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Physical Activity

Physical Activity and Subjective Well-Being

Subjective well-being (SWB) refers to how people evaluate their lives. It is a broadly-defined construct that encompasses an array of factors such as psychological well-being, satisfaction with health and physical functioning, and overall life satisfaction. Within the general population, considerable research has shown that regular participation in physical activity is associated with improvements in a wide range of SWB outcomes. In contrast, relatively little research has examined the effects of physical activity on aspects of SWB among people living with SCI.

Although a couple of Level 1 and 2 studies have been conducted, most research examining physical activity and SWB has been cross-sectional (e.g., Manns & Chad 1999; Muraki et al. 2000; Stevens et al. 2008; Tawashy et al. 2009) and is excluded from the present analysis. A wide range of SWB outcomes have been examined such as perceptions of community integration, pain, mood states, anxiety, perceived health, and self-efficacy. Some of these aspects and their relationship with physical activity are discussed in different chapters (e.g., community reintegration, pain). Other aspects (e.g., mood states, self-efficacy) have been examined in too few high quality studies to generate reliable conclusions, and have been excluded from the present analysis. Two aspects, depression and quality of life, have been relatively well-studied in relationship to physical activity. As such, this section reviews only those studies that have included a measure of depression or quality of life.

Author Year

Research Design
Total Sample Size

Methods Outcome
Hicks et al. 2003




Initial N=43; Final N=34

Population: Intervention group: Mean age: 36.9 yrs; Level of injury: Tetraplegia (11), Paraplegia (10); Mean time post-injury: 7.7 yrs. Control group: Mean age: 43.2 yrs; Level of injury: Tetraplegia (7), Paraplegia (6); Mean time post-injury:12.1 yrs.

Treatment: Intervention group: A progressive exercise training program 2d/wk for 9 mo, alternate days,90-120 min/d,  consisting of warm up, upper extremity stretching & 15 -30 min of aerobic training. As the rate of perceived exertion ↓, workload was ↑.  Some resistance training took place. Control group: Offered an education session, 2d/mo (with exercisers) on various topics.

Outcome Measures: Perceived Quality of Life Scale (PQOL).

1.     Exercisers reported a trend of ↓ stress, ↓depressive symptoms, ↑ satisfaction with their physical functioning than the controls (p=0.06).

2.     Exercisers reported ↓ pain (p<0.01) and ↑ QOL (p<0.05).

Latimer et al. 2004




Initial N=34; Final N=21

Population: Intervention group: Mean age: 38.27 yrs; Gender: 3 males, 8 females; Level of injury: Tetraplegia (7), Paraplegia (4); Severity of injury: ASIA A (5), B (1), C (3), D (1); Mean time post-injury: 10.54 yrs;

Control group: Mean age: 43.08 yrs; Gender: 2 males, 8 females; Level of injury: Tetraplegia (3), Paraplegia (7); Severity of injury: ASIA A (3), B (1), C (3), D (3); Mean time post-injury: 14.58 yrs

Treatment: Intervention group: 9 mo exercise program – 2d/wk, small group exercise sessions, 60-90 min 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 9 mo although provided with an opportunity for education.

Outcome Measures: Pain perception (two items from the Short Form Health Survey – SF-36); Perceived stress scale, Center for Epidemiological Studies Depression Scale (CES-D)

1.     Exercise group had lower stress, pain, and depression and greater life satisfaction than the control group.

2.     The effects of exercise on depression were mediated by changes in stress.

Martin Ginis et al. 2003




Initial N=34;Final N=34

Population: Mean age= 8.6 yrs; Gender: 23 males, 11 females; Mean time post-injury: 10.4 yrs

Treatment: 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 scale (PQOL); Centre for Epidemiological Studies Depression Scale (CES-D).

1.     After 3 months, when compared to controls, exercisers had:

·         ↑ QOL (p=0.007)

·         ↑ satisfaction with physical function (p<0.01)

·         ↑ satisfaction with physical appearance (p=0.007).

·         ↓depression (p=0.02).

Latimer et al. 2005





Population: Intervention group: Mean age:37.54 yrs; Gender: 9 males, 4 females; Level of injury: Tetraplegia (7), Paraplegia (6); Mean time post-injury: 9.23 yrs  Control group: Mean age:43.30 yrs; Gender: 5 males, 5 females; Level of injury: Tetraplegia (4), Paraplegia (6); Mean time post-injury:15.70 yrs

Treatment: 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); Centre of Epidemiological Studies Depression Scale (CES-D); Perceived Quality of Life (PQOL); measured at @ baseline, 3 & 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 & 6 mos, 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 & depression.

Alexeeva et al. 2011






Fixed Track Group: Mean age: 37.3± 13 yrs ; Gender: 12 males, 2 females; Level of injury: ASIA C (17%), ASIA D (83%); Cause of injury: traumatic (100%)

Treadmill Group: Mean age: 36.4±12.9 yrs ; Gender: 8 males, 1 female; Level of injury: ASIA C (36%), ASIA D (64%); Cause of injury: traumatic (100%)

Physical Therapy Group: Mean age: 43.3±15.8 yrs ; Gender: 10 males, 2 females; Level of injury: ASIA C (11%), ASIA D (89%); Cause of injury: traumatic (75%), non-traumatic (25%)

Treatment: Patients participated in a body weight supported training program (TRK or TM) or comprehensive physical therapy for 1hour/day, 3 d/wk for 13 wks.

Outcome Measures: Satisfaction with Abilities and Well-Being Scale (SAWS); Short Form Health Survey (SF-36)

1.   Immediately post-training 80% of the participants reported increased satisfaction with abilities and well-being and this was significant across groups (p<0.05).

2.   There were no significant changes in the four items from the SF-36 within groups or between groups after training.

Anneken et al. 2010


Retrospective Cross-Sectional; Observational


Population: Mean age: 41.7 ± 12.7yrs; Gender: 219 males, 58 females; Level of injury: Paraplegia (78.3%); Severity of injury: Complete (62.9%); Cause of injury: traumatic (79%),  non-traumatic (21%);

Treatment: Questionnaire

Outcome Measures: QOL Feedback


1.   The most prominent differences between the physically active and physically inactive individuals occurred in the single scales of physical domain (physical capacity in everyday life, physical activity, and mobility); all p<0.001.  In the single scales of the psychological domain, prominent differences were found in remedial exercises, energy, and self-confidence; all p<0.001.  In this study, physical exercise and sport were identified as the main influencing determinants of QOL .
Mulroy et al. 2011





Population: Exercise/Movement Optimization group:  Mean age: 47±9 yrs; Gender: 31 males, 9 females; Level of injury: ASIA A (62%), ASIA B (23%), ASIA C (8%), ASIA D (2%), Unknown (5%)

Control Group: Mean age: 47±12 yrs; Gender: 26 males, 14 females; Level of injury: ASIA A (62%), ASIA B (13%), ASIA C (13%), ASIA D (2%), UNKNOWN (10%)

Treatment: Patients received a shoulder home exercise program 3d/wk for 12 wks.  Stretching, warm-up, and resistive shoulder exercises were included.

Outcome Measures: Short Form Health Survey (SF-36); Subjective Quality of Life Scale (SQOL)

1.   All of the SF-36 subscales except for general health and vitality demonstrated a statistically significant (p<0.05) improvement in scores for participants in the exercise/movement optimization group and no change for the control group.

2.   Overall SQOL scores increased 10% following the intervention for the exercise/movement optimization group (p<0.05), but were unchanged for those in the control group.

Chen et al. 2006





Population:  Mean age: 43.8 years (range: 21-66); Gender: 9 males, 7 females; Level of injury: tetraplegia (25%),  paraplegia (75%); Severity of injury: ASIA A (56%), C (19%), D (25%); Cause of injury: traumatic (93.75%),  non-traumatic (6.25%);

Treatment: 12 wk of a weight management program (e.g., nutrition, exercise, behaviour modification training) + 1-30-min exercise session/wk for 6 wks

Outcome Measures: General Well-Being Schedule

1.   Although there were small increases in general well-being schedule scores from baseline to 12 weeks and baseline to 24 weeks, they did not reach statistical significance (p=0.12).
Hicks et al. 2005


Downs & Black score=18


Population: Chronic incomplete SCI: Age (range): 20-53 yrs; Gender: 11 males, 3 females; Level of injury: Tetraplegia (11), Paraplegia (3); Severity of injury: ASIA B (2), C (12); Mean time post-injury: 7.4 yrs

Treatment: RoboticBody weight supported treadmill training (BWSTT) – up to 45 min, 3d/week, 144 sessions (12 mo)

Outcome measures: Centre for Epidemiological Studies of Depression Scale (CES-D); Satisfaction with Life Scale (SWLS); Short-Form Health Survey (SF-36); all questionnaires administered every 36 sessions.

1.    ↑ life satisfaction & ↑ physical function satisfaction (p<0.05), after BWSTT.

2.    No change in depression or perceived health.

Semerjian et al. 2005

Downs & Black score=15



Population: Mean age: 34 yrs; Gender: 8 males, 4 females; Level of injury: Tetraplegia (7), Paraplegia (5); Time post-injury (range): 1-30 yrs

Treatment: 10 wk individualized exercise program, 2d/wk, using the Bowflex Versatrainer, the Active-Passive Trainer, the EasyStand 6000 Glider, and the Body Weight Support System treadmill trainer (BWST).

Outcome Measures: Quality of Life Index-Spinal Cord Injury Version III (QLI-SCI III) – 4 subscales: Health & Functioning, Psychological, Social & Economic and Family; the Body Satisfaction Questionnaire (BSQ); Semi-structured interview; Field notes taken during each session; Questionnaires done pre & post intervention, interview done post intervention.

1.     QOL:

·         ↑ health & functioning (p<0.001)

·         ↑ psychological (p<0.05)

·         ↑ social & economic (p<0.05)

·         ↑ overall QOL (p<0.001)

·         No change in family.

2.     Body Satisfaction:

·         ↑ body functioning (p<0.001)

·         ↑ body attractiveness (p<0.05)

3.     Interview & Field notes key themes:

·         Perceived health & physical ability improvement

·         Perceived ↑ in strength, endurance and attractiveness

·         Improved outlook on life

·         Psychological gains of standing exercise & BWST

·         Perceived recovery of function

·         Assistive device frustration

·         Independence importance

Ditor et al. 2003


Downs & Black score=14



Population: Mean age: 43.3 yrs; Gender: 5 males, 2 females; Time post-injury (range): 3-23 yrs

Treatment: Patients who previously took part in a 9 mo exercise training program were given 3 mo (2 sessions/wk) of continued supervised exercise training in a laboratory setting.

Outcome Measures: Exercise adherence (% of available sessions that were attended [max. 2/wk]), PQOL (11-item Perceived Quality of Life Scale with four additional SCI-relevant items), Pain (2 pain items from the Short-form Health Survey [SF-36]), Perceived Stress Scale

1.     ↓ exercise adherence over the 3-mos follow-up period in comparison to the 9-mos adherence rate (42.7% versus 80.65%, respectively; p<0.01).

2.     At 3 mos follow-up, ↓in PQOL (p<0.05).

3.     Also, a trend was found for increased pain (p=0.07) and stress (p=0.12).

4.     A significant negative correlation was found between pain scores at 9 mos and adherence during the 3 mos (r=-0.91; P<0.01).

Warms et al. 2004


Downs & Black score=14


Initial N=17; Final N=16

Population: Mean age: 43.2 yrs; Gender: 13 males, 3 females; Mean time post-injury: 14.4 yrs

Treatment: “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 wks,and had a final follow up 2 wks post-completion.

Outcome Measures: Physical activity (wrist-worn actigraph); Self-rated Abilities for Health Practices Scale (includes Exercise Self-efficacy subscale); Self-rated Health Scale (SRHS); Centre for Epidemiologic Studies Depression Scale (CES-D); @ baseline, 6 wk completion; 2 wks post-completion.

1.      Physical activity: Counts/day ↑ in 60% of subjects and self-reported activity ↑ in 69% of subjects, but both were not significant.

2.      Self-rated abilities: no change. Exercise self-efficacy: ↑ (p=0.01).

3.      Self-rated health: ↑ (p=0.04).

4.      Depression: no change.

Effing et al. 2006

The Netherlands

Downs & Black score=13

Case study


Population: Chronic incomplete SCI; Age range: 45-51 yrs; Gender: 3 males; Severity of injury: ASIA C (2), D (1); Time post-injury (range): 29-168 mo;

Treatment: Body weight-supported treadmill training 5d/wk for 30 min for 12 wks, each session personalized to physical abilities.

Outcome Measures: Perceived QOL: SEIQOL.

1.      QOL: ↑ in only one subject (p<0.05).
Guest et al. 1997


Downs & Black score=13



Population: Traumatic complete paraplegia; Mean age: 28.8 yrs; Gender: 12 males, 3 females; Mean time post-injury: 3.8 yrs

Treatment: Electrically stimulated walking program – 32 sessions, using the Parastep® FNS ambulation system.

Outcome Measures: The Tennessee Self-Concept Scale (TSCS) – Physical Self subscale only; Beck Depression Inventory (BDI); measurements @ baseline & completion of program.

1.     Physical Self-Concept: ↓ after electrically stimulated walking (p<0.05). Those with lower baseline score had the most significant improvements.

2.     Depression: ↓ after electrically stimulated walking (p<0.05).

Kennedy et al. 2006


Downs & Black score=11



Population: Age (range): 18-61yrs; Gender: 30 males, 5 females; Level of injury: Paraplegia  (20), Tetraplegia (15)

Treatment: Back-Up: a one wk single or multi-activity course in an integrated, residential environment. Activities include skiing, horseback riding, waterskiing, canoeing, rappelling and gliding.

Outcome Measures: Life Satisfaction Questionnaire, Hospital Anxiety and Depression Scale (HADS), Generalized Self- Efficacy Scale completed at baseline and end of 1 wk activity courses.

1.     Significant improvement (p=0.016) in life satisfaction and satisfaction with leisure (p=0.007)

2.     HADS scores demonstrated significant (p<0.01) improvement in anxiety but not depression levels over the duration of the course.

3.     No overall improvement in perceived manageability however some difference (p=0.016) post test was observed for engage “in what happens around me” indicating some use of Perceived Manageability strategy.

4.     Self-efficacy scores improved post test (p=0.012).

Bradley 1994


Downs & Black score=10



Population: Mean age: 32.03 yrs; Gender: 24 males, 13 females; Level of injury: Tetraplegia (12), Paraplegia (25); Mean time post-injury: 6.51 yrs

Treatment: Intervention group: 3 mo FES exercise program

Outcome Measures: Multiple Affect Adjective Check List Revised state form (MAACLR) – Negative affect: anxiety, depression, hostility; Positive affect: positive affect, sensation seeking; Expectations of program recorded; all at baseline & post intervention.

1.     ↑ in depression & hostility for those who had unrealistic expectations of the FES program (p<0.01 & p<0.05, respectively).

2.     No other significant effects were found.


With regards to depression, all but two studies (Hicks et al. 2005; Warms et al. 2004) showed positive effects of exercise on depressive symptoms (Guest et al. 1997; Hicks et al. 2003; Latimer et al. 2004; 2005; Martin Ginis et al. 2003). In addition, Kennedy et al. (2006) showed significant reductions in anxiety but not depression using the Hospital Anxiety and Depression Scale with their 1 week physical activity course. Given the variety of modes of physical activity examined in these studies, the consistent findings speak to the robustness of the relationship between physical activity and depression among people living with SCI. In the studies that showed no significant effects of exercise on depression (Hicks et al. 2005; Kennedy et al. 2006; Warms et al. 2004), participants’ baseline depression scale scores were already extremely low, indicating minimal depressive symptomatology and very little room for improvement. As exercise has been shown to exert its greatest effects on people with greater depressive symptomatology, these findings are not particularly surprising.

With regards to quality of life, all of the Level 1, 2, and 4 studies showed that exercise training was associated with better quality of life (Mulroy et al. 2011; Alexeeva et al. 2011; Anneken et al. 2010; Ditor et al. 2003; Effing et al. 2006; Hicks et al. 2003; 2005; Kennedy et al. 2006; Latimer et al. 2004; 2005; Martin Ginis et al. 2003; Semerjian et al. 2005). Again, given that this association held across different types of physical activity modalities and in studies that used different measures of quality of life, the physical activity-quality of life relationship appears to be robust. However, the case-study by Effing et al. (2006) did not find quality of life improvements for two of its three participants. When contrasted with the findings of the higher quality studies, these null findings speak to the importance of examining changes in quality of life over time, and in sufficiently large and representative samples, in order to properly assess the effects of physical activity on SWB.

How does physical activity improve depression, quality of life, and potentially other aspects of SWB? This question was examined in a series of papers using data from Hicks et al.’s (2003) RCT. Overall, these studies showed that exercise-induced reductions in stress and pain mediated the effects of exercise on quality of life and depression (Latimer et al. 2004; Martin Ginis et al. 2003). In other words, exercise training led to reductions in stress and pain, which, in turn, led to improvements in quality of life and depressive symptoms. Mulroy et al. (2011) also found a reduction in shoulder pain and an increase of 10% in subjective quality of life scores and an increase in all, but two, of the SF-36 subscales in the exercise/movement optimization group post-intervention with no change in the control group. There was also evidence that among people who were experiencing stressful life events, exercise helped to buffer the effects of the stress on their SWB (Latimer et al. 2005).

In general, several of the studies examining subjective well-being are constrained by an inadequate control group, making it difficult to discern whether it is the physical activity itself or some other aspect of a structured program that may be contributing to beneficial effects. Regardless, the conclusions below are based on the relative consistency across studies, despite these limitations. Of note, the trials conducted by Hicks et al. (2003) and Latimer et al. (2004) did provide an opportunity for education about exercise to their control group participants which afforded a more effective comparison than other trials which simply asked control group participants to maintain their usual activity patterns and defer initiation of an exercise program until after the study trial. Mulroy et al. (2011) also employed an education session for their attention control group. This session included a video and brochure regarding shoulder anatomy, mechanisms of injury, managing shoulder pain, and general shoulder care.


Based on level 1 and 2 evidence from 6 studies, exercise is an effective intervention for improving two aspects of SWB: quality of life and depressive symptomatology. For the most part, the level 4 and 5 evidence also supports this conclusion.

Emerging data from these studies suggest that changes in stress and pain may be the mechanisms underlying the effects of exercise on quality of life and depression. Further research is needed to examine other aspects of SWB in relation to physical activity.

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