The unique findings of this study are that strength training may provide an improvement in trait and state anxiety more than one year after stroke. We found a reduction in both state and trait anxiety in the experimental group in response to a 12-week strength training program. Likewise, when 101 patients with multiple sclerosis have been studied [22
] and the relationship between physical dysfunction and depression and anxiety has been examined, it has been concluded that two years after diagnosis these patients have higher levels of depression and anxiety, and these are associated with dysfunctions related to the pathology. Our results extend that study, in that we showed strength training improves physical measures and reduces anxiety. In addition, prior research has shown that symptoms of depression, anxiety and disability are closely related. Therefore, in a study of moderate physical activity and the association between signs of depression, anxiety, and disability in the elderly, physical activity was found to have a modifying effect on symptoms of anxiety. Physical activity plays a central role in reducing disability, and is an effective means of improving psychosocial indicators [22
Regular exercise tends to improve the quality of life [24
] and the capacity for work and leisure. Furthermore, regular exercise reduces the probability of new strokes, thereby preventing the resulting decrease in functional ability, stress and anxiety that a new attack would cause [25
]. There is evidence that participation in physical activities is the main way to reduce stress in people with disabilities and that it results in improved social functioning and emotional status, leading to reduced anxiety [26
]. Research conducted in Brazil analyzed the incidence of depression and anxiety after stroke, showing that, in the long-term, these psychosocial states are very common in people affected by cerebrovascular events [27
]. When trying to identify what caused the continuation and increase in levels of depression and anxiety, it has been noted that these indicators are significantly higher in women. Depression and anxiety are associated with issues of employment, educational level, low social activity, cognitive problems, functional dependence on another person, and even prevalence of other pathologies associated with the cerebrovascular events [27
]. Anxiety levels remain high even four months after a stroke [28
]. These are similar results to those found in the control group in our study, which even after three months showed no improvement in levels of trait and state anxiety. Similarly, the immobilization of patients after stroke tends to increase the negative aspects of the pathology, and also contributes to increased indicators of anxiety and irritability. In a previous study of 71 patients with confirmed history of stroke, lack of movement was shown to be an aggravating factor in terms of anxiety [29
]. In this sense, lack of mobility can be a factor leading to higher levels of anxiety. It has also been reported in a study from Norway that the measures of emotional health are usually neglected after a cerebrovascular event, that 20–30% of patients affected by stroke present with anxiety, that 10–15% present with emotional imbalance, and that 50–70% present with initiative reduction and increased fatigue [28
]. In addition, medical treatment tends to be based only on prescription medications, with no evidence of successful medical intervention on these psychosocial measures [30
However, our study is the first to indicate strength training may be beneficial in reducing trait and state anxiety in patients with hemiplegia due to stroke. In relation to the various cut points in the STAI scale there was no change from one major category to the next on the scale. However, there was an improvement in anxiety, as indicated by a statistically significant difference in STAI score. These significant changes detected were perhaps small, but the duration of the study was short (12 weeks). The current results indicate we can detect small improvements in the level of anxiety in as little as 12 weeks with the current program. It is in fact surprised that we were able to detect changes in trait anxiety, which is assumed to be more stable over time than state anxiety, during this short of an intervention period. Further studies are needed to determine if more clinically significant changes can be achieved with longer treatment periods.
Limitations of the present study relate to the sample size, the lack of intervention in the control group, and the size of improvements on the STAI. The small sample size of 11 participants in the experimental group of the present study may have contributed to some of the negative findings due to low statistical power. The lack of a social activity for the control group that was of equal length and frequency to the strength training group is also a limitation of the study, in that some of the improvement in the experimental group may have been due to social interaction rather than strength training per se. Although it could be argued that the measured improvements in the STAI were small, they were statistically significant. The responses were also uniform, in that there were no clear groups of responders as compared to non-responders.
The results of this pilot study indicate that state and trait anxiety may be improved by strength training in persons with minor to moderately severe disability more than one year after stroke. However, this needs to be confirmed in a large randomized controlled trial.