Journal of Rehabilitation Medicine 51-10 | Page 38

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M. R. Bovim et al.
Post-stroke PA 2 70
Pre-stroke PA 5 60
0%
No PA
60
54
59
20%
Very light PA
40%
Light PA
58
60%
Moderate PA
19
23
80%
100%
High PA
Fig. 2. Physical activity (PA) before and after stroke. Number of patients
(n) is listed for each group.
3%. After stroke, the numbers were 3%, 53%, 29%, 9% and
6%, respectively.
DISCUSSION
In this group of stroke survivors with mild symptoms of
emotional distress, a higher level of self-reported activity
before the stroke was associated with fewer symptoms
of depression, but not anxiety, 3 months after stroke.
Almost half of the patients reported the same activity
level after as before the stroke. One in 4 reported a higher
activity level, while one in 3 reported a lower activity
level after compared with before the stroke.
Previous studies have revealed the potential beneficial
effects exercise after stroke has on mood (21), and this
study confirms that higher activity is associated with less
depression symptoms after stroke. Several mechanisms
might explain this interaction, such as diversion from ne-
gative thoughts through activity, increased social contact
and self-efficacy (15). Physiological changes in endorphin
levels may also positively influence mood (15).
Post-stroke depression has been hypothesized to
have a multifactorial cause, with both biological and
psychological components (2). The effect of PA might
differ depending on the underlying causes of depres-
sion, and it is possible that the beneficial effects of
PA are present only in certain constellations of stroke
patients. It is also possible that use of antidepressant
medications interferes with this relationship, although
there are no studies confirming this.
One recent study found an association between
higher pre-stroke PA and less severe stroke (32).
However, this is, to our knowledge, the first study
investigating how premorbid PA is associated with
psychological well-being after stroke. The finding
supports the growing evidence of the benefits of PA
in promoting mental health (15, 16). Still, causality
cannot be proven, and it might be that the inactivity
among patients with higher symptoms of depression
is a consequence of the depressive state, which might
also have been present before the stroke.
www.medicaljournals.se/jrm
No association was found between PA before the
stroke and symptoms of anxiety 3 months later. Findings
from epidemiological studies differ (18, 19, 33), and even
though there are only a small number of RCTs investiga-
ting this relationship, with small sample sizes and lacking
adequate controls, the evidence suggests that anxious
patients benefit from exercise in the general population
(16, 17). The intensity of the activity reported in this
current study might not have been high enough to reduce
symptoms of anxiety, as the RCTs have investigated exer-
cise interventions. It is also possible that the low number
of anxious patients in this study reduced our capacity to
identify an association that was actually present. Anxiety
can have many different clinical manifestations, such as
social anxiety, generalized anxiety, and phobic disorders;
hence they might be a more heterogeneous group than
patients with depression (34).
The prevalence of depression and anxiety in this
cohort was generally lower than reported in the litera-
ture (2, 3). Depression seems to be more common in
patients with more severe stroke (2). Because depres-
sion was determined based on a questionnaire, the more
severely affected patients who not were able to respond,
were excluded. However, such selection bias where
the poorest patients are excluded is not unique to this
study. The form of administration of the HADS might
influence the response, as one study found that more
symptoms of depression appear to be present with use
of self-administration schemes than through interview
(35). Anonymity has been suggested as a possible ex-
planation. The HADS was originally developed as a
self-administered tool, but was mainly assessed through
telephone interviews in the LEAST study, which might
have contributed to the low prevalence of depression and
anxiety. We have no good data concerning the use of
antidepressant drugs or psychotherapy in these patients,
which might have affected the observed prevalence.
The variables included in the regression model were
tested for collinearity, because closely related variables
should not be included in the same model. However,
none of the variables had a strong correlation, which
was rather surprising for some variables, such as PA
level and mRS score. There might be several expla-
nations for this, and it might indicate that PA depends
on more than functional level alone.
More than 40% of patients reported the same activity
level before and after the stroke. We have not investigated
which variables were related to changes in PA levels, but
severe strokes affecting functional abilities are likely to
reduce PA in patients with a high pre-stroke activity level.
Many patients were categorized as having a very light to
light activity level, which might not be too hard to return
to after the stroke. In addition, patients able to respond to
the questionnaires were a selected group of patients with