Physical Activity Psychosocial

Depression and Anxiety

Anxiety and depression are two of the most commonly-measured components of psychological well-being in SCI. Symptoms of anxiety and/or depression are commonly-reported concerns amongst individuals with SCI, their care partners and/or healthcare providers, and are associated with negative outcomes among individuals with SCI including lower functional independence, more secondary complications, and less community and social integration (Fann et al., 2011). Unfortunately, the likeliness of individuals with SCI experiencing anxiety or depression is significantly higher than age-matched control without SCI (Williams & Murray, 2015). However, the outcome measures used to capture and evaluate symptoms of anxiety and depression in research vary, making the comparison of findings difficult. The goal for this section is to summarize the current state of the research investigating the role of LTPA on symptoms of anxiety and/or depression.

Author (Year) Country Research Design PEDro Score for RCTs Total Sample Size

 Methods

Outcome

Akkurt et al. 2017
Turkey
RCT
PEDro=5
N=33

 Population: Median age: Intervention group=33yr, Control group=37yr; Gender: males=29, females=4; Time since injury=>1mo; Level of injury: C=1, T=22, L=10; Severity of injury: AIS A=19, B=1, C=10, D=3.

Intervention: Participants were enrolled in a 12wk program comparing arm ergometer exercises and general rehab exercises to those that receive only general rehab exercises.

Outcome Measures: Center for Epidemiologic Studies Depression Scale (CES-D) and Hospital Anxiety and Depression Scale (HADS).

 1. No intergroup differences were seen in HADS and CES-D.
Chemtob et al. 2019
Canada
RCT
PEDro=9
N(start)=24
N(end)=22		 Population: Age=51.64±12.13yr.; Gender: males=16, females=8; Level of injury: paraplegia=24, quadriplegia=0; Level of severity: Not reported; Time since injury=15.45±12.85yr.

Intervention: Participants were randomized to either an intervention or control group. The intervention group received one, 1-hour counselling session per week for 8 weeks via online video chat with the intent to motivate patients to increase their leisure-time physical activity, while the control group continued their regular routine.

Outcome Measures: Patient-Health Questionnaire-9 (PHQ-9).

 1. Small effect sizes were found to favour the intervention group at 6 and 10 weeks for improvements in PHQ-9 score.
Coulter et al. 2017
United Kingdom
RCT
PEDro=6
NInitial=24, NFinal=21		 Population: Intervention Group: Mean age: 51.5yr; Gender: males=9, females=7; Level of injury: C3/4–L3; Severity of injury: complete=7, Incomplete=9. Control Group: Mean Age: 48.1yr; Gender: males=5, females=3; Level of injury: C3/4–L3, Severity of injury: Complete=5, Incomplete=3.

Intervention: Intervention Group: an 8wk web-based physiotherapy (2x/wk). Individual exercise programmes were prescribed based on participants’ abilities. Control Group: Usual care.

Outcome Measures: Hospital Anxiety and Depression Scale (HADS)

 1. No statistically significant difference between the intervention and control groups on the HADS depression and HADS anxiety subscale scores following the intervention.
Curtis et al. 2017
Canada
RCT Crossover
PEDro=6
N=22		 Population: Yoga group (n=10): Mean age=47.9±19.5yr; Gender: Not reported; Level of injury: paraplegia=6, tetraplegia=0, ambulatory/unspecified=4; Severity of injury: complete=2, incomplete/disease-related=8. Control group (n=12): Mean age=54.8±10.1yr; Gender: Not reported; Level of injury: paraplegia=4, tetraplegia=4, ambulatory/unspecified=4; Severity of injury: complete=5, incomplete/disease-related=7.

Intervention: Participants were randomized to a 2x/wk for 6wk Iyengar yoga group or a wait-listed control group.

Outcome Measures: Hospital Anxiety and Depression Scale (HADS)

 1. Yoga group had significantly lower scores for depression than the waitlist control group (p<0.05).
2. No differences were found for anxiety by group.
3. Fixed-factor models showed significantly lower HADS scores postintervention compared to preintervention (p<0.05) with time being the main predictor of HADS-D (depression) scores (p<0.05).
Diego et al. 2002
USA
RCT
PEDro=8
N=20		 Population: Mean age=39yr; Gender: males=15, females=5; Level of injury: tetraplegia; Time since injury=>1yr.

Intervention: One group received a 40 min massage 2x/wk for 5wk by a massage therapist while the other was taught a range of motion exercise routine that they performed 2x/wk for 5wk on their own.

Outcome Measures: State Trait Anxiety Inventory (STAI), Center for Epidemiologic Studies Depression Scale (CES-D).

 1. On pre-posttreatment days, the massage group had lower anxiety scores than the range of motion exercise group (p < .01)
2. On pre-post intervention assessments, the massage groups had greater decreases in depression scores compared to range of motion exercise group (p < .05).
Hicks et al. 2003
Canada
RCT
PEDro=8
NInitial=43 NFinal=32		 Population: Age=19-65yr; Time since injury=1-24yr.

Intervention: Experimental group participated in a progressive exercise training program twice weekly for 9mo on alternative day’s 90-120 min starting with warm up, upper extremity stretching, and 15 to 30 min of aerobic training. As the rate of perceived exertion decreased, workload was increased. Some resistance training took place.

Outcome Measures: Centre for Epidemiological Studies Depression Scale (CES-D).

 1. Exercisers reported significantly fewer depressive symptoms than the controls. (p<0.05).
Latimer et al. 2004
Canada
RCT
PEDro=6
NInitial=34, NFinal=21		 Population: Intervention group: Mean age: 38.27yr; Gender: males=3, females=8; Level of injury: Tetraplegia=7, Paraplegia=4; Severity of injury: ASIA A=5, ASIA B=1, ASIA C=3, ASIA D=1; Mean time post-injury: 10.54yr. Control group: Mean age: 43.08yr; Gender: males=2, females=8; Level of injury: Tetraplegia=3, Paraplegia=7; Severity of injury: ASIA A=3, ASIA B=1, ASIA C=3, ASIA D=3; Mean time post-injury: 14.58yr.

Intervention: Intervention group: 9mo exercise program – 2d/wk, small group exercise sessions, 60-90min duration consisting of stretching, arm ergometry & resistance exercise with student volunteer personal trainers. Control group: Asked to continue normal daily activities and not begin an exercise routine within 9mo although provided with an opportunity for education.

Outcome Measures: Center for Epidemiological Studies Depression Scale (CES-D).

 1. Exercise group had lower depression than the control group. (p<.05)
Martin Ginis et al. 2003
Canada
RCT
PEDro=6
NInitial=34 NFinal=34		 Population: Mean age=8.6yr; Gender: males=23, females=11; Mean time post injury: 10.4yr.

Intervention: Intervention group: 5min of stretching, 15-30min of aerobic arm ergometry exercise & 45-60min of resistance exercise, 2d/wk, in small groups. Control group: Asked to continue normal daily activities and not begin an exercise routine for 3mo

Outcome Measures: Center for Epidemiologic Studies Depression Scale (CES-D).

 1. After 3 months, when compared to controls, exercisers had decreased depression (p=0.02).
Alajam et al. 2020
USA
Pre-Post
NInitial=15, NFinal=11		 Population: SCI; Mean age= 38±10yr; Gender: males=8, females=3; Level of injury: T3-L1; Mean time post-injury: 8.72±10.40yr.

Intervention: Participants received walking training, 3 sessions/wk for 8wk. Participants were trained on a treadmill using a novel assistive gait training device consisting of a thigh brace attached to a pulley cable designed to assist with leg flexion.

Outcome Measures: Depression Anxiety Stress Scales-21 (DASS-21).

 1. Statistically significant decrease in mean scores for depression (2.36 point decrease, p<0.01), anxiety (1.45-point decrease, p<0.05), and stress (2.09-point decrease, p<0.01) after training.
Allin et al. 2020
Canada
Pre-Post
Ninitial=11
Nfinal=10		 Population: Age=43±8yr.; Gender: males=4, females=7; Level of injury: paraplegia=5, tetraplegia=3, not reported=3; Level of severity: Not reported; Time since injury=20±12yr.

Intervention: Participants took part in a self-paced, six-session self-management program guided by a trained peer health coach. The program lasted between 35-88 days with a total of 6 coaching sessions.

Outcome Measures: Personal Health Questionnaire Depression Scale [PHQ-9])

 1. PHQ-9 scores decreased, showing improvements, but did not reach significance (p=0.27).
Crane et al. 2017
USA
Pre-Post
NInitial=89 NFinal=45		 Population: Mean age=43.8±15.3yr; Gender: males=34, females=11; Level of injury: Paraplegia=11, Tetraplegia (C1-C4)=4, Tetraplegia (C5-C8)=8, Other=22; Severity of injury: AIS A/B=23, C/D=22.

Intervention: Participants engaged in a 3mo physical therapy group exercise class, twice per wk.

Outcome Measures: Patient Health Questionnaire-2 to assess depressive mood

 1. Total depression scores were significantly lower at post-intervention assessment (p<0.05).
Guest et al. 1997
USA
Pre-Post
N=15		 Population: Traumatic complete paraplegics; Gender: males=12, females=3; Mean age=28.8yr; Mean time post injury=3.8yr.

Intervention: Electrically stimulated walking program-32-sessions, using the Parastep® FES ambulation system.

Outcome Measures: Beck Depression Inventory (BDI).

 1. BDI decreased after electrically stimulated walking (p<0.05).
Hicks et al. 2005
Canada
Pre-Post
N=14		 Population: Chronic incomplete SCI: N=14; Tetraplegic=11, Paraplegic=3; Gender: males=11, females=3; Age range=20-53yr; Mean time post injury=7.4yr; ASIA: B=2, C=12.

Intervention: Body weight supported treadmill training (BWSTT) – up to 45 min, 3x/week, 144 sessions (12mo).

Outcome Measures: Center for Epidemiologic Studies Depression Scale (CES-D).

 1. No change in depression or perceived health (p>.05).
Kennedy et al. 2006
United Kingdom
Pre-Post
N=35		 Population: Gender: males=30, females=5; Age: 18-61yr, Level of injury: paraplegia=20, tetraplegia=15.

Intervention: ‘Back-Up Trust’ sports participation program: 1wk participation in single or multi-activity course in an integrated, residential environment. Activities include skiing, horseback riding, waterskiing, canoeing, rappelling and gliding. Questionnaires were completed at baseline and end of 1wk activity courses

Outcome Measures: Hospital Anxiety and Depression Scale (HADS).

 1. HADS scores demonstrated significant (p<0.01) improvement in anxiety levels but not in depression levels over the duration of the course.
Martin Ginis & Latimer 2007
Canada
Pre-Post
N=14		 Population: SCI; Mean age: 28.8yr; Gender: males=11, females=3; Level of injury: incomplete, ASIA B and C; Mean time since injury: 7.4yr; Chronicity: chronic.

Intervention: Participants performed three exercise sessions of body weight supported treadmill training (BWSTT). Each exercise session consisted of three separate bouts of BWSTT. Depending on the participant’s tolerance, each bout lasted from 5 to 15 min with a 10 min rest between bouts.

Outcome Measures: Profile of Mood States (POMS),

 1. Participants showed a nonsignificant small-to-medium sized improvement in the POMS in session 1, and a nonsignificant decrease in the POMS in session 2 and 3 (p>.05).
Shem et al. 2016
USA
Pre-Post
NInitial=26, NFinal=10		 Population: SCI; Mean age: 49.8±13.0yr; Gender: males=14, females=12; Level of injury: tetraplegic=16, Level of injury: paraplegic=6, unknown=4, Mean time post-injury: 25.1yr.

Intervention: Participants completed a 12-week seated Tai Chi course consisting of weekly sessions (one 90-min session/wk).

Outcome Measures: Beck Depression Inventory–II (BDI–II)

 1. No changes in the long-term effect surveys of BDI between the first and the last sessions were observed.
Warms et al. 2004
USA
Pre-Post
N=16		 Population: Gender: males=13, females=3; Mean age=43.2yr; Mean time post injury=14.4yr.

Intervention: “Be Active in Life” program: included educational materials (2 pamphlets, 2 handouts), a home visit with a nurse (90 min. scripted motivational interview, goal and personal action plan establishment), and follow up calls at day 4, 7, 11 & 28 (approx. 8 min each). Program lasted for 6wk, and had a final follow up 2wk post-completion.

Outcome Measures: Center for Epidemiologic Studies Depression Scale (CES-D)

 1. No significant change in depression was observed (p>0.05).
Foreman et al. 1997
Australia
Observational
N=121		 Population: Sport participants (n=54): Mean age: 31.93±8.23yr; Mean age at injury: 21.02±7.09yr; Gender: males=49, females=5; Level of injury: C=21. Non-sport participants (n=67): Mean age: 38.34±9.25yr; Mean age at injury: 25.02±9.40yr; Gender: males=53, females=14; Level of injury: C=45.

No Intervention: Individuals completed a set of questionnaires including requests for demographic information and assessments of depression and anxiety. Groups were sport and non-sport participants.

Outcome Measures: Centre for Epidemiological Studies Depression Scale (CES-D), State Tait Anxiety Inventory (STAI).

 1. No significant differences were found for depression between the groups (p=0.099).
1. Non sport participants had a significantly higher score in trait anxiety than sport participants (p=0.048).
Gioia et al. 2006
Italy
Observational
N=137		 Population: SCI: Mean age: 34.21±11.36yr; Gender: males=137, females=0; Time since injury: 5-10yr; Level of Injury: C5 or below; Neurological status: paraplegic=85; tetraplegic=52.

No Intervention: Wheelchair users were recruited to investigate whether sports activity is associated with better psychosocial outcomes. Participants were divided into a high activity and no activity group.

Outcome Measures: State-Trait Anxiety Inventory (STAI), Questionnaire for Depression.

 1. ANOVA showed that there was a significant main effect of participation is sports on psychological outcomes, with less active people scoring higher in anxiety and lower in extraversion (p<0.05).
2. Anxiety effectiveness was found to positively correlate with sport activity (p<0.01).
Jorgensen et al. 2017
Sweden
Observational
N=122		 Population: Mean Age=63±9yr; Gender: Males=86, Females=36; Level of Injury: C1-L5; Severity of Injury: AIS A-C=62, D=60; Mean Time Since Injury=24±12yr.

No Intervention: Not applicable. Review of data from the Swedish Aging with Spinal Cord Injury Study to assess the presence of depressive symptoms among older adults with long-term spinal cord injury.

Outcome Measures: Geriatric depression scale-15 (GDS-15), sense of coherence scale, spinal cord lesion-related coping strategies questionnaire, physical activity recall assessment for people with SCI (PARA-SCI).

 1. Sense of coherence, the coping strategy acceptance, neuropathic pain and leisure-time physical activity explained 53% of the variance in depressive symptoms. LTPA had a significant, negative relationship with depressive symptoms
Kim et al. 2020
Korea
Observational
N=103		 Population: Mean Age=36.71±9.77yr; Gender: Males=91, Females=12; Level of Injury: Cervical=59, Thoracic=39, Lumbrosacral=5; Severity of Injury: AIS A=58, B=36, C=7, D=2; Time Since Injury>1yr.

No Intervention: Cross-sectional analysis to assess the relationship between physical activity levels and mental health in individuals with SCI.

Outcome Measures: Godin Leisure-Time Exercise Questionnaire (GLTEQ), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7).

 1. Participants that were the most physically active experienced less depression (PHQ-9; p<0.001) and anxiety (GAD-7; p<0.001) than those who were the least physically active.
2. Multivariate linear regression analysis showed that reduced physical activity was a significant predictor of depression (p=0.01) and anxiety (p=0.02).
Muraki et al. 2000
Japan
Observational
N=169		 Population: Mean age:42.7yr; Gender: males=169; Level of injury: Tetraplegia=53, Paraplegia=116; Mean time post-injury: 9.23yr.

No Intervention: Questionnaire. Participants were divided into four groups according to their frequencies of sports activity; High-active (more than three times a week; n=32), Middle-active (once or twice a week, n=41), Low-active (once to three times a month, n=32), and Inactive (no sports participation, n=64).

Outcome Measures: Questions about the frequency and mode of physical activities, Self-rating Depression Scale (SDS), State-Trait Anxiety Inventory (STAI) and Profiles of Mood States (POMS).

 1. Significant differences in depression (SDS), trait anxiety (STAI), and depression and vigor (POMS) among the groups (p<0.05)
2. High-active group showed the lowest scores of depression and trait anxiety, and the highest score of vigor among the four groups.
3. There was no significant difference for any psychological measurements among modes (wheelchair basketball, wheelchair racing, wheelchair tennis and minor modes; (p>0.05).
Sweet et al. 2013
Canada
Prospective
N=395		 Population: Age=45.68±14.05yr; Gender: males=298, females=95; Level of injury: paraplegia=190, tetraplegia=194; Level of severity: ASIA A=254, ASIA B/C/D=134; Time since injury=13.51±10.35yr.

No Intervention: None – prospective design. Using a prospective design, this study examined potential intermediary constructs linking LTPA and QOL in people with SCI. Drawing from previous literature, a longitudinal structural equation model was developed and tested to determine if depression, functional independence, social integration/participation, and self-efficacy mediate the LTPA–QOL relationship.

Outcome Measures: Leisure Time Physical Activity (LTPA), Depression (Patient Health Questionnaire-9 (PHQ-9).

 1. LTPA was significantly related to depression (PHQ-9).
2. Depression was statistically significant mediators of the LTPA-QOL relationship.
Tasiemski and Brewer 2011
Poland
Observational
N=1034		 Population: Mean age: 35.93yr; Gender: males=861, females=173; I Level of injury: paraplegia: 49.8%, tetraplegia: 50.2%; Mean time since injury: 9.78yr.

No Intervention: Questionnaire based study to examine the interrelationships among athletic identity, sport participation, and psychological adjustment

Outcome Measures: Sport participation, involvement in non-sport recreational activities before and after SCI, Hospital Anxiety and Depression Scale (HADS).

 1. Being able to practice one’s favorite sport after SCI was associated with lower levels of depression (p<0.001).
2. Team sport participants reported lower anxiety (p<0.005) and depression (p<0.05) than individual sport participants did.
Tawashy et al. 2009
Canada
Observational
N=49		 Population: Mean age: 43.7yr; Gender: not reported; Level of injury: Paraplegia=67%; Injury severity: complete=61%; Mean time post-injury: 11.8yr.

No Intervention: Cross-sectional study to evaluate the relationship between physical activity levels and demographic and secondary complications factors that might relate to physical activity participation.

Outcome Measures: Physical Activity
Recall Assessment for People with SCI (PARA-SCI), Centre for Epidemiological Studies – Depression scale (CESD-10)

 1. Higher amounts of mild-intensity activity and total activity were related to less depressive symptoms (p<0.05).
VanDerwerker et al. 2020 USA Observational
N=1790		 Population: Gender: males=1324, females=466; Injury: C1-C4 non-ambulatory=175, C5 and below non-ambulatory=1034, Any level, ambulatory=563; Mean time since injury: 13yr.

No Intervention: Participants completed a mail-in self report survey at two time points (mean 3.29yr apart) and study investigated associations between doing planned exercise and probably major depressive disorder.

Outcome Measures: Patient Health Questionnaire- 9 (PHQ-9).

 1. Participants who did planned exercise three or more times per week at T1 had significantly lower odds of probable major depressive disorder at T2 (p=0.0042).
2. Compared to those who had no change, those who worked out more at T2 had significantly lower odds of probable major depressive disorder (p=0.0005) and those who did less planned exercise had higher odds (p=0.005).

Discussion

Description of studies. Overall, the studies included in this section found a positive or no relationship between LTPA and symptoms of anxiety and depression. Out of the 26 included studies, 9 were observational and 17 were interventional (8 RCTs, and 9 pre-post trials). The majority of the included studies (17/26) were conducted in North America (6 of which were RCTs, 8 pre-post, and 3 observational). Studies conducted outside of North America were observational studies (6/9) and included 1 in Poland, and 1 each from Australia, Italy, Japan, Korea, and Sweden. Out of the 3 intervention studies conducted outside of North America, 2 were from the UK (1 RCT and 1 pre-post), and 1 RCT from Turkey. Therefore, interpretations made in this section are heavily influenced by studies conducted within North America (5 RCTs, 3 pre-post, and 2 observational from Canada, and 1 RCT, 5 pre-post, and 1 observational from the USA). No studies examined just anxiety, but 16 examined depression (4 RCT, 7 pre-post, and 5 observational), and 10 examined both anxiety and depression (4 RCT, 2 pre-post, and 4 observational).

Overview of the LTPA and depression/anxiety relationship. The majority of RCT intervention studies (6/8) provided evidence in favour of the beneficial role of LTPA interventions on decreasing symptoms of depression. Interestingly, 6 of the 9 pre-post studies showed no significant effect of LTPA intervention on depressive symptoms. Anxiety was less studied; only 6/17 intervention studies (4 RCTs and 2 pre-post) included a measure of anxiety. The intervention studies that measured anxiety reported conflicting findings: 3 RCTs showed no significant effect of LTPA interventions on symptoms of anxiety while 1 RCT showed a decrease. Both pre-post studies showed a positive impact of LTPA interventions on decreasing symptoms of anxiety.

There was a large variety in the types of LTPA used in the intervention studies including arm ergometry, web-based physiotherapy exercises, yoga, tai chi, mobility/range of motion programs, activity coaching/counselling, support treadmill training (using body weight support, pulley assistance, or electrical stimulation), sport, and combined exercise programs (including progressive resistance, aerobic, and stretching training). Studies also varied in terms of the target/included SCI population, and in length and dosage of interventions. No obvious trends were seen with regards to type of LTPA intervention and effect on symptoms of anxiety and/or depression. Further, a remaining challenge is that most studies did not sample for individuals affected by anxiety or symptoms of depression and most of the included studies did not set out to primarily target anxiety or depression. With the exception of a few studies, the primary aims of included studies were related to fitness, function (e.g., walking ability) or LTPA behaviour. Another major limitation to fully understanding the role of LTPA on anxiety and depression is that no studies included individuals who were diagnosed with clinical depression and/or an anxiety disorder.

With regards to the observational studies, 5/9 looked at just depression, and 4/9 looked at both anxiety and depression. Among the 9 studies that measured depression, 7 studies showed a negative relationship between LTPA level and symptoms of depression (i.e., as physical activity increased, symptoms of depression decreased), 2 studies however showed no significant relationship between symptoms of depression and LTPA. These same 2 studies did show an inverse relationship between sports participation and symptoms of anxiety. The remaining 2 studies that looked at anxiety also supported the inverse relationship between LTPA levels and anxiety. Similar to intervention studies, the observational studies varied in the type of LTPA investigated: 4 studies looked at sports involvement while the other 5 looked at other types of LTPA. Noteworthy, the 4 studies that focused on sports ranged in sample size from n=121-1034, but 81-100% of these participants were male. Further research exploring the relationship between LTPA and symptoms of anxiety and depression across sex and/or gender is warranted.

Although the majority of observational studies reported significant findings describing the inverse relationship between LTPA levels and symptoms of anxiety and depression, we do not know if LTPA is improving these symptoms OR if having these symptoms preclude individuals with anxiety and depression to be active. It is likely that unique opportunities and behavioural strategies are needed to help support LTPA participation for individuals with anxiety or depression and SCI. For individuals who do not have a clinical diagnosis of depression or anxiety, the findings from this review suggest that LTPA is safe and may help improve mood/perceived symptoms of depression and anxiety or at least not make them worse. However, the findings from the observational studies reinforce that there is a lack of research among people with SCI with a clinical diagnosis of an anxiety or depression disorder.

Differences in the type and dosage of LTPA intervention as well as the variance in sample size and participant demographics most likely contribute to the conflicting findings across studies. Future studies and further analyses that attempt to control for type of LTPA intervention and dosage and/or SCI demographics such as age, gender, time post injury, and SCI location, and severity are needed to further explore the relationships between LTPA and anxiety and depression. Overall, there is still lots to learn about the role of LTPA on anxiety and depression in individuals with SCI. More research is needed with anxiety and/or depression as the primary outcome, that consider a global perspective and/or cultural/geographical considerations, that look at sex and/or gender differences, and that target individuals with clinical diagnoses of anxiety and depression at baseline. To inform clinical application, it would be helpful if future studies include detailed reports on intervention dosage and proposed mechanisms of effectiveness as well as measures at follow-up timepoints.

Conclusion

There is level 1a evidence from 6 RCTs – and support from level 4 evidence from 3 pre-post studies and level 5 evidence from 7 observational studies – that participation in LTPA can reduce symptoms of depression among persons with SCI. However, there is level 1b evidence from 1 RCT – along with level 4 and 5 evidence from 6 pre-post studies and 3 observational studies – showing no significant effect/relationship between LTPA and depressive symptoms among persons with SCI.

There is level 1a evidence from 2 RCTs supported by another lower level RCT that LTPA intervention had no significant effect on symptoms of anxiety among persons with SCI. There is level 4 evidence from 2 pre-post studies, supported by level 5 evidence of 4 observational studies, that LTPA participation is related to lower symptoms of anxiety for persons with SCI.

Chapter Downloads
Patient Handouts
Outcome Measures
Active Clinical Trials