“No tears or brain words”: A case report on single-session dance/movement therapy for individuals with schizophrenia spectrum disorders

Abstract

Background

Individuals diagnosed with schizophrenia spectrum disorders (SSDs) face a multitude of challenges in their lifetime including complex symptomatology, co-morbid health concerns, profound levels of stigmatization, and diminished access to quality care. Additionally, they are often the victims of unjust systemic biases and discrimination when they are able to engage with the healthcare system. This confluence of injustices leads to disparate physical and mental health outcomes for this vulnerable population. Globally, schizophrenia affects over 24 million, many of whom are experiencing healthcare disparities posing a significant public health concern. Dance/movement therapy (DMT) is an equitable healthcare provision situated in a strengths-based and trauma-informed psychotherapeutic framework. Dance/movement therapy can support the symptomatic needs of SSDs including alternate reality orientations, thought and behavioral disorganization, and diminished interpersonal engagement.

Methodology

We present an intrinsic case report nested within a larger randomized controlled trial that implemented a convergent parallel mixed method design. Data were collected simultaneously; however, initially analyzed individually first, then merged. Pre- and post-intervention quantitative data were collected through the Brief Psychiatric Rating Scale (BPRS). Qualitative data were collected post-intervention through semi-structured individual interviews.

Case presentation

This intrinsic case report examines the experience of a 37-year-old African American cisgender male, with high symptom acuity of schizoaffective disorder, who engaged in a single-session DMT intervention.

Results

Following the intervention, the participant exhibited a decrease in symptomatology as evidenced by the BPRS in total scores as well as subscales of psychological distress, positive symptoms, negative symptoms, and resistance. Moreover, following the DMT session the participant expressed having had a transformative experience, feeling like a contributing member of the group process. He also reported feeling a sense of pride, and experiencing the ability to engage in healthy relationships, and noted shared and meaningful experiences in his group process.

Discussion

Community-driven, non-verbal treatment options such as DMT, can provide opportunities for individuals with symptom acuity of SSDs. Future research should explore the potential for DMT, an inclusive and equitable treatment option, to support individuals with SSDs.

Background

Schizophrenia spectrum disorders (SSDs) are complex diagnoses that affect individuals emotionally, physically, mentally, and socially [1]. The thought and behavioral symptoms of SSDs are accompanied by movement dysregulations that align with either positive or negative presentation. For example, positive symptoms will be associated with movement difficulties such as disorganization, rigidity, and hypermobility. Whereas negative symptoms will manifest as hypomobility, limited postural activation, and decreased gesticulation [2]. Due to the multifaceted manifestations of the diagnoses, people with SSDs require specialized treatment that provides them with multiple avenues towards wellness [3].

Different presentations of the diagnoses will warrant individualized and tailored treatments [4]. Treatment goals of individuals with an acute presentation of symptoms will prioritize grounding, ego development, and interpersonal capacity. Furthermore, interventions that help with organization, attunement, and agency should be included [5]. When individuals with SSDs present with chronicity, treatment goals will include development of self- and body-image, expansion of range of motion, and overall activation [4, 6]. However, due to historical exclusion from treatment and research [7], novel and inclusive psychosocial treatment options have largely not been established, evaluated, or implemented [8].

Most people diagnosed with SSDs are not receiving the mental health services they need. Per the WHO [9], globally less than a third of individuals diagnosed with a psychotic disorder actually receive specialized mental healthcare. In 2017, the percentage of service coverage ranged from 10.9% in low-income countries, 21.5% in lower-middle-income countries, 29.2% in upper-middle-income countries, and 59.5% in high-income countries [10]. Moreover, globally, the financial resources delegated to mental healthcare services are not being efficiently spent to provide appropriate services. This lack of proper financial allocation leads to unmet needs for individuals who are in inpatient hospitalizations, over 50% of whom are diagnosed with schizophrenia. The de-institutionalization process that emerged in the United States of America (USA) in the 1950s further complicated service and community provisions for individuals with SSDs [11, 12]. Rates of homelessness, incarceration, and neglect for this population increased at rates that constituted a humanitarian crisis [11]. Although the intention was to transition people who had been institutionalized to community-based care, lack of preparation and funding towards such programs led to dire circumstances for those who were discharge to the streets with no care plans in place [11]. One potential remedy for the lack of quality, equitable, accessible, and just care for individuals with an SSD is the development of quality community-based programs that focus on the mental health needs and inclusion of these individuals [9].

Research shows that current treatment options for individuals with an SSD have not been prioritized, nor optimized to address recovery outcomes [8]. Indications of recovery percentages have been unclear due to inconsistencies amongst operational definitions of recovery. This has led to recovery levels ranging from 13.5% [8] to 50% in reports [13]. Research suggests that recovery should be inclusive of not only diminishment of clinical symptoms of SSDs, but also functional and social recovery as well [13, 14]. Moreover, cognitive behavioral therapy has been identified as an evidence-based practice for use with people with SSDs [15, 16] however; a meta-analysis by Jauhar and colleagues [16] suggested that overall the effect of such interventions on symptoms is significantly limited. One treatment option that has shown promising results for individuals with SSDs is dance/movement therapy (DMT) [6, 7, 17]; however, this psychosocial intervention would benefit from further research to bolster an evidence base.

Although under researched, DMT began as a clinical practice in the 1940s with its first inception in a psychiatric hospital both with soldiers who had returned from the war with “shellshock” and individuals who were diagnosed with schizophrenia [18]. Dance/movement therapy is defined as “the psychotherapeutic use of movement to promote emotional, social, cognitive, and physical integration of the individual, for the purpose of improving health and well-being” [18]. A form of psychotherapy, DMT focuses on non-verbal communication and the therapeutic movement relationship.

Through dance and movement, the clinician and client(s) attune to one another, which fosters kinesthetic empathy [19]. Empathy is a well-known phenomenon in the practice of psychotherapy that has long been researched [20] and continues to be a phenomenon under exploration [21]. Kinesthetic empathy is a process of witnessing, embodying, and reflecting a client’s emotional state on a non-verbal level [22]. This embodied reflection requires a sensitive and in-depth knowledge of anatomy, movement observation skills, attuning abilities, and empathy, all of which are provided in the training of becoming a dance/movement therapist. The seminal work of Fischman [23] determined that kinesthetic empathy is of particular importance when working with individuals with schizophrenia, as it can support the development of healthy ego. This occurs through the intersubjective connection of therapist and client(s) “overcoming distance through mechanisms such as: simulation, imitation, echoing or using our imagination whereby we build theories matching our own and somebody else’s experiences” [23]. The focus on nonverbal communication further supports individuals with SSDs [7] who may have difficulty with traditional, verbal forms of communication due to differing reality orientation, delusional thoughts, and disorganized speech [1]. Moreover, specific movement dysregulations are associated with a diagnosis of an SSD including movement fragmentation, sporadic movements, bizarre posturing or facial expressions, unsynchronized movement, and lack of spontaneity in movements and gestures accompanying speech [2, 7]. Research has shown that DMT is a psychosocial treatment intervention that can be beneficial for symptom stabilization [24] and it has been shown improve symptom management in people who present with both acute [7] and chronic presentations [6].

Recent research has established evidence indicating that DMT is a promising psychotherapeutic treatment intervention for individuals with SSDs [6, 7, 17]. Results from two RCTs determined that an intervention of DMT for individuals with acute [7] and chronic [6, 17] presentations of SSDs had positive responses to the DMT intervention versus a verbal therapy treatment as usual (TAU) intervention. Results indicated a decrease in positive symptoms [7] and negative symptoms, an increase in interpersonal skills and social connection [6, 7, 17], and an increase in mind-body awareness and self-awareness [6, 7]. Further findings revealed an increase in understanding of body boundaries [6] and overall motivation [6, 7].

Methodology

This case report presents a nested, intrinsic case study situated within a randomized controlled trial (RCT) conducted in 2019, the results of which were previously published [5, 7].

Primary study details

The aim of the RCT was to explore the effects of a single-session DMT intervention on thought and behavioral disorders for individuals with an SSD who were being treated in an inpatient psychiatric facility [7]. The original study was approved by Drexel University’s Institutional Review Board (IRB Approval No: 1805006298). The RCT had two primary aims. The first aim was to determine the feasibility of a research protocol for individuals who were experiencing acute exacerbation of symptoms related to SSDs. The second aim was to examine the estimate of effects of a single-session DMT intervention versus a verbal TAU intervention as they related to thought and behavioral dysfunction associated with SSDs. The hypothesis of this RCT was that participation in the single-session DMT intervention would alleviate symptoms of SSDs in the short-term.

Following an informed consent process, participants (N = 32) were randomized by draw of lots into either a single-session DMT group intervention or a treatment as usual (TAU) verbal therapy group. The protocol included a 20-minute pre-intervention interview with administration of the Brief Psychiatric Rating Scale (BPRS); a 45-minute DMT single-session group intervention or a 45-minute verbal group therapy sessions; a 30-minute post-intervention qualitative inquiry and re-administration of the BPRS. Both the pre- and post-intervention interviews were video recorded. Recordings of the qualitative interview were transcribed verbatim for analysis and coded by two independent coders. Movement analysis of the video recordings is in progress and a manuscript on these data is forthcoming.

The first author (JB), who is a Board-Certified dance/movement therapist, conducted the DMT single-session framed by object relations theory particularly focused on emotional holding and theories of potential space for creativity [25]. The session followed a traditional Chacian DMT structure [19] and began with a movement warm-up to facilitate both physical and emotional readiness for participation. Next, each session identified and developed a theme, initiated by the participants, which was explored through dance and movement. Following the approach described by Levy [19], the dance/movement therapist facilitated a cool down at the end of the group to both physically cool down the participants while simultaneously wrapping up any psychotherapeutic needs of the participants. Finally, the group members engaged in a verbal dialogue to discuss their experiences.

Quantitative data were collected immediately prior to and following the treatment intervention. A dance/movement therapist trained in the outcome measure administered the Brief Psychiatric Rating Scale (BPRS). The pre-intervention quantitative data were collected through a 20-minute seated interview. The BPRS is a 24-item, 7-point severity scale that is widely implemented to provide both self-reported (first 14 categories) and clinician-reported (last 10 categories) symptoms associated with a diagnosis of schizophrenia to account for both lived experiential data and clinician-assessed data [26]. The combination of self- and clinician-reported data may allow participant voices to be uplifted while offsetting the possible underreporting of symptoms by participants [27]. The BPRS has both high interrater reliability (r = 0.87) and internal consistency (α = 0.69, 0.68) [28]. Higher scores on the BPRS indicate higher levels of symptomatology. The following subscales are used in assessing symptoms: (1) psychological discomfort; (2) negative symptoms; (3) positive symptoms; and (4) resistance [29]. Brief Psychiatric Rating Scale scores can reflect the total score (0-168 range) or subcategories of psychological discomfort (0–42 range), negative symptoms (0–28 range), positive symptoms (0–49 range), and resistance (0–42 range).

Prior to administering the post-BPRS, the clinician conducted a brief semi-structured interview with the participant in which questions were asked about the participant’s experiences in the DMT or verbal group intervention. Semi-structured interviews included four broad and additional probative questions. Following this semi-structured interview, the BPRS was readministered. All pre- and post-intervention data collection interviews were videotaped for a movement analysis study, which will not be addressed in this paper.

We provide descriptive details of the pre- and post-test results, inferences regarding change scores, and comparison on mean scores of other participants. Furthermore, we describe conceptual, thematic, and phenomenological qualitative data presented by the participant in the semi-structured interview. We describe intervener field notes from the participants’ engagement in the intervention session as well as results from the quantitative and qualitative data.

Case report details

An intrinsic case report [30] provides an opportunity to explore an under-researched phenomena [31] In this study we deployed this approach to further detail the experience of DMT for an individual with schizoaffective disorder who was experiencing acuity of symptoms. We specifically chose to focus on this participant, as individuals with similar presentations are often excluded from clinical practice and research [7]. We chose to extract and highlight this intrinsic case [30] in greater detail due to the profound impact the single-session DMT intervention had on the identified participant. As this current case report reviewed secondary data, Jefferson IRB review was deemed not necessary. Although all participants in the original RCT were in an inpatient psychiatric facility for psychotic symptomatology, the identified case participant presented with the most acute symptomatology compared to all other participants. This participant represents past patients the first author (JB) has worked with clinically and was told by psychiatrists, nurses, and social workers that they were “too sick for treatment.” The presentation of this participant was the impetus for the RCT and particularly the feasibility component to determine if the protocol was, in fact, feasible for individuals who were experiencing acute exacerbation of symptoms of SSDs. Further exploration of this intrinsic case study can support justification for inclusion of individuals with acute symptomatology into psychotherapeutic treatment interventions, qualitative inquiries, and future research protocols, whereas they have historically been excluded from such processes. Furthermore, a closer look at this case study can help us to understand the lived experience of the participant through his own words as presented in the qualitative interview.

Case presentation and results

This case report focuses on one individual who participated in the larger RCT exploring the effects of a single-session DMT intervention on thought and behavioral dysregulation for individuals with SSDs admitted to an inpatient psychiatric facility. At the time of the study, the participant was a 37-year-old single, self-identified African American, cisgender male. He was voluntarily hospitalized in an inpatient psychiatric facility for increased psychotic symptomatology. He was first diagnosed with schizophrenia at 15 years of age, and was diagnosed was schizoaffective disorder, bipolar type at the time of the study. The participant presented with auditory hallucinations, thought broadcasting, delusional and disorganized thinking, pathological laughter, hypermobility, and regressive behaviors including thumb sucking and self-stimulation through rocking. He entered the psychiatric inpatient facility 3 days prior to participation in the research.

The first author (JB) took detailed field notes following the single session DMT intervention. As outlined in the group field notes, the identified participant began the session stating that he felt “great” and wanted to work on “self-love.” As the session began, the participant chose not to stand and engage, rather, he sat, rocking on the sagittal plane not making eye contact. He did not respond to the therapist’s invitation to join. However, shortly after the group began, a peer reached their hand out to the participant, which he took, stood, and engaged in a dance with the peer. Shortly thereafter, the participant began moving quickly, jumping, and engaging in movement tasks such as push-ups and jumping jacks. He moved intermittently between high-energy movements and sitting, rocking, and thumb sucking. The participant often caught a reflection of himself in the television set and would self-dialogue. As the group progressed, group members were sharing, verbally and non-verbally, what they loved about themselves. The participant began engaging in jumping jacks accompanied by laughter. He then joined a peer in movement, matching his movements, energy, and rhythm. Although the participant had difficulty engaging in whole group synchrony, he was able to join one peer at a time and did so spontaneously as others shared movements to exemplify what each person loved about themselves. As the group energy began to diminish, the participant was able to join in a movement cool down and focus on regulating his breathing with support from the therapist. When asked if there was anything he would like to share about our time together, the participant responded that he felt “wonderful” and “motivated.” He stated that he did not have to isolate and felt “encouraged to be myself, not just hide in my room and cry.” He noted that he was happy to have his peers join him and exhibited a sense of pride in his participation in the session.

Following the intervention, the participant showed a decrease in total BPRS score as well as each subcategory indicating a change towards health. Change scores for the identified participant exceeded the median change scores in all but one category (See Fig. 1). Each of the participant’s individual change scores were greater than that of the median change scores with the exception of negative symptoms. This aligns with the participant’s presentation, as he presented with higher levels of acuity, and thus greater presentation of positive symptomatology of his diagnosis. The comparison between DMT group median change scores and the identified participant change scores should be viewed as descriptive and illustrative, rather than inferential. The RCT findings publication provides the primary analysis of treatment effects to accompany these data [7].

Fig. 1.

BPRS change scores (towards health) for the DMT group median compared to the case study participant

Four themes emerged from the analysis of qualitative data from the RCT: (1) Establishing self-awareness through the group movement process; (2) Insight around felt changes in the DMT group process; (3) Experiencing healthy relationships; and (4) Carrying positive changes from the group forward. The identified participant’s interview data accounted for contribution to each of the four themes, with particular attention to establishing self-awareness through the group movement process.

As illustrated below, the identified participant’s qualitative responses supported the quantitative findings in each BPRS subcategory for which the participant had substantial change scores towards health (See Table 1).

Table 1.

Integration of quantitative subcategories, qualitative data, and exemplar quotes

BPRS Subcategory	Qualitative Responses	Exemplar Quotes
Psychological Distress	• Positive distraction from emotional distress • Shift in emotions with numerous comments about feeling “happy.”	“After participating [in the DMT intervention] I forgot all that sad stuff, and I was happy in that moment…Group put a smile on my face.”
Negative Symptoms	• Ability to join the session	“I was motivated. The thing about the group was me participating with the coordinator in the group…. I was interacting the entire time.”
Positive Symptoms	• Decrease in internal preoccupation	“We had a fun group. It put a smile to my face. No tears or brain words. That’s bad…I wish I could relive that moment again for the trueness of my heart…it was special.”
Resistance	• A desire for future opportunities, showing a decrease in resistant behaviors.	“I hope we can have another group. She said we could have another group tomorrow. It will definitely put a smile on my face.”

Some foci of the qualitative data were not captured by the quantitative measure; however representative of the participant’s experience in the DMT intervention. These concepts include development and maintenance of healthy intra- and interpersonal relationships, a sense of pride in participation, and having a transformative experience within the group. The participant noted, “I’m proud of myself…I was motivated…everybody was just joining along, dancing, doing singing, having fun…there wasn’t any arguments or nothing like that…combining was fun, unity!” The DMT intervention allowed for authentic self-expression, also experienced and shared by the participant:

And the effort I gave in that group…Not the effort to act like somebody else, but the effort to act like me. I did. I acted like I wanted to act like. You understand? When you are around certain people, you can’t do what they want you to do because they will take advantage of you. You got to stick with what motivates you.

Discussion and conclusions

This case report highlights the impactful effects of a single-session DMT intervention for a participant experiencing acute positive symptomatology and affective dysregulation associated with a diagnosis of schizoaffective disorder. Although considered a low-prevalence disease, schizophrenia, and SSDs, present a high global disease burden due the complexity of care necessary for this population in combination with the resounding stigmatization they experience [8, 32]. Moreover, provision of equitable and accessible services through psychosocial interventions such as DMT [33] could support the need for quality of care which could contribute to lower recidivism rates and thus cost reduction for healthcare facilities [34]. Clinically, hospitalized individuals diagnosed with SSDs are integrated into heterogeneous psychosocial therapeutic interventions, which do not focus on their explicit needs such as paranoid or disorganized thought processes or alternative reality bases. Further, the heterogeneity of diagnoses in group sessions tends to exacerbate the symptoms of individuals experiencing higher acuity levels. Historically, research has listed positive symptomatology or acute exacerbations of schizophrenia as exclusionary criteria [7]. This is not only a human rights violation [9, 35], but is also deeply rooted in stigmatization against individuals diagnosed with SSDs [36, 37]. Moreover, this disallows data collection, phenomenological experiences, and overall voices of individuals with SSDs when making decisions regarding treatment, research, and policy. Individuals diagnosed with SSDs, particularly those experiencing positive or acute symptomatology, deserve more accessible and equitable care [9]. Their experiences with and input about psychosocial and psychopharmacological interventions are invaluable in future planning.

The identified participant in this case report is one who may have otherwise been excluded from both psychosocial treatment and research opportunities due to the acuity of his presentation. Details of this case report suggest that this individual, experiencing acute symptomatology and high levels of positive symptoms, was not only able to participate in appropriately designed interventions, but he experienced changes towards health in a brief intervention. The quantitative data showed that participation in the single-session DMT intervention had a positive impact on change towards health in overall BPRS scores and in each subcategory. Each of the change scores, with the exception of negative symptomology of which the participant did not exhibit many, were greater than the median change scores for all participants in the original study. This suggests that single-session DMT interventions can be a complementary psychosocial treatment option for individuals who are being treated for symptoms associated with SSDs. It is important to note that this is a single-session intervention design, and therefore, the progress observed was immediate and represent short-term changes for the participant. The intention of the structure is that by providing opportunities for single-session DMT interventions daily, the effects would strengthen over continued and repeated experiences. Further research should explore multiple, daily single-session DMT interventions in addition to potential longitudinal effects of ongoing interventions.

When considering traditional treatment options for this population, psychopharmacological interventions are typically the gold standard of practice within the medical model of psychiatry [38, 39]. Not many research studies have been able to provide data to support psychosocial interventions to remediate positive symptomatology of schizophrenia [40]. Dance/movement therapy has the potential to reduce healthcare disparities experienced by individuals with SSDs based on its community-driven, trauma-informed, and strengths-based approach prioritizing inclusion and accessibility [33]. The data provided in this case report suggest that further research is warranted to examine the potential efficacy of the DMT intervention as it pertains to reduction of positive symptoms of schizophrenia. This could prove particularly useful, not only in tandem with a psychopharmacological treatment regime, but also because extant literature has informed of the difficulties individuals with schizophrenia have obtaining and maintaining ongoing antipsychotic medication compliance.

Psychopharmacological interventions, although helpful with positive symptoms, are not as useful for individuals who present with more negative symptomatology [41]. Although the participant did not present with prominent negative symptomatology, quantitative data scores did show a slight decrease in these symptoms. Moreover, the participant expressed feeling motivated, which is often diminished in individuals who present with negative symptoms. An activating and embodied psychosocial group intervention such as DMT could be useful in decreasing negative symptoms including isolation, lack of spontaneity, limited self-expression, and avolition, which can contribute to an improved quality of life.

Moreover, the group process could have contributed to positive experiences that were not otherwise measured quantitatively such as a sense of pride, acknowledgment of and experience engaging in healthy relationships, and a sense of community and belonging. Individuals with schizophrenia have reported experiences of stigmatization, dehumanization, and demeaning relationships with healthcare providers at rates higher than that of individuals with other mental health diagnoses. Therefore, feelings of pride, healthy interpersonal relationships, and feeling part of a community are notable for this population [7, 42]. These noted public health concerns of people with schizophrenia may be mitigated through supplemental and equitable psychosocial treatment interventions. Such provisions could help reduce the noted disparities and improve healthcare equity for individuals with SSDs.

Since this presentation is that of a case report, it is not feasible to determine what specifically led to the changes towards health experienced by the participant. However, the novel intervention of a single-session DMT intervention should be noted as something to be further researched. An inclusive and strengths-based intervention, the combination of verbal and non-verbal components of DMT provide individuals with high symptom acuity an opportunity to participate in ways that are not solely reliant upon cognitive processing and verbal articulation of needs or concerns [7]. Dance/movement therapy has the potential to reduce healthcare disparities and improve healthcare equity, as it presents an inclusive approach that considers discrepancies in healthcare that have been experienced by those diagnosed with SSDs [33]. Dance/movement therapy processes access a multitude of needs associated with SSDs simultaneously [5–7, 17]. The inclusiveness of the intervention asserts that anyone, regardless of gender expression, racial or ethnic identity, physical or mental ability, and communication preferences is able to participate in DMT. As a creative therapeutic practice, DMT provides space for emotional expression both verbally and non-verbally [19]. The therapist and group members can process unconscious material in an innocuous way, providing safety in imagery, symbols, and metaphors that come up in the therapeutic process [5]. Together, they create a place of safety for hallucinations, delusions, and paranoid thought content to be nonverbally and unconsciously processed, attending to needs of participants experiencing positive symptomatology. This safety is partially supported by the objects relation framework utilized by the first author (JB) in implementation of sessions deeply rooted in [25] concepts of holding and potential space for creativity. Further, the creative arts therapies, and thus DMT, offer mechanisms of change that include relational attunement, dialectical tensions, and intersubjective transcendence. Moreover, metaphors can be vehicles for non-verbal, unconscious meaning making for concepts that may be difficult to consciously identify and navigate. A structured theoretical framework that prioritizes a holding environment coupled with mechanisms of intersubjectivity and metaphor, through the vehicle of DMT can provide participants with SSDs a safe environment to move through their unconscious in an embodiment-prioritized process. For those with negative symptoms, the embodiment of DMT can activate individuals, allowing them to ‘practice’ coping skills in real time through dance, movement, and interaction with others [6, 7]. Finally, dance/movement therapists are keenly trained on movement observation skills that can attend to the body symptomatology that accompanies a diagnosis of SSDs [43]. Of particular note and as with any clinical practice, dance/movement therapists who adopt a single-session DMT intervention for individuals diagnosed with SSDs should have overlapping expertise in (1) movement observation; (2) psychodynamic psychotherapy frameworks, particularly object relations; and (3) DMT with individuals diagnosed with SSD who are experiencing acute positive symptomatology.

Authors’ contributions

J.B. and N.G. conceptualized the project, curated the data, developed the methodology, and reviewed and edited the final manuscript. J.B. acquired funding, analyzed the data, engaged in data visualization, wrote the main manuscript text, prepared Table 1, and oversaw the project research team. N.G. provided supervision for the project.

Funding

This study was funded by a grant from the Marian Chace Foundation (#230169).

Data availability

Data are not available for this study in order to maintain the participant privacy.

Declarations

Ethics approval and consent to participate

This study protocol was approved by the institutional review board at Drexel University (Protocol #1805006298). The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to the start of the study.

Consent for publication

Written informed consent and consent to publish clinical details and research results were obtained from the individuals whose data are included in this manuscript. No identifying images were published.

Competing interests

The authors declare no competing interests.