2.00) and physical health perception (Cohen's d = 2.60), with moderately large effects. These findings align with and extend existing literature on expressive arts therapies in medical rehabilitation. 4.2 Mechanisms of Therapeutic Benefit 4.2.1 Emotional Expression and Stress Reduction The significant reduction in perceived stress (p = 0.013) and depressive symptoms (p = 0.045) suggests that drama therapy facilitated emotional processing and cognitive reframing of illness experiences. Drama therapy capacity for symbolic, embodied and metaphorical expression may provide access to emotional material inaccessible through conventional talk therapy particularly valuable for individuals with communication impairments secondary to neurological injury. The enactment and externalization of stressors through dramatic means may enable cognitive distance and perspective taking, reducing subjective distress and fostering adaptive coping. The lack of significant anxiety reduction despite improvements in stress and depression warrants consideration. Anxiety may represent a more persistent trait like feature in some individuals recovering from neurological injury potentially requiring longer intervention periods or supplementary cognitive behavioral approaches. Alternatively the short intervention duration (6 weeks) may be insufficient to substantially modify anxiety patterns in those with chronic treatment resistant symptoms. 4.2.2 Identity Reconstruction and Self Esteem The large and highly significant increase in self esteem (p < .001, Cohen's d = 2.00) represents one of the study's most meaningful findings. Neurological injury frequently precipitates identity disruption and loss of self worth as individuals grapple with altered physical capacity changes in social roles and revised self concepts. Drama therapy unique capacity to facilitate role exploration and role taking within a supportive environment directly targets these identity related challenges. By successfully embodying diverse characters and witnessing their own dramatic competence participants experienced direct evidence of personal agency and capacity despite physical limitations directly counteracting the learned helplessness and reduced self efficacy associated with acquired disability. 4.2.3 Group Cohesion and Social Connection The marked improvements in group engagement (p < .01) and reduction in avoidance (p < .01) indicate that drama therapy successfully fostered interpersonal connection and psychological safety. This is theoretically important because social isolation and reduced interpersonal engagement are common post neurological injury complications that independently predict poor psychological outcomes. The collaborative, improvisational and ensemble based nature of drama therapy inherently promotes mutual interdependence, peer validation and sense of belonging mechanisms recognized as fundamental therapeutic agents in group based interventions. 4.3 Quality of Life and Functional Benefits The highly significant improvements in both physical (p = 0.0007) and mental components of quality of life (p < .0001) suggest substantial carry over effects from psychosocial gains to global well being perception. This pattern is consistent with an integrated biopsychosocial model of recovery wherein psychological stabilization facilitates enhanced engagement in rehabilitation improved motivation and greater functional gains. The large effect size for mental health perception (Cohen's d = 6.98) is particularly noteworthy and suggests that drama therapy exerts profound effects on subjective well being and life satisfaction. 4.4 Lack of Significant Sleep Improvement The absence of significant change in insomnia severity (p = 0.952) is notable. Although insomnia is frequently comorbid with depression and anxiety in neurological populations and both of these symptoms improved, sleep quality did not follow the expected pattern. This may reflect the multi factorial etiology of insomnia in neurological populations (including pain, spasticity, nocturia and neurobiological factors) that may be less amenable to psychosocial intervention alone. Alternatively the 6 week intervention period may be insufficient for substantial sleep architecture change which typically develop more gradually. The reduction in inter individual variability (standard deviation decreased from 5.03 to 3.99) however suggests potential stabilization of sleep patterns deserving further investigation. 4.5 Comparison with Existing Literature These findings are broadly congruent with prior research on creative arts therapies in rehabilitation. Kongkasuwan's randomized trial of creative art therapy in stroke patients documented significant reductions in depression and improvements in physical function and quality of life paralleling the current findings. Similarly systematic reviews of performing arts interventions (including theater and drama) in Parkinson's disease identified robust effects on quality of life and emotional wellbeing consistent with the substantial mental health improvements observed here. However, the current study extends existing literature by specifically examining a structured protocol driven drama therapy intervention in a medically diverse neurological population employing a broader battery of validated psychosocial and functional outcome measures. The Pilot Study while limited in causal inference nevertheless provides preliminary evidence of efficacy that warrants follow up randomized controlled trials. 4.6 Study Limitations Several methodological limitations warrant explicit acknowledgment and discussion: Small sample size and lack of control group : With n = 7 and no untreated control group, the study cannot definitively establish that improvements are attributable to drama therapy rather than to: ( 1 ) nonspecific therapeutic attention or social contact ( 2 ) temporal changes in recovery trajectory independent of intervention or ( 3 ) placebo/expectancy effects. Absence of long term follow up Post intervention assessments were conducted immediately upon completion of the 6 week intervention. The sustainability of psychological and functional gains beyond the immediate post intervention period remains unknown. Longer term follow up (e.g., 3, 6, 12 months) is essential to determine whether benefits persist and whether participants maintain engagement with learned coping strategies. Heterogeneous neurological diagnoses The sample included individuals with stroke, traumatic brain injury and spinal cord injury etiologically and neurobiologically distinct conditions. Outcome heterogeneity may reflect differential responsiveness across diagnoses stratified analyses by diagnosis were not possible given the small sample size. Lack of attention to individual differences While the study reports group level statistics, individual response patterns were heterogeneous (e.g., some participants improved substantially in anxiety while others did not). Systematic exploration of baseline characteristics predicting treatment response (e.g., baseline depression severity, cognitive status, motivation) was not conducted. Non blinded assessment The absence of blinded outcome assessment increases risk of observer bias particularly for subjective measures. Participants' knowledge of study hypotheses may have influenced self report responses. Absence of treatment fidelity monitoring While session attendance was high systematic documentation of drama therapy delivery consistency protocol adherence and therapist competence were not provided limiting confidence in the independent variable's integrity. 4.7 Implications and Future Directions Despite these limitations the findings have several important implications. First they provide preliminary evidence that structured protocol driven drama therapy is feasible and acceptable in in patient neuro rehabilitation settings as evidenced by high attendance rates and positive participant feedback. Second the magnitude of benefits particularly for mental health and self esteem suggests drama therapy warrants further investigation as a complementary modality. Third the heterogeneity in individual responses indicates need for research identifying baseline characteristics or moderating variables that predict optimal responsiveness to drama therapy. Future research should prioritize: ( 1 ) randomized controlled trials with adequate sample sizes and active or waitlist control groups to establish definitive efficacy and isolate drama therapy's specific contribution ( 2 ) longer term follow up (≥ 6 months) to determine sustainability of gains ( 3 ) stratified or subgroup analyses examining differential effects across neurological diagnoses ( 4 ) investigation of mechanisms of change through mediational analyses ( 5 ) assessment of cost effectiveness and feasibility in diverse rehabilitation settings and ( 6 ) qualitative research exploring participants' subjective experience of drama therapy and mechanisms underlying perceived benefit. 5. Conclusion This study provides preliminary evidence that drama therapy when integrated as an adjunctive modality alongside conventional neuro rehabilitation significantly improves key psychosocial and quality of life outcomes in individuals with acquired neurological conditions. Participants demonstrated statistically significant improvements in perceived stress, depressive symptoms, self esteem, physical and mental health perception and group cohesion. These findings support the integration of expressive action oriented creative modalities to address the holistic recovery needs of individuals navigating neurological rehabilitation. The psychosocial benefits observed particularly the large improvements in self esteem and mental health perception represent meaningful gains for individuals whose identity and psychological well being are substantially compromised by neurological injury. The fostering of group cohesion and interpersonal connection addresses an important dimension of recovery often neglected by biomedically focused rehabilitation. However, the pilot study, small sample and lack of control group preclude definitive causal attribution. Rigorous randomized controlled trials are necessary to establish the specific efficacy of drama therapy determine optimal intervention parameters and identify individuals most likely to benefit. Future research should also examine mechanisms of change longer term sustainability of benefits and cost effectiveness in diverse rehabilitation contexts. In summary drama therapy shows promise as evidence informed patient centered adjunct to conventional neuro rehabilitation. Integration of such creative modalities within mainstream rehabilitation practice could advance toward a truly holistic biopsychosocial model of neuro rehabilitation that addresses not only physical and cognitive restoration but also the profound psychological and existential challenges inherent in neurological recovery. Declarations Conflict of Interest Statement: The authors declare no conflicts of interest. Funding Statement: This research received no specific grant from any public, commercial, or not for profit funding agency. Data Availability Statement: The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request, subject to ethical approvals and participant confidentiality protections Consent to Publish declaration : Informed consent for publication of anonymized data was obtained from all participants. Ethics declaration : The study was approved by the Institutional Sub Ethics Committee of Dr D Y Patil College of Physiotherapy Pimpri Pune Maharashtra India under Dr D Y Patil Vidyapeeth Pune. Consent to Participate declaration : Written informed consent was obtained from all participants and their caregivers prior to participation in the study. Author contributions S.K. conceived and designed the study, supervised the project and critically revised the manuscript for important intellectual content.B.B. contributed to participant recruitment, data collection and drafting of the methods and results sections.A.M. helped implement the intervention, coordinated drama therapy sessions and contributed to writing the intervention protocol.M.K. conducted the literature review, assisted in data entry and drafted parts of the introduction and discussion.R.N. administered outcome measures, managed study documentation and contributed to revision of the results section.A.N. assisted with group facilitation during drama therapy sessions, contributed to interpretation of clinical findings and reviewed the manuscript for clinical relevance.A.S. supported statistical analysis, prepared tables and critically reviewed the discussion and conclusion.T.D. managed references, formatting and language editing and contributed to final manuscript preparation.A.B. assisted in background literature search, organization of figures and tables and gave final approval of the version to be submitted. O.P. Drafted the full manuscript. All authors discussed the results commented on previous versions of the manuscript and approved the final manuscript and agree to be accountable for all aspects of the work. References Langhorne P, Bernhardt J, Leape B. Stroke rehabilitation. Lancet. 2011;377(9778):16931702. Salter K, Foley N, Teasell R. Psychological considerations in stroke recovery. Top Stroke Rehabil. 2010;17(5):338346. Hackett ML, Pickles K. Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies. Int J Stroke. 2014;9(8):10171025. Sagen U, Vik TG, Moum T, Mørland T, Finset A, Dammen T. Screening for depression and anxiety after stroke: comparison of the Hospital Anxiety and Depression Scale and the Montgomery and Åsberg Depression Rating Scale. J Psychosom Res. 2009;67(4):330335. Cao Y, Rajkumar R, Weingarten CP, Faraco CC, Pulay AJ. Post stroke depression: impact of lesion location and across different neurological recovery phases. Front Neurol. 2016;7:90. Vangent G, Nicol A, Ashworth M. An exploration of the impact of stroke on the identity, role and sexuality of younger adults: implications for occupational therapy. Disabil Rehabil. 2012;34(12):10181026. Eyre HA, Acevedo B, Yang H, Siddarth P, Van Dyk K, Ercoli L, et al. Changes in neural connectivity and BOLD activation during creative cognition after a one week multisensory art intervention. Behav Brain Res. 2016;305:112116. Kaimal G, Ayaz H, Herres J. Neurophysiological measures of aesthetic experience and its connection with creativity. In: Pelowski M, Akiba F, Leder H, PGiorgio R, editors. Aesthetic Science: Connecting Minds, Brains and Experiences. Oxford University Press; 2017. p. 189215. Kongkasuwan R, Voraakhom K, Mankongdej U, Ung NO, Jivaoin T. Creative art therapy to enhance rehabilitation for stroke patients. J Stroke Cerebrovasc Dis. 2016;25(2):441447. Barnish MS, Barran SM. Active group based performing arts interventions in Parkinson's disease: an updated systematic review and meta-analysis. Front Neurol. 2025;16:1314586. Fung K, Ho RTH, Fung J. A randomised controlled trial of expressive arts based intervention for young stroke survivors: protocol and baseline characteristics. JMIR Res Protoc. 2020;9(12):e23729. Jones P. Drama as Therapy: Theory, Practice and Research. 3rd ed. Routledge; 2012. Berghs S, Atkin K, Graham H, Hubbard R, Parkinson J. Drama therapy for children and adolescents with mental health problems: a systematic review. Front Psychiatry. 2022;13:808826. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385396. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67(6):361370. Aben I, Verhey F, Lousberg R, Lodder J, Honig A. Validity of the Hospital Anxiety and Depression Scale for use with patients with stroke. J Psychosom Res. 2002;52(1):3337. Rosenberg M. Society and the Adolescent Self Image. Princeton University Press; 1965. Morin CM, Belleville G, Bélanger L, Ivers H. The insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601608. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:6165. Ware JE, Sherbourne CD. The MOS 36 item Short Form Health Survey (SF 36). Med Care. 1992;30(6):473483. MacKenzie KR, Tschuschke V. Relatability: essence of the curative milieu. Int J Ther Communities. 1993;14(2):131143. Oczkowski C, Mazzini L, Parekh JR, Lauda F, Kraglievich G, González A, et al. The use of melatonin in managing post stroke sleep disorders: a systematic review. Sleep Med Rev. 2017;34:6171. Additional Declarations No competing interests reported. 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Introduction","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Clinical Burden of Neurological Disorders\u003c/h2\u003e \u003cp\u003eAcquired neurological conditions such as stroke, traumatic brain injury and spinal cord injury result in profound alterations to motor, cognitive and psychosocial functioning. While conventional neuro rehabilitation including physiotherapy, occupational therapy and speech language pathology focuses primarily on restoring physical and cognitive capacities. the psychosocial sequelae of neurological injury remain incompletely addressed. Patients frequently experience significant emotional dysregulation, social withdrawal, diminished self-worth and impaired role adjustment factors that substantially impede motivation for rehabilitation participation and long term functional recovery.\u003c/p\u003e \u003cp\u003eThe impact of these psychosocial challenges on quality of life is substantial. Longitudinal studies document that individuals recovering from stroke and spinal cord injury exhibit elevated rates of depression, anxiety and post traumatic stress with psychological distress acting as an independent predictor of poor functional outcomes and reduced community reintegration. Traditional biomedical rehabilitation models by emphasizing primarily physical restoration, inadvertently neglect the identity reconstruction and emotional processing necessary for holistic recovery. This therapeutic gap underscores the pressing need for integrative patient centered interventions that address both the physical and psychological dimensions of neurological disability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Expressive Arts Therapies in Rehabilitation\u003c/h2\u003e \u003cp\u003eIn recent years, expressive art therapies including visual art, music, dance and drama have gained increasing empirical support as adjunctive modalities within rehabilitation settings. These creative approaches operate on the principle that nonverbal embodied expression provides accessible pathways for emotional processing and psychological integration particularly for individuals whose verbal communication or executive cognitive abilities may be compromised post neurological injury.\u003c/p\u003e \u003cp\u003eA randomized controlled trial by Kongkasuwan and colleagues demonstrated that integration of creative art therapy with conventional physical therapy for stroke survivors produced superior reductions in depression, improvements in physical function and enhanced quality of life compared to physical therapy alone. Systematic reviews of performing arts interventions in Parkinson disease identified evidence for beneficial effects on quality of life, emotional wellbeing and social participation across dance, singing and theatrical modalities. Furthermore expressive arts based interventions show promise in addressing psychosocial spiritual dimensions of recovery, facilitating emotional catharsis and rebuilding social connectedness in young stroke survivors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Drama Therapy: Rationale and Mechanisms\u003c/h2\u003e \u003cp\u003eDrama therapy, also termed dramatherapy is defined as the deliberate application of dramatic and theatrical processes including role play, improvisation, character work and symbolic enactment to achieve psychological growth, emotional regulation and enhanced social functioning. Unlike theatrical performance drama therapy prioritizes the therapeutic process over aesthetic product creating a psychologically safe container for participants to explore identity, rehearse adaptive coping strategies and experience mastery through successful role enactment.\u003c/p\u003e \u003cp\u003eMechanistically drama therapy facilitates therapeutic change through multiple processes. First role taking enables cognitive reframing and perspective taking. allowing participants to experimentally engage with alternative responses to illness and disability. Second embodied dramatic action provides a physical medium for expressing emotions that may be inaccessible through verbal means alone particularly relevant to individuals with communication impairments. Third the inherent collaborative and improvisational elements of group drama foster interpersonal connection, mutual support and a sense of belonging factors recognized as fundamental therapeutic agents in group settings. Finally witnessing one's own dramatic competence and receiving affirming feedback from peers and facilitators directly counters the diminished self efficacy and identity disruption commonly experienced in the post neurological injury period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Literature Gap and Study Rationale\u003c/h2\u003e \u003cp\u003eAlthough emerging evidence supports creative and expressive therapies in neurological rehabilitation a distinct paucity of controlled research specifically examines the efficacy of drama therapy as a structured adjunctive intervention in adult populations with acquired neurological conditions such as hemiplegia and paraplegia. Existing literature predominantly focuses on psychiatric, pediatric, or neurodegenerative (e.g. Parkinson's disease) cohorts leaving a critical evidence gap in acute and post acute neuro rehabilitation of motor impaired populations. Additionally most studies employ non randomized designs limiting causal inference regarding drama therapy's specific contribution to recovery.\u003c/p\u003e \u003cp\u003eThe present Pilot study was designed to address this gap by evaluating whether structured drama therapy when integrated alongside conventional neuro rehabilitation significantly improves validated measures of psychosocial wellbeing (stress, anxiety, depression, self esteem)and functional capacity and quality of life in individuals with acquired neurological conditions. The findings may inform the development of evidence based integrative rehabilitation protocols and advance a holistic biopsychosocial model of neuro rehabilitation practice.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design and Setting\u003c/h2\u003e \u003cp\u003eThis was a Pilot Study of pre-post design conducted at the Department of Physiotherapy, Dr. D.Y. Patil College of Ayurveda and Research, between. Participants were consecutively recruited from the inpatient rehabilitation ward. Written informed consent was obtained from all participants and where applicable, their legal guardians prior to enrollment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants and Inclusion/Exclusion Criteria\u003c/h2\u003e \u003cp\u003eParticipants were adults (\u0026ge;\u0026thinsp;18 years) with clinically diagnosed hemiplegia or paraplegia secondary to acquired neurological conditions, admitted for in patient rehabilitation. Inclusion criteria were: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) clinically stable medical status; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) ability to understand and follow verbal instructions in Hindi; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) adequate cognitive capacity to provide informed consent or assent; and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) willingness to participate in group drama therapy sessions.\u003c/p\u003e \u003cp\u003eExclusion criteria were: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) severe cognitive or communication deficits precluding meaningful participation in drama therapy; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) acute or unstable psychiatric or medical conditions contraindicated for group participation; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) current acute suicidality or self harm risk; and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) significant hearing or vision impairments uncompensated by assistive devices.\u003c/p\u003e \u003cp\u003eA total of 10 individuals were initially screened. Three were excluded: one was transferred to an alternative facility, one declined study participation and one was discharged prior to intervention initiation. The final sample comprised 7 participants (6 male, 1 female; mean age 45.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8 years).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Intervention Protocol\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Conventional Physiotherapy\u003c/h2\u003e \u003cp\u003eAll participants received conventional neuro rehabilitation delivered by qualified physiotherapists five days per week. Standard interventions included independent transfer training, core stabilization exercises, upper and lower limb strengthening, balance training and gait training tailored to individual deficits and goals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Drama Therapy Intervention\u003c/h2\u003e \u003cp\u003eThe drama therapy intervention was structured in three phases over 6 weeks, delivered three times per week in 60 minute sessions by a therapist.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 1 (Week 1): Introductory and Individual Sessions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAn initial group orientation session introduced participants to dramatherapy principles, objectives and group norms establishing psychological safety and informed participation. Thereafter individual drama therapy sessions (approximately 15 minutes each) were conducted with each participant to establish rapport, assess individual preferences and comfort levels and introduce foundational dramatic techniques (e.g. breathing, movement exploration, simple character work).\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 2 (Weeks 2\u0026ndash;5): Group Drama Therapy Sessions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStructured group drama therapy sessions (60 minutes, three times weekly) were conducted with all participants. Sessions employed a consistent format (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) warm up and check in (10 minutes), (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) focused dramatic work using improvisation, role play and story creation techniques tailored to themes of identity, coping and social connection (35 minutes) and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) group reflection and closure (15 minutes). All group sessions were video recorded with participant consent to enable review and performance improvement across sessions.\u003c/p\u003e \u003cp\u003eThe dramatic content was delivered in Hindi, the language spoken by all participants to ensure comprehension and accessibility. Specific dramatic techniques included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eRole play and role reversal\u003c/b\u003e: Participants enacted scenarios related to pre and post disability identity, family relationships and coping with functional limitations with opportunity to explore multiple perspectives.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eImprovisation and ensemble work\u003c/b\u003e: Collaborative unscripted creative activities fostered spontaneity, interpersonal responsiveness and mutual support within the group.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSymbolic and metaphorical work\u003c/b\u003e: Participants used props, movement and symbolic representation to externalize and process emotions associated with neurological injury and recovery.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eReflective dialogue\u003c/b\u003e: Structured post activity discussion enabled participants to integrate dramatic experience, articulate insights and apply learning to real world situations.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 3 (Week 6): Performance and Closure\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn the final week participants prepared and presented a culminating group drama performance before an audience comprising physiotherapy department staff. This public enactment provided opportunity for participants to demonstrate competence, receive external validation and celebrate collective achievement factors hypothesized to reinforce self esteem and group cohesion.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Outcome Measures\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1 Primary Psychosocial Outcomes\u003c/h2\u003e \u003cp\u003e \u003cb\u003ePerceived Stress Scale (PSS).\u003c/b\u003e The 10 item PSS assesses the degree to which individuals perceive situations in their lives as unpredictable, uncontrollable and overwhelming over the preceding 2 weeks. Items are rated on a 5 point Likert scale (0\u0026thinsp;=\u0026thinsp;never to 4\u0026thinsp;=\u0026thinsp;very often). Total scores range from 0 to 40, with higher scores indicating greater perceived stress. The PSS has demonstrated good reliability (α\u0026thinsp;=\u0026thinsp;0.78) and validity across diverse populations, including those with chronic illness.\u003c/p\u003e \u003cp\u003e \u003cb\u003eHospital Anxiety and Depression Scale (HADS).\u003c/b\u003e The HADS is a 14 item self report instrument comprising two 7 item subscales assessing anxiety (HADS A) and depression (HADS D) symptoms over the preceding 2 weeks specifically designed to minimize overlap with somatic symptoms of medical illness. Items are rated on a 3 or 4 point scale subscale scores range from 0 to 21. The HADS has been extensively validated in medical populations including those with neurological conditions demonstrating adequate internal consistency (α\u0026thinsp;\u0026gt;\u0026thinsp;0.70 for both subscales) and sensitivity to treatment induced change.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRosenberg Self Esteem Scale (RSES).\u003c/b\u003e The RSES is a 10 item unidimensional scale measuring global self worth through self reflective statements rated on a 4 point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree to 4\u0026thinsp;=\u0026thinsp;strongly agree). Total scores range from 10 to 40 higher scores indicate more positive self esteem. The RSES is the most widely employed self esteem measure in clinical and research settings with robust psychometric properties (α\u0026thinsp;\u0026gt;\u0026thinsp;0.80).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e2.4.2 Functional and Sleep Outcomes\u003c/h2\u003e \u003cp\u003e \u003cb\u003eInsomnia Severity Index (ISI).\u003c/b\u003e The ISI is a validated 7 item self report measure assessing the nature, severity and impact of insomnia symptoms. Items address sleep onset, sleep maintenance, early morning awakening, sleep dissatisfaction, functional impairment and distress related to insomnia each rated on a 0\u0026ndash;4 scale. Total scores range from 0 to 28 with categories 0\u0026ndash;7 (no clinically significant insomnia), 8\u0026ndash;14 (subthreshold insomnia), 15\u0026ndash;21 (clinical insomnia moderate) and 22\u0026ndash;28 (clinical insomnia severe). The ISI demonstrates excellent test retest reliability (r\u0026thinsp;=\u0026thinsp;0.92) and sensitivity to therapeutic change.\u003c/p\u003e \u003cp\u003e \u003cb\u003eModified Barthel Index (mBI).\u003c/b\u003e The mBI is a 10 item instrument assessing functional independence in activities of daily living including feeding, personal hygiene, bathing, dressing, transfers, toileting, bladder/bowel continence, ambulation and stair climbing. Each item is scored on a 5 point ordinal scale reflecting the level of assistance required (0\u0026thinsp;=\u0026thinsp;dependent to 4\u0026thinsp;=\u0026thinsp;independent). Total scores range from 0 to 100 with higher scores indicating greater functional independence. The mBI is a standard and validated outcome measure in neuro rehabilitation demonstrating strong inter rater reliability and responsiveness to intervention.\u003c/p\u003e \u003cp\u003e \u003cb\u003eShort Form 36 Health Survey (SF 36).\u003c/b\u003e The SF 36 is a widely used 36 item instrument measuring health related quality of life across 8 domains that are physical functioning, role limitations (physical), bodily pain, general health, vitality, social functioning, role limitations (emotional) and mental health. Responses are transformed to 0 to 100 subscale scores and combined to generate two composite summary scores Physical Component Summary (PCS) and Mental Component Summary (MCS). Higher scores represent better perceived health and wellbeing. The SF 36 has been validated across diverse populations, including those with neurological conditions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e2.4.3 Group Process Outcome\u003c/h2\u003e \u003cp\u003e \u003cb\u003eGroup Climate Questionnaire (GCQ).\u003c/b\u003e The GCQ is a 12 item instrument assessing three dimensions of group therapeutic environment: Engagement (mutual trust, active participation, emotional involvement), Conflict (tension, disagreement, confrontation) and Avoidance (withdrawal, reluctance to share). Each item is rated on a 6 point Likert scale (1\u0026thinsp;=\u0026thinsp;not at all to 6\u0026thinsp;=\u0026thinsp;extremely). The GCQ has demonstrated adequate internal consistency (subscale α ranging from .73 to .78) and is commonly used to evaluate group therapy dynamics and outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Assessment Timeline\u003c/h2\u003e \u003cp\u003eAll outcome measures were completed at baseline (pre intervention) and after 6 weeks of drama therapy intervention (post intervention) with the exception of the mBI which was not formally reported in final analyses due to incomplete data collection across all participants. Baseline assessments were conducted within 48 hours of study enrollment. Post intervention assessments were administered within 48 hours following completion of the 6 week intervention period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Data Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics (mean, standard deviation and range) were calculated for all measures. Paired samples t tests were conducted to assess within group pre post differences for continuous outcome variables, with statistical significance defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (two tailed). Effect sizes were estimated using Cohen's d. Data analysis was performed using SPSS version 26.0 (IBM Corporation, Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Ethical Considerations\u003c/h2\u003e \u003cp\u003eWritten informed consent was obtained from all participants. Participants were informed that participation was voluntary and that they could withdraw at any time without impact on clinical care. Confidentiality and anonymity were ensured in all reporting. There were no anticipated adverse events associated with drama therapy however any participant distress during sessions was managed through established de-escalation techniques and if necessary referral to mental health services. All methods were performed in accordance with the ethical standards of the institutional research committee and in compliance with the Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participant Characteristics\u003c/h2\u003e \u003cp\u003eSeven individuals (6 male, 1 female) completed the study. Mean age was 45.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8 years. All participants had diagnoses of acquired neurological conditions five with hemiplegia (secondary to stroke or traumatic brain injury) and two with paraplegia (secondary to spinal cord injury). Mean time from neurological event to study enrollment was 8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2 weeks. All participants attended a minimum of 15 of 18 scheduled drama therapy sessions (83% attendance rate or).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Perceived Stress Scale\u003c/h2\u003e \u003cp\u003ePre intervention PSS scores (n\u0026thinsp;=\u0026thinsp;7) ranged from 21 to 33 with a mean of 24.14\u0026thinsp;\u0026plusmn;\u0026thinsp;4.72 indicating mild to moderate perceived stress. Two participants scored in the high stress range (\u0026ge;\u0026thinsp;27). Post intervention mean PSS score was 18.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23. A paired samples t test revealed a statistically significant reduction in perceived stress from pre to post intervention (t\u0026thinsp;=\u0026thinsp;3.38, p\u0026thinsp;=\u0026thinsp;0.013, Cohen's d\u0026thinsp;=\u0026thinsp;2.14). The mean reduction was 5.57 points (95% confidence interval 1.44\u0026ndash;9.70). All participants exhibited reductions in perceived stress scores. the magnitude of change ranged from 2 to 14 points. The decrease in both the mean and standard deviation suggests notable reduction and stabilization of stress levels following the intervention.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerceived Stress Scale: Pre and Post Intervention Comparison\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre Intervention Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost Intervention Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eStatistical Analysis\u003c/b\u003e: t\u0026thinsp;=\u0026thinsp;3.38, p\u0026thinsp;=\u0026thinsp;0.013*; Cohen's d\u0026thinsp;=\u0026thinsp;2.14\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Hospital Anxiety and Depression Scale\u003c/h2\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Depression Subscale\u003c/h2\u003e \u003cp\u003ePre intervention HADS D scores (n\u0026thinsp;=\u0026thinsp;7) ranged from 1 to 11 with a mean of 7.14\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53. Post intervention mean HADS D score was 6.29\u0026thinsp;\u0026plusmn;\u0026thinsp;3.45. A paired samples t test indicated a statistically significant decrease in depressive symptoms (t\u0026thinsp;=\u0026thinsp;2.52, p\u0026thinsp;=\u0026thinsp;0.045, Cohen's d\u0026thinsp;=\u0026thinsp;0.96). The mean reduction was 0.86 points (95% confidence interval: 0.03\u0026ndash;1.69). Individual changes in depression scores ranged from 0 to 4 point reductions. Participants P03, P04 and P05 demonstrated the most substantial improvements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Anxiety Subscale\u003c/h2\u003e \u003cp\u003ePre intervention HADS A scores ranged from 3 to 14 with a mean of 6.86\u0026thinsp;\u0026plusmn;\u0026thinsp;3.85. Post intervention mean HADS A score was 6.71\u0026thinsp;\u0026plusmn;\u0026thinsp;3.90, reflecting minimal overall change. A paired samples t test revealed no statistically significant difference between pre and post intervention anxiety scores (t\u0026thinsp;=\u0026thinsp;1.00, p\u0026thinsp;=\u0026thinsp;0.356, Cohen's d\u0026thinsp;=\u0026thinsp;0.04). The mean change was \u0026minus;\u0026thinsp;0.14 points (95% confidence interval: \u0026minus;0.48 to 0.21). While some participants (e.g., Mubarak, Sikander) demonstrated modest anxiety reductions, others (e.g., Rohit, Peter) showed no change or slight increases. This variability indicates inconsistent treatment response for anxiety symptoms across the sample.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHospital Anxiety and Depression Scale: Pre and Post Intervention Scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHADS Depression Pre Test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.045*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHADS Depression Post Test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHADS Anxiety Pre Test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.356\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHADS Anxiety Post Test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Rosenberg Self Esteem Scale\u003c/h2\u003e \u003cp\u003eAll 7 participants demonstrated improvements in self esteem across the 6 week intervention period. Pre intervention RSES scores ranged from 15 to 23 (out of 30), with a group mean of 19.43\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57. Post intervention scores ranged from 21 to 27 with a mean of 24.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23. A paired samples t test revealed a statistically significant increase in self esteem (t\u0026thinsp;=\u0026thinsp;8.72, p \u0026lt; .001, Cohen's d\u0026thinsp;=\u0026thinsp;2.00). The mean increase was 5.14 points (95% confidence interval: 3.75\u0026ndash;6.53). Individual improvements ranged from 2 to 7 points. Participants with initially lower baseline self esteem scores (P07: 15 \u0026rarr; 21; P04: 19 \u0026rarr; 26; P05: 19 \u0026rarr; 26) exhibited the largest absolute gains suggesting particular benefit for those with greater baseline self worth deficits.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIndividual Pre and Post Intervention Rosenberg Self Esteem Scale (RSES) Scores (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre Intervention Score (/30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost Intervention Score (/30)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGroup Descriptive Statistics for Rosenberg Self Esteem Scale (RSES) Scores Before and After the Intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre Intervention Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost Intervention Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStatistical Analysis\u003c/strong\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;8.72, p \u0026lt; .001***; Cohen's d\u0026thinsp;=\u0026thinsp;2.00\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Insomnia Severity Index\u003c/h2\u003e \u003cp\u003ePre intervention ISI scores (n\u0026thinsp;=\u0026thinsp;7) ranged from 4 to 17 with a mean of 11.57\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03 indicating mild insomnia on average. Post intervention scores ranged from 6 to 16 with a mean of 11.71\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99. A paired samples t test revealed no statistically significant difference in insomnia severity (t\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.06, p\u0026thinsp;=\u0026thinsp;0.952). The mean change was +\u0026thinsp;0.14 points (95% confidence interval: \u0026minus;3.53 to 3.81), indicating minimal overall effect. However, the reduction in standard deviation (from 5.03 to 3.99) suggests that inter individual variability in insomnia symptoms decreased following the intervention, potentially reflecting stabilization of sleep patterns despite lack of significant group level improvement. Individual responses were heterogeneous with three participants improving two remaining stable and two showing slight increases in insomnia severity.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInsomnia Severity Index: Pre and Post Intervention Comparison\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInterpretation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre Test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMild Insomnia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost Test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMild Insomnia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStatistical Analysis\u003c/strong\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.06, p\u0026thinsp;=\u0026thinsp;0.952 (not significant)\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Group Climate Questionnaire\u003c/h2\u003e \u003cdiv id=\"Sec28\" class=\"Section3\"\u003e \u003ch2\u003e3.6.1 Overall Group Climate\u003c/h2\u003e \u003cp\u003ePre intervention group climate assessed across the three GCQ dimensions yielded an overall mean score of 2.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53 (range: 2.24\u0026ndash;3.54), indicating a moderately balanced yet suboptimal therapeutic environment. Post intervention overall mean was 2.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98 (range: 1.40\u0026ndash;4.27). The lack of overall group level change masks dimension specific improvements detailed below.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section3\"\u003e \u003ch2\u003e3.6.2 Engagement Dimension\u003c/h2\u003e \u003cp\u003eThe Engagement dimension increased substantially from pre intervention mean 2.6 to post intervention mean 4.0 reflecting heightened group participation mutual support and emotional involvement. A paired samples t test indicated a statistically significant increase (t\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;7.25, p \u0026lt; .01, Cohen's d\u0026thinsp;=\u0026thinsp;2.90). This marked improvement suggests that drama therapy successfully fostered active engagement and emotional connection among group members.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec30\" class=\"Section3\"\u003e \u003ch2\u003e3.6.3 Conflict Dimension\u003c/h2\u003e \u003cp\u003eThe Conflict dimension decreased from pre intervention mean 3.66 to post intervention mean 3.0 reflecting a moderate reduction in interpersonal tension and disagreement. A paired samples t test indicated a statistically significant decrease (t\u0026thinsp;=\u0026thinsp;3.10, p \u0026lt; .05, Cohen's d\u0026thinsp;=\u0026thinsp;1.24). This pattern is interpreted as beneficial indicating that while some degree of healthy disagreement and openness persisted (reflecting mature group functioning), overall tension and confrontation diminished.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec31\" class=\"Section3\"\u003e \u003ch2\u003e3.6.4 Avoidance Dimension\u003c/h2\u003e \u003cp\u003eThe Avoidance dimension decreased markedly from pre intervention mean 2.5 to post intervention mean 1.6 reflecting substantially reduced withdrawal and emotional reluctance among members. A paired samples t test indicated a statistically significant decrease (t\u0026thinsp;=\u0026thinsp;5.45, p \u0026lt; .01, Cohen's d\u0026thinsp;=\u0026thinsp;2.18). Participants demonstrated increased willingness to express emotions, engage in group discussions and participate openly in dramatic activities.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGroup Descriptive Statistics for Group Climate Questionnaire Scores Before and After the Intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre Intervention Score (Overall)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost Intervention Score (Overall)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGroup Climate Questionnaire Dimension Wise Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre Intervention Mean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost Intervention Mean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCohen's d\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEngagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;7.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConflict\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.05*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Short Form 36 Quality of Life\u003c/h2\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003e3.7.1 Physical Component Summary\u003c/h2\u003e \u003cp\u003ePre intervention SF 36 Physical Component Summary (PCS) scores ranged from 20 to 28.7 with a mean of 23.49\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42. Post intervention PCS scores ranged from 27.5 to 32.5 with a mean of 29.87\u0026thinsp;\u0026plusmn;\u0026thinsp;2.29. A paired samples t test revealed a statistically significant improvement in perceived physical health and functioning (t\u0026thinsp;=\u0026thinsp;6.50, p\u0026thinsp;=\u0026thinsp;0.0007, Cohen's d\u0026thinsp;=\u0026thinsp;2.60). The mean improvement was 6.38 points (95% confidence interval: 4.20\u0026ndash;8.56). All participants demonstrated improvements in perceived physical health, with increases ranging from 2.5 to 10.5 points.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003e3.7.2 Mental Component Summary\u003c/h2\u003e \u003cp\u003ePre intervention SF 36 Mental Component Summary (MCS) scores ranged from 19.9 to 27.2 with a mean of 23.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52. Post intervention MCS scores ranged from 35.2 to 40.6 with a mean of 37.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88. A paired samples t test revealed a highly statistically significant improvement in perceived mental health and emotional wellbeing (t\u0026thinsp;=\u0026thinsp;17.43, p \u0026lt; .0001, Cohen's d\u0026thinsp;=\u0026thinsp;6.98). The mean improvement was 13.79 points (95% confidence interval: 12.18\u0026ndash;15.40). This represents one of the most pronounced treatment effects observed in the study. All participants exhibited substantial improvements in mental health perception, with increases ranging from 8.2 to 16.7 points.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIndividual Pre and Post Physical Component Summary of SF 36 Quality of Life (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre PCS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost PCS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIndividual Pre and Post Mental Component Summary of SF 36 Quality of Life (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre MCS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost MCS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSF 36 Quality of Life: Pre and Post Intervention Comparison\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCohen's d\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF 36 Physical Component Summary Pre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0007***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF 36 Physical Component Summary Post\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF 36 Mental Component Summary Pre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF 36 Mental Component Summary Post\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec35\" class=\"Section2\"\u003e \u003ch2\u003e3.8 Summary of Primary Findings\u003c/h2\u003e \u003cp\u003eThe intervention produced statistically significant and clinically meaningful improvements across the majority of psychosocial and quality of life measures. Significant benefits were observed for perceived stress, depressive symptoms, self esteem and both physical and mental components of quality of life. Group climate improved substantially in the dimensions of engagement and avoidance though conflict remained moderate. Anxiety symptoms and insomnia severity did not show significant group level improvement, though individual variability was evident.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab11\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 11\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComprehensive Summary of All Outcome Measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre Intervention M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost Intervention M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCohen's d\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived Stress Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.14\u0026thinsp;\u0026plusmn;\u0026thinsp;4.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.013*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHADS Depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.14\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.29\u0026thinsp;\u0026plusmn;\u0026thinsp;3.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.045*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHADS Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.86\u0026thinsp;\u0026plusmn;\u0026thinsp;3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.71\u0026thinsp;\u0026plusmn;\u0026thinsp;3.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRosenberg Self Esteem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.43\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsomnia Severity Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.57\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.71\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.952\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGCQ Engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;7.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGCQ Conflict\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.05*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGCQ Avoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF 36 Physical Component\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.49\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.87\u0026thinsp;\u0026plusmn;\u0026thinsp;2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.0007***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF 36 Mental Component\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;mean; SD\u0026thinsp;=\u0026thinsp;standard deviation; HADS\u0026thinsp;=\u0026thinsp;Hospital Anxiety and Depression Scale; GCQ\u0026thinsp;=\u0026thinsp;Group Climate Questionnaire; SF 36\u0026thinsp;=\u0026thinsp;Short Form 36 Health Survey. *p \u0026lt; .05; **p \u0026lt; .01; ***p \u0026lt; .001.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Primary Findings and Clinical Significance\u003c/h2\u003e \u003cp\u003eThis quasi experimental study provides evidence that structured drama therapy when integrated alongside conventional neuro rehabilitation produces statistically and clinically meaningful improvements in key psychosocial and quality of life domains for individuals with acquired neurological conditions. The most pronounced benefits were observed in mental health perception (Cohen's d\u0026thinsp;=\u0026thinsp;6.98), self esteem (Cohen's d\u0026thinsp;=\u0026thinsp;2.00) and physical health perception (Cohen's d\u0026thinsp;=\u0026thinsp;2.60), with moderately large effects. These findings align with and extend existing literature on expressive arts therapies in medical rehabilitation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec38\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Mechanisms of Therapeutic Benefit\u003c/h2\u003e \u003cdiv id=\"Sec39\" class=\"Section3\"\u003e \u003ch2\u003e4.2.1 Emotional Expression and Stress Reduction\u003c/h2\u003e \u003cp\u003eThe significant reduction in perceived stress (p\u0026thinsp;=\u0026thinsp;0.013) and depressive symptoms (p\u0026thinsp;=\u0026thinsp;0.045) suggests that drama therapy facilitated emotional processing and cognitive reframing of illness experiences. Drama therapy capacity for symbolic, embodied and metaphorical expression may provide access to emotional material inaccessible through conventional talk therapy particularly valuable for individuals with communication impairments secondary to neurological injury. The enactment and externalization of stressors through dramatic means may enable cognitive distance and perspective taking, reducing subjective distress and fostering adaptive coping.\u003c/p\u003e \u003cp\u003eThe lack of significant anxiety reduction despite improvements in stress and depression warrants consideration. Anxiety may represent a more persistent trait like feature in some individuals recovering from neurological injury potentially requiring longer intervention periods or supplementary cognitive behavioral approaches. Alternatively the short intervention duration (6 weeks) may be insufficient to substantially modify anxiety patterns in those with chronic treatment resistant symptoms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec40\" class=\"Section3\"\u003e \u003ch2\u003e4.2.2 Identity Reconstruction and Self Esteem\u003c/h2\u003e \u003cp\u003eThe large and highly significant increase in self esteem (p \u0026lt; .001, Cohen's d\u0026thinsp;=\u0026thinsp;2.00) represents one of the study's most meaningful findings. Neurological injury frequently precipitates identity disruption and loss of self worth as individuals grapple with altered physical capacity changes in social roles and revised self concepts. Drama therapy unique capacity to facilitate role exploration and role taking within a supportive environment directly targets these identity related challenges. By successfully embodying diverse characters and witnessing their own dramatic competence participants experienced direct evidence of personal agency and capacity despite physical limitations directly counteracting the learned helplessness and reduced self efficacy associated with acquired disability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec41\" class=\"Section3\"\u003e \u003ch2\u003e4.2.3 Group Cohesion and Social Connection\u003c/h2\u003e \u003cp\u003eThe marked improvements in group engagement (p \u0026lt; .01) and reduction in avoidance (p \u0026lt; .01) indicate that drama therapy successfully fostered interpersonal connection and psychological safety. This is theoretically important because social isolation and reduced interpersonal engagement are common post neurological injury complications that independently predict poor psychological outcomes. The collaborative, improvisational and ensemble based nature of drama therapy inherently promotes mutual interdependence, peer validation and sense of belonging mechanisms recognized as fundamental therapeutic agents in group based interventions.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec42\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Quality of Life and Functional Benefits\u003c/h2\u003e \u003cp\u003eThe highly significant improvements in both physical (p\u0026thinsp;=\u0026thinsp;0.0007) and mental components of quality of life (p \u0026lt; .0001) suggest substantial carry over effects from psychosocial gains to global well being perception. This pattern is consistent with an integrated biopsychosocial model of recovery wherein psychological stabilization facilitates enhanced engagement in rehabilitation improved motivation and greater functional gains. The large effect size for mental health perception (Cohen's d\u0026thinsp;=\u0026thinsp;6.98) is particularly noteworthy and suggests that drama therapy exerts profound effects on subjective well being and life satisfaction.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec43\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Lack of Significant Sleep Improvement\u003c/h2\u003e \u003cp\u003eThe absence of significant change in insomnia severity (p\u0026thinsp;=\u0026thinsp;0.952) is notable. Although insomnia is frequently comorbid with depression and anxiety in neurological populations and both of these symptoms improved, sleep quality did not follow the expected pattern. This may reflect the multi factorial etiology of insomnia in neurological populations (including pain, spasticity, nocturia and neurobiological factors) that may be less amenable to psychosocial intervention alone. Alternatively the 6 week intervention period may be insufficient for substantial sleep architecture change which typically develop more gradually. The reduction in inter individual variability (standard deviation decreased from 5.03 to 3.99) however suggests potential stabilization of sleep patterns deserving further investigation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec44\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Comparison with Existing Literature\u003c/h2\u003e \u003cp\u003eThese findings are broadly congruent with prior research on creative arts therapies in rehabilitation. Kongkasuwan's randomized trial of creative art therapy in stroke patients documented significant reductions in depression and improvements in physical function and quality of life paralleling the current findings. Similarly systematic reviews of performing arts interventions (including theater and drama) in Parkinson's disease identified robust effects on quality of life and emotional wellbeing consistent with the substantial mental health improvements observed here.\u003c/p\u003e \u003cp\u003eHowever, the current study extends existing literature by specifically examining a structured protocol driven drama therapy intervention in a medically diverse neurological population employing a broader battery of validated psychosocial and functional outcome measures. The Pilot Study while limited in causal inference nevertheless provides preliminary evidence of efficacy that warrants follow up randomized controlled trials.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec45\" class=\"Section2\"\u003e \u003ch2\u003e4.6 Study Limitations\u003c/h2\u003e \u003cp\u003eSeveral methodological limitations warrant explicit acknowledgment and discussion:\u003c/p\u003e \u003cp\u003e \u003cb\u003eSmall sample size and lack of control group\u003c/b\u003e: With n\u0026thinsp;=\u0026thinsp;7 and no untreated control group, the study cannot definitively establish that improvements are attributable to drama therapy rather than to: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) nonspecific therapeutic attention or social contact (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) temporal changes in recovery trajectory independent of intervention or (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) placebo/expectancy effects.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAbsence of long term follow up\u003c/strong\u003e \u003cp\u003ePost intervention assessments were conducted immediately upon completion of the 6 week intervention. The sustainability of psychological and functional gains beyond the immediate post intervention period remains unknown. Longer term follow up (e.g., 3, 6, 12 months) is essential to determine whether benefits persist and whether participants maintain engagement with learned coping strategies.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHeterogeneous neurological diagnoses\u003c/strong\u003e \u003cp\u003eThe sample included individuals with stroke, traumatic brain injury and spinal cord injury etiologically and neurobiologically distinct conditions. Outcome heterogeneity may reflect differential responsiveness across diagnoses stratified analyses by diagnosis were not possible given the small sample size.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLack of attention to individual differences\u003c/strong\u003e \u003cp\u003eWhile the study reports group level statistics, individual response patterns were heterogeneous (e.g., some participants improved substantially in anxiety while others did not). Systematic exploration of baseline characteristics predicting treatment response (e.g., baseline depression severity, cognitive status, motivation) was not conducted.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNon blinded assessment\u003c/strong\u003e \u003cp\u003eThe absence of blinded outcome assessment increases risk of observer bias particularly for subjective measures. Participants' knowledge of study hypotheses may have influenced self report responses.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAbsence of treatment fidelity monitoring\u003c/strong\u003e \u003cp\u003eWhile session attendance was high systematic documentation of drama therapy delivery consistency protocol adherence and therapist competence were not provided limiting confidence in the independent variable's integrity.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec46\" class=\"Section2\"\u003e \u003ch2\u003e4.7 Implications and Future Directions\u003c/h2\u003e \u003cp\u003eDespite these limitations the findings have several important implications. First they provide preliminary evidence that structured protocol driven drama therapy is feasible and acceptable in in patient neuro rehabilitation settings as evidenced by high attendance rates and positive participant feedback. Second the magnitude of benefits particularly for mental health and self esteem suggests drama therapy warrants further investigation as a complementary modality. Third the heterogeneity in individual responses indicates need for research identifying baseline characteristics or moderating variables that predict optimal responsiveness to drama therapy.\u003c/p\u003e \u003cp\u003eFuture research should prioritize: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) randomized controlled trials with adequate sample sizes and active or waitlist control groups to establish definitive efficacy and isolate drama therapy's specific contribution (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) longer term follow up (\u0026ge;\u0026thinsp;6 months) to determine sustainability of gains (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) stratified or subgroup analyses examining differential effects across neurological diagnoses (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) investigation of mechanisms of change through mediational analyses (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) assessment of cost effectiveness and feasibility in diverse rehabilitation settings and (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) qualitative research exploring participants' subjective experience of drama therapy and mechanisms underlying perceived benefit.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study provides preliminary evidence that drama therapy when integrated as an adjunctive modality alongside conventional neuro rehabilitation significantly improves key psychosocial and quality of life outcomes in individuals with acquired neurological conditions. Participants demonstrated statistically significant improvements in perceived stress, depressive symptoms, self esteem, physical and mental health perception and group cohesion. These findings support the integration of expressive action oriented creative modalities to address the holistic recovery needs of individuals navigating neurological rehabilitation.\u003c/p\u003e \u003cp\u003eThe psychosocial benefits observed particularly the large improvements in self esteem and mental health perception represent meaningful gains for individuals whose identity and psychological well being are substantially compromised by neurological injury. The fostering of group cohesion and interpersonal connection addresses an important dimension of recovery often neglected by biomedically focused rehabilitation.\u003c/p\u003e \u003cp\u003eHowever, the pilot study, small sample and lack of control group preclude definitive causal attribution. Rigorous randomized controlled trials are necessary to establish the specific efficacy of drama therapy determine optimal intervention parameters and identify individuals most likely to benefit. Future research should also examine mechanisms of change longer term sustainability of benefits and cost effectiveness in diverse rehabilitation contexts.\u003c/p\u003e \u003cp\u003eIn summary drama therapy shows promise as evidence informed patient centered adjunct to conventional neuro rehabilitation. Integration of such creative modalities within mainstream rehabilitation practice could advance toward a truly holistic biopsychosocial model of neuro rehabilitation that addresses not only physical and cognitive restoration but also the profound psychological and existential challenges inherent in neurological recovery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement:\u003c/strong\u003e The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement:\u003c/strong\u003e This research received no specific grant from any public, commercial, or not for profit funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request, subject to ethical approvals and participant confidentiality protections\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e: Informed consent for publication of anonymized data was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declaration\u003c/strong\u003e: The study was approved by the Institutional Sub Ethics Committee of Dr D Y Patil College of Physiotherapy Pimpri Pune Maharashtra India under Dr D Y Patil Vidyapeeth Pune.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate declaration\u003c/strong\u003e: Written informed consent was obtained from all participants and their caregivers prior to participation in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.K. conceived and designed the study, supervised the project and critically revised the manuscript for important intellectual content.B.B. contributed to participant recruitment, data collection and drafting of the methods and results sections.A.M. helped implement the intervention, coordinated drama therapy sessions and contributed to writing the intervention protocol.M.K. conducted the literature review, assisted in data entry and drafted parts of the introduction and discussion.R.N. administered outcome measures, managed study documentation and contributed to revision of the results section.A.N. assisted with group facilitation during drama therapy sessions, contributed to interpretation of clinical findings and reviewed the manuscript for clinical relevance.A.S. supported statistical analysis, prepared tables and critically reviewed the discussion and conclusion.T.D. managed references, formatting and language editing and contributed to final manuscript preparation.A.B. assisted in background literature search, organization of figures and tables and gave final approval of the version to be submitted. O.P. Drafted the full manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors discussed the results commented on previous versions of the manuscript and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLanghorne P, Bernhardt J, Leape B. Stroke rehabilitation. Lancet. 2011;377(9778):16931702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalter K, Foley N, Teasell R. Psychological considerations in stroke recovery. Top Stroke Rehabil. 2010;17(5):338346.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHackett ML, Pickles K. Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies. Int J Stroke. 2014;9(8):10171025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSagen U, Vik TG, Moum T, M\u0026oslash;rland T, Finset A, Dammen T. Screening for depression and anxiety after stroke: comparison of the Hospital Anxiety and Depression Scale and the Montgomery and \u0026Aring;sberg Depression Rating Scale. J Psychosom Res. 2009;67(4):330335.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCao Y, Rajkumar R, Weingarten CP, Faraco CC, Pulay AJ. Post stroke depression: impact of lesion location and across different neurological recovery phases. Front Neurol. 2016;7:90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVangent G, Nicol A, Ashworth M. An exploration of the impact of stroke on the identity, role and sexuality of younger adults: implications for occupational therapy. Disabil Rehabil. 2012;34(12):10181026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEyre HA, Acevedo B, Yang H, Siddarth P, Van Dyk K, Ercoli L, et al. Changes in neural connectivity and BOLD activation during creative cognition after a one week multisensory art intervention. Behav Brain Res. 2016;305:112116.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaimal G, Ayaz H, Herres J. Neurophysiological measures of aesthetic experience and its connection with creativity. In: Pelowski M, Akiba F, Leder H, PGiorgio R, editors. Aesthetic Science: Connecting Minds, Brains and Experiences. Oxford University Press; 2017. p. 189215.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKongkasuwan R, Voraakhom K, Mankongdej U, Ung NO, Jivaoin T. Creative art therapy to enhance rehabilitation for stroke patients. J Stroke Cerebrovasc Dis. 2016;25(2):441447.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarnish MS, Barran SM. Active group based performing arts interventions in Parkinson's disease: an updated systematic review and meta-analysis. Front Neurol. 2025;16:1314586.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFung K, Ho RTH, Fung J. A randomised controlled trial of expressive arts based intervention for young stroke survivors: protocol and baseline characteristics. JMIR Res Protoc. 2020;9(12):e23729.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones P. Drama as Therapy: Theory, Practice and Research. 3rd ed. Routledge; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerghs S, Atkin K, Graham H, Hubbard R, Parkinson J. Drama therapy for children and adolescents with mental health problems: a systematic review. Front Psychiatry. 2022;13:808826.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385396.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67(6):361370.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAben I, Verhey F, Lousberg R, Lodder J, Honig A. Validity of the Hospital Anxiety and Depression Scale for use with patients with stroke. J Psychosom Res. 2002;52(1):3337.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosenberg M. Society and the Adolescent Self Image. Princeton University Press; 1965.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorin CM, Belleville G, B\u0026eacute;langer L, Ivers H. The insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601608.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:6165.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWare JE, Sherbourne CD. The MOS 36 item Short Form Health Survey (SF 36). Med Care. 1992;30(6):473483.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacKenzie KR, Tschuschke V. Relatability: essence of the curative milieu. Int J Ther Communities. 1993;14(2):131143.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOczkowski C, Mazzini L, Parekh JR, Lauda F, Kraglievich G, Gonz\u0026aacute;lez A, et al. The use of melatonin in managing post stroke sleep disorders: a systematic review. Sleep Med Rev. 2017;34:6171.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"discpsy","sideBox":"Learn more about [Discover Psychology](https://www.springer.com/44202)","snPcode":"","submissionUrl":"","title":"Discover Psychology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"dramatherapy, psychosocial outcomes, emotional expression, neurological disorders","lastPublishedDoi":"10.21203/rs.3.rs-8624445/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8624445/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eNeurological disorders frequently impair emotional expression, social interaction and psychological wellbeing dimensions inadequately addressed by conventional rehabilitation protocols alone. Drama therapy an action oriented expressive modality employing theatrical techniques offers a complementary approach to address these psychosocial dimensions during neurological recovery.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo evaluate the efficacy of structured drama therapy as an adjunctive intervention alongside conventional neuro rehabilitation in improving psychosocial and functional outcomes in individuals with acquired neurological conditions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA Pilot pretest and posttest design was conducted with 7 participants (mean age 45.3 years) with hemiplegia and paraplegia. Participants received 6 weeks of drama therapy (three 60 minute sessions weekly) alongside conventional physiotherapy. Primary outcomes included perceived stress (Perceived Stress Scale), anxiety and depression (Hospital Anxiety and Depression Scale), self-esteem (Rosenberg Self Esteem Scale), insomnia severity (Insomnia Severity Index), group cohesion (Group Climate Questionnaire) and quality of life (Short Form 36 Health Survey). Analysis employed paired t tests and descriptive statistics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSignificant improvements were observed in perceived stress (t\u0026thinsp;=\u0026thinsp;3.38, p\u0026thinsp;=\u0026thinsp;0.013), depression (t\u0026thinsp;=\u0026thinsp;2.52, p\u0026thinsp;=\u0026thinsp;0.045), self-esteem (t\u0026thinsp;=\u0026thinsp;8.72, p \u0026lt; .001), Physical Component Summary (t\u0026thinsp;=\u0026thinsp;6.50, p\u0026thinsp;=\u0026thinsp;0.0007) and Mental Component Summary of quality of life (t\u0026thinsp;=\u0026thinsp;17.43, p \u0026lt; .0001). Group engagement significantly increased (t\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;7.25, p \u0026lt; .01) and conflict decreased (t\u0026thinsp;=\u0026thinsp;3.10, p \u0026lt; .05). Anxiety (t\u0026thinsp;=\u0026thinsp;1.00, p\u0026thinsp;=\u0026thinsp;0.356) and insomnia severity (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) showed no significant change.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDrama therapy demonstrated efficacy in reducing core psychological distress and improving self-esteem and quality of life when integrated with standard neuro rehabilitation. These findings support the integration of expressive creative modalities to address the holistic recovery needs of individuals with neurological conditions. Further randomized controlled trials are warranted to establish definitively the specific mechanisms and long term sustainability of drama therapy benefits.\u003c/p\u003e","manuscriptTitle":"Exploring The Integration Of Drama Therapy With Neurorehabilitation For Psychosocial And Functional Outcomes A Pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-16 05:41:49","doi":"10.21203/rs.3.rs-8624445/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-26T22:38:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T19:52:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T12:48:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T09:52:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216431833594750509277297372969521945325","date":"2026-02-19T06:40:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-18T08:04:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-15T08:27:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232497361231118392023195426491613813733","date":"2026-02-15T03:53:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-13T16:10:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-11T09:36:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211117564614435886937610348851267885350","date":"2026-02-11T09:29:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"112476751467297574371328655555643762784","date":"2026-02-10T19:12:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21366349024273069650320235985711739972","date":"2026-02-10T07:55:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T07:18:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119780238946049530894315972081350009354","date":"2026-02-10T07:15:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54523732597578738286152483825666820636","date":"2026-02-10T06:59:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102200243135499098971885748524172499133","date":"2026-02-10T06:56:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56305386653670910646306617337660606131","date":"2026-02-10T06:46:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329682565897460519291303833566820636677","date":"2026-02-10T06:35:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"249003735542780256190544531745516990796","date":"2026-02-10T05:42:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-10T03:06:07+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-09T20:20:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-09T18:36:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-09T11:15:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Psychology","date":"2026-02-09T10:59:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"discpsy","sideBox":"Learn more about [Discover Psychology](https://www.springer.com/44202)","snPcode":"","submissionUrl":"","title":"Discover Psychology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e07b435f-a86a-4dab-849a-94bd23fc8e18","owner":[],"postedDate":"February 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-16T06:53:07+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-16 05:41:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8624445","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8624445","identity":"rs-8624445","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}