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.
