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Brain injury:
Effects of aerobic exercise on depression
Rehabilitation physiotherapist Marika Schwandt

Physiotherapy study:

Feasibility and effect of aerobic exercise for lowering depressive symptoms among individuals with traumatic brain injury: a pilot study, by Marika Schwandt MSc, PT et al.

Abstract

Purpose: The purpose of this pilot study was to establish the feasibility and effect of an aerobic exercise intervention on depressive symptoms among individuals with traumatic brain injury.

Methods: A pre-post single group. Four community dwelling participants (>11 months post) with residual physical impairment were recruited from an outpatient clinic to attend a 12 week aerobic exercise program. Primary outcome measure, The Hamilton Rating Scale for Depression; secondary measures: aerobic capacity (cycle ergometer, heart rate at reference resistance, perceived exertion); Rosenberg Self-Esteem Scale and program perception (survey).

Analysis: Descriptive statistics to depict change in outcome measure scores. Answers from the survey were collated and presented as summary statements.

Results: All participants lowered depressive symptoms, improved aerobic capacity and self esteem. High satisfaction with the program was reported with no adverse effects.

Conclusion: An aerobic exercise program was reviewed positively by individuals with traumatic brain injury. Findings suggest that aerobic exercise can improve depressive symptoms, cardiovascular fitness, and self-esteem. Future research is needed to determine the intensity, frequency, and duration required to reach and maintain improvement.


Introduction

Depression is the most common psychiatric diagnosis post TBI and regardless of injury severity, individuals are at high risk for developing depression across all stages of recovery.1 Additionally, depression is associated with poor functional outcome,2 cognitive deficits,3 and reduced quality of life.2

Treatment methods to address depressive symptoms post TBI vary and are complicated by multiple aetiologies (e.g. organic or psychosocial reaction). Medication is a commonly used for treating depression post TBI.4,5 However, there is a high rate of medication discontinuance, with 25%-40% of prescriptions stopped by physicians due to intolerance or lack of effect.6,7 Cognitive behavioural therapy (CBT) has been used to ameliorate depressive symptoms in individuals with TBI however; CBT may be difficult for those with cognitive and or behavioural deficits.5 A study reviewing treatment preference post TBI found that individuals prefer psychotherapy and exercise compared to medication5 which is consistent with research involving adults in primary care.7,8 Exercise has been recommended in the treatment of depression for cardiovascular disease,9 multiple sclerosis,10 and stroke.11 In addition, trials involving individuals with depression in the general population have found exercise to be equal or superior to antidepressant medication.8,12 It may be that stigma and adverse effects from medication play a prominent role in treatment preference and adherence.

Recent review articles have found that aerobic exercise is beneficial for improved cardiovascular fitness, mobility and function post TBI.13,14 Only three studies have assessed the impact of aerobic exercise on depression.15-17 Bateman et al examined aerobic exercise and depression in an inpatient setting and found no effect while Gordon et al and Driver et al reported positive outcomes among individuals living in the community. However, only 56% of participants in the study by Bateman et al achieved target heart rate and the study by Gordon et al was retrospective making it difficult to determine exercise impact. Driver et al examined the effect of aerobic (swim exercises) and resistance training but did not provide results on achievement of target aerobic capacity.

What is not clear is whether a prospective, defined aerobic exercise program for individuals in the chronic stage of TBI recovery can be appropriately designed and implemented to facilitate ease, safety and effectiveness in reducing depressive symptoms. Therefore, the purpose of this pilot study was to determine the effectiveness and feasibility (examining compliance, achievement of aerobic capacity) of an aerobic exercise program on depressive symptoms among individuals a minimum of six months post TBI.

Discussion

We designed a pilot study in order to determine if 1) aerobic exercise can positively affect depressive symptoms among individuals in the chronic stage of TBI recovery and 2) they have the physical capacity and interest to participate. Findings from our study suggest that depressive symptoms can be reduced with 30 minutes of aerobic exercise done three times per week for 12 weeks. In addition, aerobic exercise had positive effects on aerobic capacity and self-esteem. Participants reported a high level of satisfaction with the program and few difficulties, indicating feasibility for future trials. Importantly, our study contributes evidence to the growing concern surrounding the dearth of literature on aerobic exercise and TBI.13

We found a consistent decrease in depressive symptoms over time. These findings concur with studies concluding that non-pharmaceutical interventions are effective in the treatment of depression occurring in other neurological condtions.25,26 In the only comparative study, Driver et al16 found significantly improved mood scores among eight individuals with TBI after completing an eight week swimming and resistance program. The study by Bateman et al.17 did not find an effect for aerobic exercise on depression, however; at baseline individuals recorded mood scores indicative of mild to no depressive symptoms, thus limiting any impact. Initial scores for depression in our study indicated moderate-to-severe (19-25) depressive symptoms. At post intervention there was one participant in the mild-to-moderate range (17) and three had scores indicating no depressive symptoms (>10). This is preliminary evidence that aerobic exercise can impact depression at the severe end of the continuum. In addition, we found an increase in self-esteem. Past research has demonstrated a strong relationship between self-esteem and depression.26,27 The increase in self-esteem and exercise participation in this study may have been complimentary, with both contributing to a reduction in HAMD scores.

The results of our study agree with those that have investigated aerobic exercise and its benefit on cardiovascular fitness among individuals with TBI17,28 and other neurological conditions.10,11 Participants had a combination of impairments consisting of weakness, poor coordination, and spasticity but were still able to achieve target aerobic thresholds without adverse effects. Encouragement and monitoring of heart rate targets was required, involving individual attention. Providing heart rate monitors may provide the encouragement and motivation needed to sustain this type of program without clinician attention. Further research is needed to determine the level of supervision required for safety and motivation.

We found that individuals participated consistently in the intervention program. There are several postulated reasons. The program took place at the rehabilitation hospital where all participants completed their rehabilitation, providing a familiar and comfortable setting. It may be necessary to provide transitional programming so individuals will have confidence accessing community fitness facilities. We provided a variety of exercise equipment that was easily adapted to each person’s physical needs and the program was supervised by a physical therapist, providing a safe and effective program not available in most community facilities. In addition, participants were not involved in any other rehabilitation programs. This is in contrast with Bateman et al17 where participants were also involved in inpatient programs possibility resulting in fatigue, and were given no choice of exercise equipment which may account for lower adherence rates. To encourage attendance we provided transit tickets and arranged transportation with specialized disability services when necessary.

Limitations

The sample size was small, limiting analysis; however, this was a pilot study intended to generate preliminary data in a novel area of research. The sample may not be representative of all individuals who might benefit from the intervention. The presence of a therapist (e.g. attention, positive feedback) and participation in a program (e.g. social contact) may have positively affected the results. A control group would help to diminish these possible influences and help us understand to what extent improvements in mood are due to exercise or increased attention/socialization. Though we had difficulty recruiting participants, it was not due to lack of interest but rather conflict with work and school; this may have been prevented by offering an evening program.

Conclusion

We have demonstrated that aerobic training is feasible with individuals who have sustained a mild to moderate TBI. Additionally, we found improvement in depressive symptoms, self esteem, and aerobic capacity. Further research using well designed trials is required to determine treatment parameters and community implementation.

Acknowledgements

Funding for this study for AC was obtained from the Canadian Institutes for Health Research, The Toronto Rehabilitation Institute, and a grant from the Ministry of Health and Long Term Care. Support for this study was given to MS from the Toronto Rehabilitation Institute and a Fellowship from the Women's College Research Institute; to JEH in a CIHR Fellowship Award and a Strategic Training Fellowship in Health Care, Technology and Place (FRN: STP 53911).

Authors:

Marika Schwandt, MSc, PT, Graduate Program in Rehabilitation Sciences, University of Toronto

Jocelyn E Harris, PhD, OT, Post Doctoral Fellow, Toronto Rehabilitation Institute

Scott Thomas, PhD, Associate Professor Faculty of Physical Education and Health, University of Toronto

Michelle Keightley, PhD, Associate Professor, Department of Occupational Science and Occupational Therapy, University of Toronto

Abe Snaiderman, MD, F.R.C.P(C), Toronto Rehabilitation Institute, Departments of Psychiatry and Medicine (P.M.R.)

Angela Colantonio, PhD, OT, Toronto Rehabilitation Institute; Department of Occupational Science and Occupational Therapy, University of Toronto

 

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