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Mental Health After SCI

Physical Interventions

Strategies to encourage health, reduce secondary complications and consequently support positive emotional adjustment following SCI have emerged as a source of increasing research interest. As examples, the following studies review the impact of regular exercise upon various measures of physical health and emotional well-being.

Discussion

Three studies evaluated physical activity in improving anxiety symptoms post SCI. Akkurt et al. (2017) found no significant difference in levels of anxiety among those in the arm ergometer plus standard exercise group compared to standard exercise alone. Curtis et al. (2017) found participation in a yoga program resulted in decreased symptoms of anxiety post intervention. Kennedy et al. (2006) found increasing level of physical activities such as skiing, horseback riding, resulted in improvement in anxiety levels post intervention.

Conclusion

There is level 1b evidence (Curtis et al. 2017) that yoga may decrease symptoms of anxiety post SCI.

There is level 4 evidence (Kennedy et al. 2006) that increased physical activity through various outlets may improve anxiety symptoms.

Author Year
Country
Research Design
PEDro Score
Total Sample Size
Methods Outcome
Akkurt et al., (2017)
Turkey
RCT
PEDro=5
N=33
Population: Mean age: Not reported;
Median age: Intervention group=33 yr,
Control group=37 yr; Gender:
males=29, females=4; Time since
injury=>1 mo, not specified further;
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 12-wk program comparing arm
ergometer exercises and general
exercises to those that receive only
general exercises.
Outcome Measures: Psychological
status (Center for Epidemiologic Studies
Depression Scale and Hospital Anxiety
and Depression Scale).
1. . No intergroup differences were seen
in HADS
2. No statistically significant differences
over the assessment period between
the intervention and control groups in
disability levels, QOL, or metabolic
syndrome parameters (p=>0.05 for
all).
Curtis et al., (2017)
Canada
RCT Crossover
PEDro=6
N=22
Population: Yoga group (n=10): Mean
age=47.9±19.5 yr; Gender: Not
reported; Level of injury: paraplegia=6,
tetraplegia=0,
ambulatory/unspecified=4; Severity of
injury: complete=2, incomplete/diseaserelated=8.
Control group (n=12): Mean
age=54.8±10.1 yr; Gender: Not
reported; Level of injury: paraplegia=4,
tetraplegia=4,
ambulatory/unspecified=4; Severity of
injury: complete=5, incomplete/diseaserelated=7.
Intervention: Participants were
randomized to a 6 wk, twice wkly
Iyengar yoga group or a 6 wk wait-listed
control group, then after the first yoga
group completed their sessions, the
wait-list control group engaged in the
yoga protocol.
Outcome Measures: Pain (brief pain
inventory (BPI), pain catastrophizing
scale (PCS)), psychological
(acceptance and action questionnaire
(AAQ), hospital anxiety and depression
scale (HADS), general self-efficacy
scale (GSES), posttraumatic growth
inventory (PTGI-SF), Connor-Davidson
resilience scale (CD-RISC), self
compassionate scale (SCS) and
mindfulness (five-facet mindfulness
questionnaire (FFMQ) measures taken
1-2 wk before and after the program.
1. Yoga group had significantly lower
scores for the HADS (p<0.05) and
significantly higher scores for the
SCS (p<0.05) at post-intervention
than at baseline.
2. Fixed-factor models showed
significantly lower HADS scores
postintervention compared to
preintervention (p<0.05) with time
being the main predictor of HADS
scores (p<0.05). 3. There was a trend noticed for FFMQ scores from preintervention to postintervention for total scores (p=0.09) and observing scores (p=0.06). 4. Postintervention scores for the SCS and FFMQ were both significantly higher than at preintervention (p>0.05).
Kennedy et al., (2006)
United Kingdom
Pre-Post
N=35
Population: Gender: males=30,
females=5; Age: 18-61 yr, Level of
injury: paraplegia=20, tetraplegia=15.
Intervention: Back-Up: 1 wk 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 1 wk activity
courses
Outcome Measures: Life Satisfaction
Questionnaire (LSQ), Hospital Anxiety
and Depression Scale (HADS)
1. HADS scores demonstrated
significant (p<0.01) improvement in
anxiety levels over the duration of the
course.

Discussion

In an RCT, Tan et al. (2011) found no significant difference in anxiety symptoms between participants in the cranial electrotherapy stimulation (CES) compared to sham group. Two studies examined the effect of transcranial direct current stimulation (tDCS) on anxiety after SCI (Fregni et al. 2006; Soler et al. 2010). Soler et al. (2010) found significant reduction in symtposm among those in the tDCS compared to the sham group. Participants in the TDCS combined with visual illusion group had the greatest decrease in anxiety symptoms. Fregni et al. (2006) found no significant effects of tDCS on anxiety compared to sham group. Kennedy et al.,(2006) found participation in an integrated sports activity program resulted in a significant decrease in anxiety symptoms compared to baseline. Diego et al. (2002) found participants in a massage therapy group experienced significant reduction in anxiety compared to those in the home exercise group.

Conclusion

There is level 2 evidence from 1 RCT, that cranial electrotherapy stimulation may not be effective at reducing symptoms of anxiety after SCI.

There is conflicting evidence from 2 RCTs that transcranial direct current stimulation alone may reduce symptoms of anxiety after SCI.

There is level 2 evidence that combined transcranial direct current stimulation and visual illusion walking may help reduce symptoms of anxiety after SCI

There is level 2 evidence from 1 RCT, that massage may reduce symptoms of anxiety after SCI compared to home exercise.

There is level 4 evidence from 1 pre-post study, that participation in sports activity may reduce symptoms of anxiety after SCI.

Author Year
Country
Research Design
PEDro Score
Total Sample Size
Methods Outcome
Tan et al., (2011)
USA
RCT
PEDro=8
NInitial=105 NFinal=100
Population: Mean age=52yr; Gender:
males=90, females=15; Level of injury:
paraplegia=66, quadriplegia=37,unknown=2; Severity of injury:
incomplete=52, complete=42,
unknown=11; Mean time post
injury=15yr; Anxiety status=symptoms.
Intervention: Individuals with chronic
neuropathic pain were randomized to
receive active (treatment, n=46) or
sham (control, n=59) cranial
electrotherapy stimulation (CES) 1hr/d
for 21d. Outcomes were assessed pre
and post treatment.
Outcome Measures: Center for
Epidemiologic Studies Depression
Scale – Short Form (CES-D-SF), StateTrait Anxiety Inventory – Short Form
(STAI-SF).
1. At baseline, the treatment group had
significantly poorer scores on STAISF (p<0.05).
2. There was no significant main effect
of time on STAI-SF in either group.
3. There were no significant time x
group interactions on STAI-SF.
Soler et al. (2010)
Spain
RCT
PEDro=8
N=39
Population: Mean age=45yr; Gender:
males=31, females=9; Level of injury:
paraplegia=30, quadriplegia=10;
Severity of injury: incomplete=8,
complete=32; Mean time post
injury=9yr; Anxiety status=symptoms.
Intervention: Individuals with chronic
neuropathic pain were randomized to
receive transcranial direct current
stimulation (tDCS, n=10), visual illusion
(VI, n=10), tDCS with VI (n=10), or
sham tDCS (placebo, n=10) during 10
sessions over 2wk. Outcomes were
assessed pre and post treatment, and
2, 4, and 12wk follow-up.
Outcome Measures: Numerical Rating
Scale for Anxiety (NRS-A).
1. NRS-A score significantly decreased
in the tDCS, tDCS+VI, and VI groups
(p<0.019), but not the placebo group.
2. NRS-A score improvements were
only maintained in the tDCS+VI
group at all follow-ups (p<0.04).
Fregni et al., (2006)
USA
RCT
PEDro=8
NInitial=17 NFinal=15
Population: Mean age=35yr; Gender:
males=14, females=3; Level of injury:
paraplegic=8, quadriplegic=9; Severity
of injury: incomplete=6, complete=11;
Mean time post injury=3.5yr; Anxiety
status=symptoms.
Intervention: Individuals with central
pain were randomized to receive active
(treatment, n=11) or sham (control, n=6)
transcranial direct current stimulation
(tDCS) 20min/d for 5d. Outcomes were
assessed at baseline, 1-5d pre and post
treatment, and 16d follow-up.
Outcome Measures: Beck Depression
Inventory (BDI), Visual Analogue ScaleAnxiety (VAS-A).
1. On VAS-A, there was a significant
effect of time (p=0.001), but not
group (p=0.42) or time x group
(p=0.99).
Diego et al., (2002)
USA
RCT
PEDro=8
N=20
Population: Mean age=39yr; Gender:
males=15, females=5; Level of injury:
quadriplegia; Time post injury>1yr;
Anxiety status=symptoms.
Intervention: Participants were
randomized to receive massage therapy
(treatment, n=10) or perform a home
exercise routine (control, n=10) 2x/wk
for 5wk.
Outcome Measures: Center for
Epidemiologic Studies Depression
Scale (CES-D), State Trait Anxiety
Inventory (STAI).
1. The treatment group showed a
significantly greater decrease in STAI
(p<0.01) scores after treatment than
controls.
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