Stroke remains one of the highest leading causes of death and long-term disability (Virani et al., 2020). There is increasing evidence of poststroke cognitive decline among survivors, with a prevalence of 38%, and this cognitive decline was one of the most significant factors contributing to long-term disability and dependence (Huang et al., 2022). Cognitive functions, especially executive function, play a crucial role in predicting poststroke long-term rehabilitation outcomes (Shea-Shumsky et al., 2019). Executive function is an umbrella term for a variety of higher cognitive functions, of which working memory, flexibility, and inhibition are the core elements (Povroznik et al., 2018). Successful independent living requires the ability to independently perform instrumental activities of daily living (IADLs), such as cooking, shopping, financial management, and medication management (Ghaffari et al., 2021). Unfortunately, poststroke executive dysfunction (PSED) affects more than 75% of survivors, making it challenging for them to perform these complex living tasks and to adversely impact their quality of life (Povroznik et al., 2018). In addition, patients with PSED demonstrate lower rates of functional recovery due to their misunderstanding of the treatment instructions and lower attendance in therapy activities due to attention deficits and decreased self-efficacy (Park et al., 2015; Shao et al., 2020). Consequently, individuals with PESD are at a higher risk of recurrent stroke or even death (Kwan et al., 2021), potentially leading to prolonged hospital stays and further ongoing expenses.

While various cognitive rehabilitation approaches have been investigated with mixed results (Chung et al., 2013), it remains unclear if these interventions have clinical effectiveness in improving executive function, IADL performance, and community participation (Gibson et al., 2022). Arts and crafts therapy (ACT) is a cost-effective and highly efficient alternative intervention that has received limited research attention and could potentially improve cognitive functions and motivate patients' participation. ACT provides intellectual stimulation and has been considered advantageous for neuronal processes underlying cognitive impairment (Camic et al., 2016). Furthermore, ACT involves using skillful craft activities that are motivating and engaging to enrich the lives of individuals, families, and communities (Tubbs and Droke, 2016). Notably, the art-making processes require the demonstration of executive abilities such as planning, decision-making, shifting, emotional regulation, and problem solving to address the challenges met in the process and complete the final crafts.

While some studies have reported improvements in general cognitive function and self-reported executive function with ACT, the cognitive performance of executive function has been less explored (Abbing et al., 2019). Similarly, a few qualitative studies have highlighted the benefits of arts and crafts in improving cognitive function, self-confidence, quality of life, and wellbeing among stroke survivors (Reynolds et al., 2008; Beesley et al., 2011). However, these studies have low certainty, and it remains unclear whether the results show clinical significance for use with patients with PSED.

This quantitative study aims to address this evidence gap by exploring the effects of stroke survivors' engagement in ACT on their cognitive performance aspects of executive function and participation experience.

The results of this study revealed that the IRT+ ACT group had significantly better scores on executive function assessments compared to the active control group. These findings provide quantitative evidence suggesting that ACT might enhance intervention plans for patients who have PSED. Additionally, implementing ACT is more flexible and cost-effective, with the supplies of the therapy costing under USD$ 10 per session. ACT can be implemented in both outpatient and inpatient settings, even with a short length of stay. Also, the group format of ACT provides equal face-to-face therapy time and peer support. Importantly, ACT can be administered in patients' homes, enabling them to practice independently in their familiar environments and experience comparable benefits.

The therapeutic use of arts was initially proposed by Adrian Hill in the 1940s and was first used in patients with tuberculosis and later in patients with stress disorders (Hogan, 2001; Stuckey and Nobel, 2010). Arts and crafts have since become prevalent in many clinical settings. They hold special therapeutic values as they afford purposeful and productive occupations that combine elements of recreation and therapy (Johnson, 1920). Additional benefits include providing pleasure, reducing negative emotions, enhancing self-esteem, and improving cognitive functions.

In Witkoski and Chaves's (2007) study, 11 participants diagnosed with Alzheimer's disease enrolled in painting or modeling ACT for 31 months. After the intervention, they had significant improvement in their cognitive functioning. Pike's (2013) and Yu et al.'s (2021) studies showed similar results; participants who had cognitive impairments performed significantly better in memory-related activities after art therapy. In addition, King et al. (2013) demonstrated that the therapeutic use of writing improved the self-confidence and cognitive function of 11 individuals diagnosed with mental health disorders in a pilot study. Nevertheless, there are only two studies that mention the benefits of ACT in improving the quality of life and wellbeing among stroke survivors (Reynolds et al., 2008; Kongkasuwan et al., 2016).

While this study indicates the results consistent with those of Beesley et al.'s (2011) qualitative study (Beesley et al., 2011), this study is the first quantitative study aimed at exploring both the clinical effectiveness and subjective satisfaction of ACT on patients with PSED. This study utilized a rigorous study methodology, with a control group, a relatively larger sample (N = 57), and a strict study design. In addition, pre-intervention and postintervention changes were evaluated comprehensively with multiple assessment tools based on the functioning and disability part of the International Classification of Functioning, Disability, and Health on multiple levels: body functions, body structure, activity, and participation. At the level of body functions and body structure, the TMT and the Stroop test were mainly used to evaluate individuals' brain structure and brain function; at the level of activity, the TOH and the Lawton–Brody IADL Scale were chosen to reflect individuals' performances on specific activities; and at the level of participation, the eight domains in Lawton–Brody IADL Scale were utilized to assess individuals' participation within their environment.

In the current study, the comparison of the two groups revealed significant differences on TMT-A (time), TMT-B, and Stroop test (time) between the experimental group and the active control group, whereas similar differences were not found in the outcomes of other assessments. This may be a result of the relatively low difficulty level of the TMT-A; almost all subjects in the two groups could finish the task without errors. However, the speed and efficacy of completion of the experimental were significantly greater than the active control group. We also compared within-group differences on the TMT-A and the TMT-B to determine differences in the performance of the same group of patients on the two tests and found significant differences in both time and errors (p < 0.01). Subjects in both groups performed worse on the TMT-B. The TMT-B is widely used to evaluate working memory and cognitive flexibility. In this study, the experimental group performed better in TMT-B and showed greater executive function than the active control group. Although errors on the Stroop test were not noted as significantly different between groups, the experimental group was more fluent. Thus, it might be considered that those in the experiment group had faster and better control of inhibition. The TOH is a challenging activity requiring high executive functioning. Although, between groups, the required time and steps of the TOH after the intervention were not statistically different, the experimental group gained significant progress on time to complete the TOH compared to their pre-intervention performance, and the active control group showed even worse results, suggesting that the experimental group performed better. Following the intervention, however, both groups did not demonstrate significant improvements in scores on Lawton–Brody IADL Scale. This was perhaps caused by the fact that progress in executive functions cannot be shown on this scale in a timely manner and has a certain lag. However, as expected, subjects who received ACT gained greater improvement compared to those in the active control group.

Stroke survivors, especially those with executive dysfunction, often show low self-confidence, low attendance, and low self-esteem resulting from living with reduced capabilities caused by physical and cognitive conditions (Robinson-Smith et al., 2000). ACT in this study involved creativity, skillful art-making process, and productive crafts, which had numerous benefits for patients with PSED. First, creative activities often include a multistep art-making process that can activate stroke survivors' brain lobes to organize and plan for complicated tasks (Johnson, 1920; Stuckey and Nobel, 2010). Second, ACT requires subjects to follow instructions to complete the tasks and track their own performance during the work, which are beneficial to working memory, inhibition, and task monitoring. Furthermore, during the art-making process, patients with PSED often pay more attention to their work, rather than to their symptoms or illness, which decreases negative emotions such as anxiety or depression (Kongkasuwan et al., 2016). In addition, ACT emphasizes the healing power of productive crafts (Tubbs and Droke, 2016). In this study, productive art materials were utilized as art mediums (i.e., coloring, painting, drawing, calligraphy, and paper cutting). Patients with PSED express likes or dislikes during the process and then produce their crafts to express themselves and connect with others (Papangelo et al., 2020). It is believed that viewing self-productive crafts activates patients' medial orbitofrontal cortex, which enables them to have rewarding and positive experiences (Ishizu and Zeki, 2011; Morelli et al., 2015).

Overall, ACT emphasizes holistic therapy and occupational engagement and therefore might be an effective and efficient rehabilitation for improving an individual's physical, cognitive, and psychological disabilities.

Although this study complies with the principle of randomization, control, balance, and repetition as far as possible, the physical therapy was not completed by the same therapist due to clinical work stress. Fortunately, the interventions for the subjects were the same. Future studies should attempt to minimize any potential confounding elements by unifying treatment therapists between groups. Second, this study is also limited by a lack of follow-up evaluation; thus, the long-term effects of a combination of ACT and IRT on patients with PSED should be further explored. Finally, although this study utilized relatively comprehensive neuropsychological assessment tools, a lack of neuroimaging assessment was a limitation. Future studies with a larger sample size, longer intervention periods, and the integration of neuroimaging tools to further explore the mechanism of arts and crafts on patients with PSED are needed.

This pilot study is the first quantitative study to explore the therapeutic effects of arts and crafts for patients with PSED. This study provides preliminary quantitative evidence that ACT could improve executive function among patients with PSED and should be considered for practice.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by the Ethics Committee of the Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

RY was responsible for paper writing and data analyzing. RY and HZ were responsible for study design and data collection. JC and JG were responsible for paper writing and language polishing. ZZ was responsible for data collection, format checking and paper revisions. All authors contributed to the article and approved the submitted version.