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Mental Health After SCI

Physical Activity

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.

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 and CES-D.
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),
selfcompassionate 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).
Latimer et al., (2004)
Canada
RCT
PEDro=1
N=23
Population: Intervention group: Mean
age:37.54 yr; Gender: 9 males, 4
females; Level of injury: Tetraplegia (7),
Paraplegia (6); Mean time post-injury:
9.23 yr; Control group: Mean age:43.30
yr; Gender: 5 males, 5 females; Level of
injury: Tetraplegia (4), Paraplegia (6);
Mean time post-injury:15.70 yr
Intervention: Intervention group: A 6
mo exercise program 2d/wk in small
groups (avg 3-5 people), ran by student
volunteer personal trainers. Control
group: Asked to continue normal daily
activities and not begin an exercise
routine within 6 mo
Outcome Measures: Perceived Stress
Scale (PSS); Center for Epidemiologic
Studies Depression Scale (CES-D);
Perceived Quality of Life (PQOL);
measured at at baseline, 3 and 6 mo
1. At baseline, ↑ stress levels were
related to ↑ depression rates
(p<0.05). At 6 mos, the exercise
group’s stress and depression
association had ↓ but remained
significant in the control group
(p<0.05).
2. At baseline, ↑ stress levels were
associated to ↓perceived QOL
(p<0.05). At 3 and 6 mo the exercise
group’s stress and QOL association
↓, but remained ↑ across all time
points for the control group (p<0.05).
3. Exercise was found to buffer the
effects of stress on QOL and
depression.
Hicks et al., (2003)
Canada
RCT
PEDro=8
NInitial=43 NFinal=32
Population: Age=19-65 yr; Gender:
both; Time since injury=1-24 yr.
Intervention: Experimental group
participated in a progressive exercise
training program twice weekly for 9 mo
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: Changes in
depression, cardiovascular function,
muscle strength and quality of life.
1. Quality of life components:
Exercisers reported less stress, fewer
depressive symptoms, and greater
satisfaction with their physical
functioning than the controls.
(p=0.06). Exercisers reported less
pain (p<0.01) and a better Q of L
(p<0.05).
Martin Ginis et al., (2003)
Canada
RCT
PEDro=6
NInitial=34 NFinal=34
Population: Mean age=8.6 yr; Gender:
23 males, 11 females; Mean time postinjury: 10.4 yr
Intervention: Intervention group: 5 min
of stretching, 15 -30 min of aerobic arm
ergometry exercise & 45-60 min of
resistance exercise, 2d/wk, in small
groups. Control group: Asked to
continue normal daily activities and not
begin an exercise routine for 3 mo
Outcome Measures: Perceived Quality
of Life (PQOL); Center for
Epidemiologic Studies Depression
Scale (CES-D).
1. After 3 months, when compared to
controls, exercisers had:
– ↑ QOL (p=0.007)
– ↓depression (p=0.02)
Diego et al., (2002)
USA
RCT
PEDro=8
N=20
Population: Mean age=39 yr; Gender:
males=15, females=5; Level of injury:
tetraplegia; Time since injury=>1 yr.
Intervention: One group received a 40
min massage 2x/wk for 5 wk by a
massage therapist while the other was
taught an exercise routine that they
performed 2x/wk for 5 wk on their own.
Outcome Measures: State Trait
Anxiety Inventory (STAI), Center for
Epidemiologic Studies Depression
Scale (CES-D).
1. CES-D scores obtained on first day
versus last day assessment by
group. Repeated measures ANOVA
showed a group by day interaction
effect (p<0.05).
2. T-tests revealed greater decrease in
CES-D depression scores for the
massage therapy group (p<0.05).
Crane et al., (2017)
USA
Pre-Post
NInitial=89 NFinal=45
Population: Intervention Group:Mean
age=43.8±15.3 yr; 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
3-mo physical therapy group exercise
class, twice per wk.
Outcome Measures: Pre-post
intervention interviews about exercise
frequency and intensity, perceived
health, pain, mood, sleep and television
watching habits.
1. Significant improvement in state of
health as well as a significant
increase in days per week of
moderate to vigorous activity (p<0.05
for both).
2. Total Patient Health Questionnaire-2
depression scores were significantly
lower at post-intervention
assessment (p<0.05).
3. Participant comments from the
interviews reinforced the program’s
positive influence on their health.
Curtis et al., (2015)
Canada
Pre-Post
N=11
Population: Mean age=48.4±15 yr;
Gender: males=1, females=10; Time
since injury=157.4±191.8 mo; Level of
injury: complete=3, incomplete=6;
unknown=1, not reported=1; Severity of
injury: tetraplegia=2, paraplegia=6,
unknown=1, not reported=2.
Intervention: Participants took part in
an 8-wk modified yoga program with
assessments taken at baseline and
post-intervention.
Outcome Measures: Pain (Brief Pain
inventory (BPI), Pain Catastrophizing
Scale (PCS), fatigue (Fatigue Severity
Scale (FSS), psychological factors
(General Self-Efficacy Scale (GSES),
The Positive and Negative Affect Scale
(PANAS)) and mindfulness (Toronto
Mindfulness Scale (TMS) through selfreport.
1. 5 of the 11 participants finished at
least 4 sessions and Fisher’s exact
test revealed that participants who
were outpatients were significantly
more likely to complete the program
than in-patients (p<0.05).
2. No significant differences between
baseline and exit scores for any
measure (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.
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=20-53 yr; Mean time post
injury=7.4 yr; ASIA: B=2, C=12.
Intervention: Body weight supported
treadmill training (BWSTT) -robotic – up
to 45 min, 3x/week, 144 sessions (12
mo).
Outcome Measures: Center for
Epidemiologic Studies Depression
Scale(CES-D)
1. Increased life satisfaction and
increased physical function
satisfaction (p<0.05), after BWSTT.
2. No change in depression or
perceived health.
Warms et al., (2004)
USA
Pre-Post
N=16
Population: Gender: males=13,
females=3; Mean age=43.2 yr; Mean
time post injury=14.4 yr.
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 6 wk, and had a final follow up 2 wk
post-completion.
Outcome Measures: Self Rated Health
Scale (SRHS), Center for Epidemiologic
Studies Depression Scale (CES-D)
1. Physical activity: Counts/day
increased in 60% of subjects and
self-reported activity increased in
69% of subjects, but both were not
significant.
2. Depression: no change
Guest et al., (1997)
USA
Pre-Post
N=15
Population: Traumatic complete
paraplegics; N=15; Gender: males=12,
females=3; Mean age=28.8 yr; Mean
time post injury=3.8 yr.
Intervention: Electrically stimulated
walking program-32-sessions, using
the Parastep® FNS ambulation
system.
Outcome Measures: Tennessee Self
Concept Scale (TSCS), Beck
Depression Inventory (BDI)
1. Physical Self-Concept: decreased
after electrically stimulated walking
(p<0.05). Those with lower baseline
score had the most significant
improvements.
2. Depression: decreased after
electrically stimulated walking
(p<0.05).
Bradley et al., (1994)
USA
Cohort
N=37
Population: Gender: males=24,
females=13; Mean age=32.03 yr; Level
of injury: tetraplegic=12, paraplegic=25;
Mean time post injury=6.51 yr
Intervention: Intervention group: 3
mos. Functional Electrical Stimulation
(FES) exercise program; Control group:
no intervention.
Outcome Measures: Multiple Affect
Adjective Check List (MAACLR)
1. Increased in depression & hostility
for those who had unrealistic
expectations of the FES program
(p<0.01 & p<0.05, respectively).

Discussion

Several studies (Akkurt et al. 2017; Crane et al. 2017; Hicks et al. 2003; Latimer et al. 2004; Martin Ginis et al. 2003) evaluated the effect of exercise programs which included stretching, aerobic arm ergometry and resistance exercises among those with SCI. The studies found significant reduction in depressive symptoms post SCI post-treatment (Crane et al. 2017; Hicks et al. 2003; Latimer et al. 2004; Martin Ginis et al. 2003).

A Canadian pre-post study Hicks et al. (2005) examined the effect of Body weight supported treadmill training provided three times a week. This study reported an increase in life satisfaction and physical function satisfaction after 1 year of exercise; however, there was no change in reports of depressive symptoms.

Two studies (Curtis et al. 2017; Curtis et al. 2015) evaluated the effectiveness of yoga among persons with SCI. Curtis et al. (2017) found participants receiving  twice weekly yoga had a significant decrease in depressive symptoms compared to the waitlist control group. While, a pre-post study found no effect of yoga among those with SCI (Curtis et al. 2015).

Two studies, (Bradley 1994; Guest et al. 1997) examined the effects of an electrically stimulated walking program on individuals with SCI. In a cohort study, Bradley (1994) reported a significant increase in depression in participants with “unrealistic” expectations of their program. In contrast, Guest et al. (1997) used a pre-post design and found a decrease in reported depression after completion of their study intervention.

Warms et al. (2004) reported no change in participant depression levels after six weeks of increased physical activity through a “Be Active in Life” intervention program. A pre-post study (Kennedy et al. 2006), found an intensive 1-week residential program (“Back Up”) involving participation in recreational activities resulted in fewer symptoms of anxiety and depression.

Conclusion

There is level 1a evidence (from three randomized controlled trials: Hicks et al. 2003; Latimer et al. 2004; Martin Ginis et al. 2003) that small group exercise based programs reduced depressive symptoms post SCI.

There is level 4 evidence that body weight supported treadmill training (Hicks et al. 2005), or functional electrical stimulation exercise (Bradley 1994) may not improve symptoms of depression post SCI.

There is level 1b evidence (Curtis et al. 2017) that yoga improves depressive symptoms post SCI.

There is level 4 evidence (Guest et al. 1997) that Parastep FNS ambulation training may result in decrease in depressive symptoms post SCI.

There is level 4 evidence (Kennedy et al. 2006) that integrating sports and recreational activities may result in reduction of depressive symptoms post SCI.

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