The Anthroposophic Artistic Movement Assessment for Eurythmy Therapy (AART-ASSESS-EuMove). A validation study.

OBJECTIVE: Eurythmy Therapy (ET) is a mindfulness oriented therapy developed in the context of anthroposophic medicine. Despite commonly used in practice, it remains unclear whether active participation (Inner Correspondence) during ET can be observed in eurythmy gestures (EGest). So far, no validated peer-report instrument to evaluate EGest exists. METHOD: To validate an 83-item ET peer-report scale, a nested study on a sample of n = 82 breast cancer survivors with cancer-related fatigue was conducted. EGest were evaluated twice, at baseline and at 10-week follow-up, by peer-reports from two separate therapists. Interrater-reliability (IRR) was estimated by Cohen's weighted kappa (κw) across all items. Additionally, reliability-(RA) and principal component analyses (PCA) were conducted. Patients completed two self-report scales: Satisfaction with ET (SET) and Inner Correspondence with the Movement Therapy (ICPH). RESULTS: IRR was greater than or equal (κw ≥ 0.25) for 41 items (49.3%) with a mean weighted kappa of κ̅w = 0.40 (SD = 0.17, range = 0.25-0.85). RA resulted in the exclusion of 25 items with insufficient item-total correlations < 0.40. A PCA with 16 items revealed 3 subscales: 1. Mindfulness in Movement (8 items), 2. Motor Skills (5 items), 3. Walking Pattern (3items) explaining 63.86% of total variance. Internal consistency (Cronbach's alpha) was high for the sum score with α = 0.89 and for the subscales with α = 0.88, 0.86 and 0.84 respectively. Significant small to moderate subscale correlations were found ranging from r = 0.29-0.63 (all p < 0.01). Mindfulness in Movement correlated with Inner Correspondence (r = 0.32) and with Satisfaction with ET (r = - 0.25, both p < 0.05). CONCLUSIONS: The new AART-ASSESS-EuMove is the first consistent and reliable peer-report instrument to evaluate EGest. It shows associations between peer-reported Mindful Movement and patients' self-reported ICPH and SET.

Four-year follow-up on fatigue and sleep quality of a three-armed partly randomized controlled study in breast cancer survivors with cancer-related fatigue.

Cancer-related fatigue (CRF) is a frequent long-term symptom in non-metastasized breast cancer patients (BC). This 4-year follow-up intended to compare the long-term effects of a 10-week multimodal therapy (MT: sleep education, psychoeducation, eurythmy- and painting therapy) and combination therapy [CT: MT plus aerobic training (AT)] to AT-control. BC-patients were randomized or allocated by preference to three arms in a comprehensive cohort study. Primary outcome was a composite score including Pittsburgh Sleep Quality Index (PSQI) and Cancer Fatigue Scale (CFS-D), captured at baseline, after 10 weeks of intervention (T1), 6 months later (T2), and after 4 years (T3). We exploratively tested for superiority of MT and CT versus AT after 4 years (T3) based on the statistical model of the main analysis. Of 126 (65 randomized) BC-patients included, 105 started treatments and 79 were re-assessed for long-term effects (T3). MT and CT were superior over AT after 4 years regarding PSQI/CFS-D and PSQI sum-score, respectively (all p < 0.05), but not for CFS-D. The multimodal and combination treatment for breast cancer patients with CRF indicates sustainable long-term superiority over aerobic training for the outcomes sleep quality and combined sleep quality/fatigue. A confirmative randomized controlled trial is warranted.

The Anthroposophic Art Therapy Assessment Paint (AART-ASSESS-P): A peer-report instrument to assess patients' pictorial expression during Anthroposophic Painting Therapy.

OBJECTIVE: Anthroposophic painting therapy (APT) is a specific form of art therapy that aims to activate self-healing capacities through painting aquarelles. METHODS: The Anthroposophic Art Therapy Assessment-Paint' (AART-ASSESS-P) was developed to measure pictorial expression and validated in the framework of a comprehensive cohort design study. The validation study examined 68 breast cancer patients with fatigue. Art therapists made pre- and post-assessments of spontaneously drawn water-color paintings with a preliminary version of the AART-ASSESS-P (58 items). Inter-rater reliability (IRR) for the items was examined with Cohen's weighted Kappa (κw). Additionally, a reliability- and factor analysis (FA) were conducted. Convergence criteria were patients' self-report measures: the Satisfaction with Painting Therapy, Inner Correspondence with Painting Therapy and the Self-Regulation Questionnaire. RESULTS: IRR for the items was heterogeneous (κw= 0.09-0.89, Mean κw= 0.40, SD = 0.17). Thirty-six items were excluded due to insufficient IRR and item-total correlation (κw= < 0.30, ρitem-total< 0.30). A FA with 22 items revealed 5 subscales: Shape Development (6 items), Shape Arrangement (6 items), Order and Symmetry (5 items), Color Application (3 items), and Color Quality (2 items) explaining 61% of total variance. Psychometric properties for the AART-ASSESS-P were satisfying with Cronbach's alpha coefficients (rα = 0.60-0.81) across subscales. Due to weak inter-subscale correlations (r = 0.18-0.48, p < 0.05) and the ambiguity of face validity a sum-score was not formed. Correlations between subscales and self-reports were small (all p < 0.05). CONCLUSION: The AART-ASSESS-P is the first reliable instrument to measure pictorial expression during APT.

Reliability and first validity of the inner correspondence questionnaire for painting therapy (ICPTh) in a sample of breast cancer patients.

Objectives Art therapy (ArT) such as mindfulness-oriented painting therapy is increasingly used in psychosomatic, oncological integrative and rehabilitative medicine. Though it remains unknown how ArT works, we hypothesize that an engaged participation with painting ('Inner-Correspondence') contributes to improved symptom scores. In the context of a comprehensive cohort study for breast cancer survivors with cancer-related fatigue, we developed a patient-reported outcome measure to assess 'Inner Correspondence' with painting therapy and conducted a first validation study. Design A 24-item questionnaire on 'Inner Correspondence' (ICPTh) was administered after ten weeks of intervention and at six month followup together with concurrent scales (Inner Correspondence and Peaceful Harmony, Cancer Fatigue Scale, Hospital Anxiety and Depression Scale, Internal Coherence Scale). Statistical assessment included reliability- and factor analyses. Results A total of n = 68 BC (mean age, 58.2 years, SD = 8.7) participated in the preliminary validation study. Exploratory factor analysis revealed a robust 22-item scale with an unambiguous four-factor solution explaining 78% of total variance and the following subsales: 1) therapy congruence and relaxation (11 items), 2) inner development and mood (6 items), 3) artistic skill (3 items) and 4) task congruence (2 items). The 22-item ICPTh yielded high reliability (Cronbach's alpha = .966, item-total correlation = .497 - .883, test-retest reliability = .888). Conclusions We present a reliable instrument to measure 'Inner Correspondence' with painting therapy. Due to the small sample size and sample selection further validation studies are indicated.

Do we have predictors of therapy responsiveness for a multimodal therapy concept and aerobic training in breast cancer survivors with chronic cancer-related fatigue?

Cancer-related fatigue (CRF) is a burdensome symptom for breast cancer (BC) patients. In this pilot study, we tested several questionnaires as predictors for treatment responsiveness, along with the implementation of a multimodal therapy concept consisting of sleep, psycho-education, eurythmy, painting therapy and standard aerobic training. At the Community Hospital Havelhöhe and the Hannover Medical School, 31 BC patients suffering from CRF could be evaluated in a 10-week intervention study. CRF was assessed by the Cancer Fatigue Scale (CFS-D). Further questionnaires were the Pittsburgh Sleep Quality Index, the autonomic regulation scale, Self-Regulation Scale (SRS), the Internal Coherence Scale (ICS) and the European Organization of Research and Treatment Health-Related Quality of Life Core Questionnaire scale. We estimated the regression coefficients of all scales on CFS-D by simple and multiple linear regression analyses and compared regression slopes and variances between the different questionnaires on CFS-D at the end of treatment. We found a significant impact of SRS and ICS at baseline on CFS-D at the end of the intervention [absolute standardised multiple regression coefficient values ranging from 0.319 (SRS) to 0.269 (ICS)] but not for the other questionnaires. In conclusion, this study supports the hypothesis that the SRS or ICS measuring adaptive capacities could be more appropriate as outcome predictors than classical questionnaire measures in complex interventions studies.

Impact of autonomic and self-regulation on cancer-related fatigue and distress in breast cancer patients--a prospective observational study.

PURPOSE: Cancer-related fatigue (CRF) has a major impact on the quality of life in breast cancer patients (BC). So far, only a few prospective studies have investigated the effect of adaptive salutogenic mechanisms on CRF. The aim of our study was to evaluate the possible prospective influence of autonomic Regulation (aR) and self-regulation (SR) on CRF and distress in long-term survivors. METHODS: 95 BC and 80 healthy female controls (C) had been included in the observational study between 2000 and 2001 and completed the questionnaires on aR, SR and Hospital Anxiety and Depression Scale (HADS). Of these, 62 BC, and 58 C participated in the re-evaluation 6.6 years later: 16 participants were deceased (14 BC and 2 C). During follow-up, participants were requested to answer questions involving (Cancer Fatigue Scales) CFS-D, aR, SR and HADS. Multiple regression analysis was used to evaluate the influence of aR, SR, age, Charlson co-morbidity-index and diagnosis on CFS-D and HADS, and to select further potentially relevant factors. RESULTS: High aR values showed significant effects, namely inverse relationships with CFS-D, cognitive fatigue, anxiety and depression. SR showed a reduced influence on anxiety and depression (all p < 0.05). CONCLUSIONS: Autonomic regulation might have an independent, reductive influence on global fatigue, cognitive fatigue and--together with self-regulation--it seems to have a protective influence on anxiety and depression. The connection between these parameters is still unclear and awaits further evaluation. IMPLICATION FOR CANCER SURVIVORS: AR seems to be a prognostic factor in breast cancer survivors, capable of reducing cancer-related fatigue and self-regulation distress as well. Further research is necessary in order to show how aR can be improved by therapeutic interventions.

Validation of the State Version Questionnaire on Autonomic Regulation (State-aR) for cancer patients.

OBJECTIVES: Current quality of life inventories used in oncology mainly measure the effects of chemo- or radiotherapy alongside functional and role scales. A new approach is to measure the autonomic state of regulation with the trait-inventory of autonomic regulation (Trait-aR). Loss of Trait-aR has been shown in different medical conditions such as breast cancer (BC) but not in colorectal cancer patients (CRC). In this paper we report the validation of a new state autonomic regulation scale (State-aR) of the last week. METHODS: Study 1 included 114 participants: (41 women/16 men with cancer and 57 age- and gender-matched healthy people) to conduct a reliability-, factor- and validity-analysis. Concurrent and convergent validity was evaluated with Trait-aR, Fatigue-Numerical-Scale, Hospital Anxiety and Depression Scale (HADS-D) and the self-regulation scale, 65 participants were retested. Study 2 completed 42 participants: 17 with BC and 25 with CRC receiving chemotherapy. The State-aR was administered prior, during and after chemotherapy for measuring responsiveness. RESULTS: The factor analysis loaded to four subscales of State-aR (rest-activity, orthostatic-circulatory, thermo-sweating and digestive regulation) with a: Cronbach-α r(α) = 0.77?0.83 and a test-retest-reliability r(rt) = 0.60?0.80. The sum- and subscales correlated with their concurrent subscales in the Trait-aR (0.48?0.74) and with the sum-scale moderately with all convergent criteria (r = 0.41?-0.44; p <0.001). During chemotherapy the State-aR-sum and rest-activity-scale decreased significantly compared to the change in the Trait-aR (p <0.05). CONCLUSIONS: These findings support that the state autonomic regulation scale has satisfactory to good reliability, good validity and acceptable responsiveness in the context of chemotherapy treatment.

Validation of a questionnaire measuring the regulation of autonomic function.

BACKGROUND: To broaden the range of outcomes that we can measure for patients undergoing treatment for oncological and other chronic conditions, we aimed to validate a questionnaire measuring self-reported autonomic regulation (aR), i.e. to characterise a subject's autonomic functioning by questions on sleeping and waking, vertigo, morningness-eveningness, thermoregulation, perspiration, bowel movements and digestion. METHODS: We administered the questionnaire to 440 participants (female symbol: N = 316, male symbol: N = 124): 95 patients with breast cancer, 49 with colorectal cancer, 60 with diabetes mellitus, 39 with coronary heart disease, 28 with rheumatological conditions, 32 with Hashimoto's disease, 22 with multiple morbidities and 115 healthy people. We administered the questionnaire a second time to 50.2% of the participants. External convergence criteria included the German version of the Hospital Anxiety and Depression Scale (HADS-D), a short questionnaire on morningness-eveningness, the Herdecke Quality of Life Questionnaire (HLQ) and a short version questionnaire on self-regulation. RESULTS: A principal component analysis yielded a three dimensional 18-item inventory of aR. The subscales orthostatic-circulatory, rest/activity and digestive regulation had internal consistency (Cronbach-alpha: ralpha = 0.65 - 0.75) and test-retest reliability (rrt = 0.70 - 85). AR was negatively associated with anxiety, depression, and dysmenorrhoea but positively correlated to HLQ, self-regulation and in part to morningness (except digestive aR) (0.49 - 0.13, all p < 0.05). CONCLUSION: An internal validation of the long-version scale of aR yielded consistent relationships with health versus illness, quality of life and personality. Further studies are required to clarify the issues of external validity, clinical and physiological relevance.

Validation of the German version of the Cancer Fatigue Scale (CFS-D).

Fatigue is a very important factor determining the quality of life in patients with malignancies. Cancer fatigue occurs with anaemia, during and after chemo- or radiotherapy and in patients with advanced tumours. The Cancer Fatigue Scale (CFS) is a three-dimensional inventory with 15 items which was originally developed in Japan. We present the results of a validation study of the German version (CFS-D) of this instrument. The CFS-D was administered to 114 participants in a matched-pair study. In total, 57 (41 women) of the participants had malignant conditions, and 57 (41 women) were healthy volunteers. The Fatigue Numerical Scale was used to test convergence. The physical and performance status of the cancer patients was assessed by the Karnofsky-Index. Criteria for testing multidimensionality were the Hospital Anxiety and Depression Scale, and the questionnaire on autonomic regulation. We generated a three-dimensional inventory of the CFS-D with the subscales physical fatigue/vitality, cognitive and affective fatigue. The reliability results for the complete scale: Cronbach's alpha: r(alpha) = 0.94, retest reliability: r(rt) = 0.82. The convergence criteria correlate between r = 0.44-0.65 (all P < 0.001). The CFS-D is highly reliable and has construct validity in relation to other measures.

[Development of a questionnaire for endogenous regulation--a contribution for salutogenesis research]. / Entwicklung eines Fragebogens zur endogenen Regulation--ein Beitrag zur Salutogeneseforschung.

INTRODUCTION: Objective of this study was to develop a questionnaire for endogenous regulation (eR) and to evaluate its relevance in clinical and preventive medicine. The inventory included items about sleeping and waking, orthostatic regulation, thermoregulation, and circadian well-being. METHODS: 158 age-matched women with diabetes (1/2, n = 53), breast cancer (n = 52) and healthy controls (n = 53) filled in the Havelhöhe constitutional questionnaire (HKF1.0), and a 24-h-Oxford-FD3-ECG was recorded. RESULTS: We developed a twelve-items scale for eR, which is according to test theory an objective and reliable instrument (Cronbach-alpha: r alpha = 0.71, retest reliability: rt = 0.83). The validity analysis confirmed that the breast cancer and diabetic group show a lower eR than the control group (both p < 0.001). Furthermore, high eR is correlated with a 'rare tendency to feel quite low', 'less allergies', 'less period pains', and a 'shorter duration of breast cancer'. Therefore eR can be regarded as a marker for health and well-being. High eR correlates as well with personality traits as morningness, 'needing less time for thinking through', 'being less unsure at important decisions', and 'being less confidential'. We can show first correlations between eR and the rhythmical marker 'nightly pattern predominance'. With both methods we are achieving for women until 60 years a satisfying discrimination between breast cancer and healthy individuals. CONCLUSIONS: We are achieving a first validation of our scale of endogenous regulation. Further studies for the evaluation of the conceptual, clinical, rehabilitative, and preventive medicine relevance of eR are necessary.