Aims: To explore the effectiveness of sports activities to improve the psychological status through progression in anxiety and depression level of Spinal Cord Injury patients. Methods: The design of the study was prior and after an experimental design of quantitative research. The data were collected from inpatient SCI Unit, Centre for the Rehabilitation of the Paralysed (CRP), Bangladesh. The study involved thirtyone (31) male participants with SCI selected by conveniently and they were participating in sports three weeks. The assessor was blind (Single blinded study). The dependable variable was psychological status (anxiety and depression), assessed with Strait-trait anxiety inventory X2 for anxiety, Depression Measurement Scale and Hospital Anxiety and Depression Score (HADS) - for Anxiety & depression. Independent variables included socio-demographic factors (age, sex, marital status etc), sports, type of paralysis and type of patients. Data analyzed by paired T-test considering the questionnaire as parametric Test in SPSS 20 version.

Results: Analysis of difference revealed major positive change and reduced the anxiety and depression level of SCI patients after participating in sports. The mean age was 34.81 years and the paraplegic patient was 25 and tetraplegic 6, while the complete patient was 16 and incomplete 15. Mean score between Strait Trait Anxiety-X2 (STAI-X2) before 55.9 and after 45.9, Depression Measurement Scale (DMS) 104.9 and 76.3, Hospital Anxiety Depression Scale (HADS) for anxiety 13.1 and 10 and HADS for depression 13.7 and 10.3. There was significance variance within Scale. In addition, paraplegic and incomplete participants were more improved then tetraplegic and complete participants. The ‘p’ value of the variable is (<0.05).

Conclusion: Sports activities play an important role to alleviate anxiety and depression level after spinal cord injury. Both were hampering their quality of life. The study would indicate that improvement was higher in paraplegic and incomplete person with SCI.

Keywords: Anxiety, Depression, Psychological status, Spinal cord injury, Sports

Spinal cord injury is the unanticipated and extemporary occurrence that may bring implausible change to injured people. It leads to comprehensive health-related problems [1]. The person with complete and incomplete SCI experienced with the temporary and permanent loss of motor function, loss of sensation below the lesion, which include loss of body function, loss of activities, participation restriction, and mobility. It leads to physical, social and employment activities impairment and harmful impression on person’s health [2].

Several studies revealed that SCI increased the risk of psychological disturbance which may lead to depression and despondency. The negative effect on psychology correlated with the person with SCI. Poor psychological status aggravated the rate of suicide and drug addiction after the injury and half of large young adult associated with depression [3].

Another study found moreover one-fourth of inpatient spinal cord Injury patients suffer from depression. The exquisite impacts on mental health in the persons with spinal cord injury has been expressed by depression, anxiety and negative emotion through changes of behaviour, personality and perception [4], [5] . Moreover, social participation can be restricted and thus affects the quality of life [6].

Having depression and anxiety has been treated with diverse rehabilitation procedure. Sports activity are the vital therapeutic tool in the rehabilitation process [7]. In particular, many studies have suggested that sports activity reduce stress, depression, anxiety. Study elicited that wheelchair user who are engaged with athletic activity has better psychological status than wheelchair user who are not engaged with athletic activities. Whereas sports provided new life, better physical activity, better mobility for a disabled person and it also improved social participation and reintegration [8]. Individuals of SCI people who dynamically involved in sports and physical exercise, they had better quality of life within the physical, psychological, social and context field than physically inactive individuals [9].

The study revealed, participating in wheelchair sports activities has greater influence to improve psychological status that can be used as an effective intervention to manage depression [8].Hence the study is focused on diverse sports and their effects on psychological status especially anxiety and depression for SCI persons in Bangladesh.

Study design
Prior and after the experimental design of quantitative research was conducted with a single group. The design had no control group to compare with the experimental group. This design is valuable for rehabilitation professionals to better apprehend and determine effects resulting from selected interventions [10].

Study site and participants
The site of the study was Centre for the Rehabilitation of the Paralysed(CRP) established in 1979 and working on a holistic approach to Rehabilitation and Community integration for people with disabilities.

The study population was patients admitted to SCI Unit, Centre for the Rehabilitation of the Paralysed (CRP) Savar, Dhaka 1343. Currently, 100-bed indoor facility emerges from acute to reintegration phase and acute stage for 42 days, Stabilizing stage (2 weeks), Rehabilitation stage (2 weeks) and Re-integration (2 weeks). In 2015-16, a total of 358 patients (male 307, female 51) has been served [11] and the study carried out from February- March 2016 although it took approximately one year to collect the data. Thirty-one male participants conveniently selected for the study. Interested females were lower in number (n=1) and they were not interested to participate in sports activity.

Blind: Assessor blind (Single blinded study)

Subject Inclusion Criteria

• Both paraplegic and tetraplegic patient (C5 to L2)
• Completed minimum four weeks of rehabilitation and reintegration stages.
• Spinal cord injury patient who have their injury below C5 level.
• Age group: 15–65 years.
• Able to engage in sports at least three weeks.
• Complete and incomplete (ASIA A-E) both participant.
• Both male and female patient.

Subject Exclusion Criteria

• Higher tetraplegia patients.
• Acute injured SCI patient.
• Patients in bed rest.
• Patients who have pressure sore and any other disease.
• Patients in traction.
• Patients with the cognitive problem.
• A patient who were not willing to participate in the study.
• Patient with others mental or physical illness.

Ethical Consideration
Written and verbal consent has been taken from the patients. A research proposal was submitted for approval to the administrative bodies of ethical committee. The researcher applied for permission from Institutional Review Board (IRB) of Bangladesh Health Profession Institute (BHPI) and Clinical department of physiotherapy in CRP, Saver. The participants have explained the purpose and goal of the study. Subjects have participated voluntarily and they were also told that confidentiality would be maintained. Furthermore, the researcher would be available to answer any questions in regard to the study. All information was kept secure. Ensure patient safety. The study followed the World Health Organization (WHO) and Bangladesh Medical and Research Council (BMRC) guideline and strictly maintains the confidentiality.

Measurement tools
Participants were interviewed face to face using Bangla questioner. The questioner developed on the numerous scales. The scales are State-Trait Anxiety Inventory- X2 [5], Depression Measurement Scale which was developed by Zahir Uddin and Dr Mahmudul Rahman, Department of the clinical psychology [11] and Hospital Anxiety and Depression Score (HADS) for anxiety and depression measurement. Demographic data had 11-item questionnaire (age, sex, marital status, educational level, occupation, religion) and the health-related questioner (date of injury, type of injury, the cause of injury, level of injury).

Validity and reliability
State-Trait Anxiety Inventory- X2: 20 item has present for measure anxiety, while is used for SCI patients. The response of the individual to each item are on 4 point scale (1= rare to 4= often) [12].

Depression Measurement Scale: 30 item has been widely used for measure depression and it had 5 point scale (1= Not At all to Applicable to 5= Fully Applicable). The severity Norm of the Depression scale, minimal= 30- 100, mild= 101-114, moderate =115- 123, severe =124-150). Developed by: Zahir Uddin and DrMahmudul Rahman, Department of the clinical psychologist [11].

Hospital Anxiety and Depression Score (HADS) - for Anxiety & depression: 12 item with four point scale used for measurement the scoring are 0-7 = Normal, 8-10 = Borderline abnormal (borderline case), 11-21 = Abnormal (case) [13].

Intervention and parameters
All of the participants were actively participated in a three weeks sports program, one hour per day and weekly five days. All sports were compatible with patient capacity and supervised by sports trainer. Wheelchair basketball, table tennis, ball throw, hand volleyball were selected for the person of SCI.

Data analysis
After participating in sports in the same way as the pre-test data are collected which gives the post-test score. Then calculate the difference between pre-test and post-test score. Data has been analyzed by paired T-test considering the questionnaire as parametric Test in SPSS 20 version.

Hypothesis
Engaging Sports Activities is an effective intervention for improving psychological status in anxiety and depression parameter of person with spinal cord injuries.

Significant levels
The hypothesis of the experimental study was one-tailed hypothesis because it was predicting a specific direction to the result. The ‘p’ value was <0.05 that was accepted by the researcher to show the significance of the study.

Socio-demographic information of the participants
Out of thirty-one participants, the mean age of SCI population was 34.8 years. Seventy-one percent married and twenty percent were unmarried. In family member 5 or less were 21.8%, 6 to 7 member 32.3% and 8 or more 41.9%. Among 19.4% no education, 32.3% primary, secondary 25.8%, and post secondary 22.6%. In the profession, there were several manual workers 54.8%, non-manual worker 29%, unemployed 16.1%. Types of paralysis, paraplegia were more 80.6% and tetraplegia 19.4%, according to ASIA complete 51.6%, incomplete, 41.4% and a thoracic lesion in more than others 58%. Health-related and socio-demographic presented in Table 1.

Difference between mean score of pre-test and post-test
State-Trait Anxiety Inventory- X2 (STAI-X2): Among thirty-one participants presented different level anxiety. It was measured by State-Trait Anxiety Inventory- X2 (STAI-X2) and it presented different mean score on different variables. The anxiety level was more whose were suffered chronic injured patients, tetraplegic, and incomplete patients. The mean difference of duration of injury was 54.6 and 44.2, paraplegic were 55 and 44.9 and incomplete patients were 54.9 and 43.4. Table 2 showed mean difference of SIAI-X2.

Depression measurement scale
Table 3 has shown measurement of depression scale and the mean difference between pretest and posttest were 104.9 ±17.1 and 76.3 ±19.4. Depression scale evaluated that, acute injured people were significantly improved, but in this scale paraplegic patient’s depression level more reduced than tetraplegia and as like anxiety and incomplete patient more improved than complete (Table 3).

Hospital anxiety and depression score (HADS) - Anxiety Score has shown Pretest and posttest measurement, long duration highly significant than the short duration. According to HADS anxiety level of paraplegia patients have alleviated more than tetraplegia (Table 4). The mean difference between incomplete patients was 3.2 and the complete patient was 3. Incomplete patient extremely elevated rather than complete.

Hospital anxiety and depression score (HADS) – depression score
Similarly, Hospital Anxiety and Depression Score (HADS) scale for Depression level and the mean difference of long duration was more than the short duration and paraplegia patient and incomplete patient were highly elevated than tetraplegia and the complete patients (Table 5). This analysis demonstrated that sports activity has a powerful influencing capability those can alleviate the anxiety and depression scores in SCI patient.

Mean difference between before and after sports participation in the different scale
The distinction between different types of measurement scale is indicated in Figure 1. It also represented pre and post sports program on a different scale. State-trait anxiety-X2 presented prior and after mean differences 55.9 and 45.9, depression measurement scale also showed mean difference and it was 104.9 and 76.3 and Hospital Anxiety and Depression score for depression (HADS) were 13.1 and 10 HADS for Anxiety 13.7 and 10.3. The depression and anxiety level were more before attended sports program and the mean difference indicates that mean difference was after sports program.

The purpose of this study was to investigate whether sports activity is associated with the better psychological profile like as anxiety and depression in patients with SCI and to evaluate the effect of demographic factors on psychological benefits. But another study they did not find any association between socio-demographic factors [5].

The present study was done within 3 months according to Bangladesh context. Participant of the study was cooperative. Generally, context people don’t work for anxiety and depression in Bangladesh. The study shows that sports activity made a difference between the scores of STAI-X2 and depression measurement scale of SCI patients. Initially, the state of anxiety and depression were moderate and after participating, sports depression level had a significant decrease but no change in the anxiety state. Previous research revealed significance variance between Self-Rating Depression Scale and STAI-X2[5].

Our research worked for diverse sports such as wheelchair basketball, hand volleyball, table tennis, ball throw. Mean age was 34.8 years and all participant were male, the female was few numbers that are why researcher has been excluded in influence data. The similar study revealed years and female participation in sports activity was very low, so they excluded that data from the analysis [8] . In this study, paraplegic patient was more than tetraplegic. Sports activity improve the psychological status especially reduction of depression and anxiety level. Another study showed mean age 42.7 years and they also worked for diverse sports also [5]. The sports can improve physical status as strength, coordination power, cardiovascular status, pulmonary function and that all can improve their psychological status and quality of life that helps to lessen the anxiety and depression [9].

Some data showing the better reduction of anxiety and depression between tetraplegia and paraplegic groups participating in sports activity.The recent study showed in psychological status, paraplegic patients improved rather than tetraplegic. But on the contrary, the study showed there is no relation between levels of injury with psychological status. Both groups were the positive impact on sports activity [14]. Sports participants are benefited physically, psychologically and socially from the sports activity [15].

However, the researcher found that influence of different external factors, such as age, educational level, marital status or occupational status, which is independent of neurological status, and participation in sports recreation might be associated with different psychological conditions. But for small sample size and short time duration, it may not be possible to generalize the study result of reducing in sports to reduce the anxiety and depression level of SCI patients on sports.

The determination of this quasi-experimental study had two main objectives: to examine sports activity is related to better psychological profiles in SCI patients and to have a relationship between demographic factors on psychological benefits. The researcher revealed there was the association between educational level, economic status, and anxiety and depression level. But another study showed there is no association between socio-demographic and psychological status [8].

From the overall discussion, we may comment that to reduce the anxiety and depression level sports have a greater impact and can play an effective role. The null hypothesis of this study was sports cannot reduce the anxiety and depression level of spinal cord injury patients, but in this study, we vindicate that sports activity help to abate the anxiety and depression level of Spinal cord injury patients. So, the null hypothesis was rejected in this study.

Strength
It was the maiden study in the field of SCI to measure impacts of sports in a developing country in Bangladesh. Sports has not yet been integrated into SCI rehabilitation protocol widely in Bangladesh.

Limitation
The limitations were studied was confined to the hospital setting, there was no long-term follow up, no women were found for the study, the overall changes in quality of life has not been measured and wheelchair basketball is not a popular sport in Bangladesh. The study would be much incorporated if cricket could be included and the impacts of sports in the community could be revealed.

Spinal cord injury patients faced with the reality of disability. They experience anxiety and depression, and lost their confidence, as a result, their quality of life has been reduced. Anxiety and depression both are the prominent terminal psychiatric disorder, so it should be considered with greater priority. Though improvement was higher in paraplegic and incomplete spinal cord injury patients, changes have been noted in the patients with all level of injury. Early detection and proper management of this condition are very essential. Sports activity could provide desirable psychological status showing a particularly strong association with general level of anxiety and depression.

1. Kirchberger I, Biering-Sørensen F, Charlifue S, et al. Identification of the most common problems in functioning of individuals with spinal cord injury using the international classification of functioning, disability and health. Spinal Cord 2010 Mar;48(3):221–9.   [CrossRef]   [Pubmed]    
2. Craig A, Tran Y, Middleton J. Psychological morbidity and spinal cord injury: A systematic review. Spinal Cord 2009 Feb;47(2):108–14.   [CrossRef]   [Pubmed]    
3. Fullerton DT, Harvey RF, Klein MH, Howell T. Psychiatric disorders in patients with spinal cord injuries. Arch Gen Psychiatry 1981 Dec;38(12):1369–71.   [CrossRef]   [Pubmed]    
4. Bombardier CH, Adams LM, Fann JR, Hoffman JM. Depression trajectories during the first year after Spinal cord injury. Arch Phys Med Rehabil 2016 Feb;97(2):196–203.   [CrossRef]   [Pubmed]    
5. Hancock KM, Craig AR, Dickson HG, Chang E, Martin J. Anxiety and depression over the first year of spinal cord injury: A longitudinal study. Paraplegia 1993 Jun;31(6):349–57.   [CrossRef]   [Pubmed]    
6. Muraki S, Tsunawake N, Hiramatsu S, Yamasaki M. The effect of frequency and mode of sports activity on the psychological status in tetraplegics and paraplegics. Spinal Cord 2000 May;38(5):309–14.   [CrossRef]   [Pubmed]    
7. Hanson CS, Nabavi D, Yuen HK. The effect of sports on level of community integration as reported by persons with spinal cord injury. Am J Occup Ther 2001 May–Jun;55(3):332–8.   [CrossRef]   [Pubmed]    
8. Gioia MC, Cerasa A, Di Lucente L, Brunelli S, Castellano V, Traballesi M. Psychological impact of sports activity in spinal cord injury patients. Scand J Med Sci Sports 2006 Dec;16(6):412–6.   [CrossRef]   [Pubmed]    
9. Anneken V, Hanssen-Doose A, Hirschfeld S, Scheuer T, Thietje R. Influence of physical exercise on quality of life in individuals with spinal cord injury. Spinal Cord 2010 May;48(5):393–9.   [CrossRef]   [Pubmed]    
10. Dimitrov DM, Rumrill PD Jr. Pretest-posttest designs and measurement of change. Work 2003;20(2):159–65.   [Pubmed]    
11. Centre for the rehabilitation of the paralysed. Annual report 2015–2016. 2016;12. [Available at: http://www.crp-bangladesh.org/wp-content/uploads/2016/04/Annual-Report-2015-2016-part-1.pdf ]    
12. Rahman MM, Uddin Z. Development of a scale of depression for use in Bangladesh. Journal of Psychologly 2005;15:25–44.    
13. Metzger RL. A reliability and validity study of the state-trait anxiety inventory. Journal of Clinical Psychology 1976;32(2):276–8.   [CrossRef]    
14. Al Aseri ZA, Suriya MO, Hassan HA, et al. Reliability and validity of the hospital anxiety and depression scale in an emergency department in Saudi Arabia: A cross-sectional observational study. BMC Emerg Med 2015 Oct 12;15:28.   [CrossRef]   [Pubmed]    
15. Foreman PE, Cull J, Kirkby RJ. Sports participation in individuals with spinal cord injury: Demographic and psychological correlates. Int J Rehabil Res 1997 Jun;20(2):159–68.   [CrossRef]   [Pubmed]